Awake craniotomy for microsurgical obliteration of mycotic aneurysms: technical report of three cases.

PubMed

Lüders, Jürgen C; Steinmetz, Michael P; Mayberg, Marc R

2005-01-01

Infectious (mycotic) aneurysms that do not resolve with medical treatment require surgical obliteration, usually requiring sacrifice of the parent artery. In addition, patients with mycotic aneurysms frequently need subsequent cardiac valve repair, which often necessitates anticoagulation. Three cases of awake craniotomy for microsurgical clipping of mycotic aneurysms are presented. Awake minimally invasive craniotomy using frameless stereotactic guidance on the basis of computed tomographic angiography enables temporary occlusion of the parent artery with neurological assessment before obliteration of the aneurysm. A 56-year-old woman presented with progressively worsening mitral valve disease and a history of subacute bacterial endocarditis and subarachnoid hemorrhage 30 years previously. A cerebral angiogram revealed a 4-mm left middle cerebral artery (MCA) angular branch aneurysm, which required obliteration before mitral valve replacement. The second patient, a 64-year-old woman with a history of rheumatic fever, had an 8-mm right distal MCA aneurysm diagnosed in the setting of pulmonary abscess and worsening cardiac function as a result of mitral valve disease. The third patient, a 57-year-old man with a history of fevers, night sweats, and progressive mitral valve disease, had an enlarging left MCA angular branch aneurysm despite the administration of antibiotics. Because of their location on distal MCA branches, none of the aneurysms were amenable to preoperative test balloon occlusion. After undergoing stereotactic computed tomographic angiography with fiducial markers, the patients underwent a minimally invasive awake craniotomy with frameless stereotactic navigation. In all cases, the results of the neurological examination were unchanged during temporary parent artery occlusion and the aneurysms were successfully obliterated. Awake minimally invasive craniotomy for an infectious aneurysm located in eloquent brain enables awake testing before permanent clipping or vessel sacrifice. Combining frameless stereotactic navigation with computed tomographic angiography allowed us to perform the operation quickly through a small craniotomy with minimal exploration.

Predictive modeling and in vivo assessment of cerebral blood flow in the management of complex cerebral aneurysms.

PubMed

Walcott, Brian P; Reinshagen, Clemens; Stapleton, Christopher J; Choudhri, Omar; Rayz, Vitaliy; Saloner, David; Lawton, Michael T

2016-06-01

Cerebral aneurysms are weakened blood vessel dilatations that can result in spontaneous, devastating hemorrhage events. Aneurysm treatment aims to reduce hemorrhage events, and strategies for complex aneurysms often require surgical bypass or endovascular stenting for blood flow diversion. Interventions that divert blood flow from their normal circulation patterns have the potential to result in unintentional ischemia. Recent developments in computational modeling and in vivo assessment of hemodynamics for cerebral aneurysm treatment have entered into clinical practice. Herein, we review how these techniques are currently utilized to improve risk stratification and treatment planning. © The Author(s) 2016.

Cerebral aneurysms: Formation, progression and developmental chronology

PubMed Central

Etminan, Nima; Buchholz, Bruce A.; Dreier, Rita; Bruckner, Peter; Torner, James C.; Steiger, Hans-Jakob; Hänggi, Daniel; Macdonald, R. Loch

2015-01-01

The prevalence of unruptured intracranial aneurysms (UAIs) in the general population is up to 3%. Existing epidemiological data suggests that only a small fraction of UIAs progress towards rupture over the lifetime of an individual, but the surrogates for subsequent rupture and the natural history of UIAs are discussed very controversially at present. In case of rupture of an UIA, the case-fatality is up to 50%, which therefore continues to stimulate interest in the pathogenesis of cerebral aneurysm formation and progression. Actual data on the chronological development of cerebral aneurysm has been especially difficult to obtain and, until recently, the existing knowledge in this respect is mainly derived from animal or mathematical models or short-term observational studies. Here, we highlight the current data on cerebral aneurysm formation and progression as well as a novel approach to investigate the developmental chronology of cerebral aneurysms. PMID:24323717

Sexual Activity as a Risk Factor for the Spontaneous Rupture of Cerebral Aneurysms.

PubMed

Blanke-Roeser, Constantin; Matschke, Jakob; Püschel, Klaus

2016-06-01

Subarachnoid hemorrhages from ruptured cerebral aneurysms have a high clinical relevance and often lead to death. Approximately 2% to 5% of the people worldwide, even of younger age, are said to have aneurysms at cerebral arteries. In many cases, they remain clinically unapparent for decades. However, there are numerous risk factors for the rupture of an aneurysm, including temporary raises of the blood pressure. Such changes of the blood pressure can be induced even by several everyday behaviors. For example, any sort of sexual activities may cause extensive raises of the blood pressure because of several physical and psychological factors. The term "sexual activity" covers sexual intercourse as well as masturbation. In this article, the remarkable case of a 24-year-old woman with a ruptured cerebral aneurysm in the context of masturbation is presented. It is discussed with respect to the possible pathophysiological effects of sexual activity on cerebral aneurysms.

Vascular Variations Associated with Intracranial Aneurysms.

PubMed

Orakdogen, Metin; Emon, Selin Tural; Somay, Hakan; Engin, Taner; Is, Merih; Hakan, Tayfun

2017-01-01

To investigate the vascular variations in patients with intracranial aneurysm in circle of Willis. We used the data on 128 consecutive intracranial aneurysm cases. Cerebral angiography images were analyzed retrospectively. Arteries were grouped as anterior cerebral arterial system (ACS), posterior cerebral arterial system (PCS) and middle cerebral arterial system (MCS) for grouping vascular variations. Lateralization, being single/multiple, gender; and also any connection with accompanying aneurysms" number, localization, dimension, whether bleeding/incidental aneurysm has been inspected. Variations were demonstrated in 57.8% of the cases. The most common variation was A1 variation (34.4%). The rate of variations was 36.7%, 24.2% and 10.2% respectively in ACS, PCS and MCS. MCS variations were significantly higher in males. Anterior communicating artery (ACoA) aneurysm observance rates were significantly higher and posterior communicating artery (PCoA) aneurysm and middle cerebral artery (MCA) aneurysm observance rates were significantly lower when compared to "no ACS variation detected" cases. In "PCS variation detected" cases, PCoA aneurysm observance rates and coexistence of multiple variations were significantly higher. The rate of vascular variations in patients with aneurysms was 57.8%. Arterial hypoplasia and aplasia were the most common variations. ACS was the most common region that variations were located in; they were mostly detected on the right side. Coexistence of ACoA aneurysm was higher than PCoA and MCA aneurysms. In the PCS variations group, PCoA aneurysms were the most common aneurysms that accompanying the variation and multiple variations were more common than in the other two groups. The variations in MCS were most common in males.

Aneurysm treatment practice patterns for newly appointed dual-trained cerebrovascular/endovascular neurosurgeons: Comparison of open surgical to neuroendovascular procedures in the first 2 years of academic practice.

PubMed

Jiang, Bowen; Bender, Matthew T; Hasjim, Bima; Hsu, Frank P K; Tamargo, Rafael J; Huang, Judy; Colby, Geoffrey P; Coon, Alexander L; Lin, Li-Mei

2017-01-01

The practice patterns of a hybrid open cerebrovascular/neuroendovascular (CVNV) neurosurgeon in early academic practice is unknown. We performed a multi-institutional retrospective cohort study of patients with cerebral aneurysms that were treated within the first 24 months of the neurosurgeon's practice. A total of 533 aneurysms were treated by the three senior authors within the first 24 months of their academic practice. Of these aneurysms, 172 were treated with microsurgical clipping, 191 with coiling, and 170 with flow diversion. Treatment in the setting of acute subarachnoid hemorrhage (SAH) occurred in 23% (122/533) of the aneurysms. Majority of the clipped aneurysms (70%, 121/172) were anterior cerebral artery (ACA), anterior communicating artery (ACOM), or middle cerebral artery (MCA) in location. In comparison, only 23% (82/361) of aneurysms treated with coiling or flow diversion therapy were ACA, ACOM, or MCA in location ( P < 0.05). Additionally, majority of the flow diverted aneurysm (65%, 111/170) were cavernous or ophthalmic/paraophthalmic in location. During the second year of practice, there appeared to be a trend towards more aneurysms treated with neuroendovascular techniques (22% increase), particularly in flow diversion. Although the CVNV neurosurgeon treats cerebral aneurysms more commonly with neuroendovascular techniques, a third of the cerebral aneurysms are still selected for microsurgical clipping. Aneurysms located along the ACA/ACOM or MCA are the most frequent aneurysms reserved for microsurgical clipping. The CVNV neurosurgeon must be prepared to manage a high percentage of ACA/ACOM or MCA aneurysms microsurgically.

Younger age of menopause in women with cerebral aneurysms.

PubMed

Ding, Christine; Toll, Valerie; Ouyang, Bichun; Chen, Michael

2013-07-01

The incidence of subarachnoid hemorrhage in women surges following menopause. Estrogen fluctuations have been implicated in cerebral aneurysm formation, growth and rupture and are thought to explain the well-known gender disparity. The aim of this study was to examine the association between age at menopause, which can determine lifetime estrogen exposure, and the presence of cerebral aneurysms. A retrospective case-control study was conducted by interviewing postmenopausal women with intradural cerebral aneurysms about their basic medical and gynecologic histories. This information was compared with the same data points collected from 4682 women contacted through random digit phone dialing in the National Institute of Child Health and Human Development-sponsored Contraceptive and Reproductive Experiences Study published in 2002. Among 76 consecutive postmenopausal women with cerebral aneurysms who were treated by a single physician and interviewed, multivariate logistic regression showed that later menopause age (OR 0.79, CI 0.63 to 0.996, p=0.046) was significantly associated with a lower aneurysm incidence. Premature menopause (<40 years) was seen in 26% of cases and 19% of controls (p=0.15). Each categorical increase in menopause age (<40, 40-44, 45-49, 50-54, ≥55 years) decreased the likelihood by 21%. Despite a trend towards earlier mean age at menopause in the case group, the difference was not statistically significant. There is a trend showing that an earlier age at menopause is associated with the presence of a cerebral aneurysm. This suggests that loss of estrogen earlier in a woman's life may contribute to the pathogenesis of cerebral aneurysm. These data may identify a risk factor for cerebral aneurysm pathogenesis and also a potential target for future therapies.

Fabrication of cerebral aneurysm simulator with a desktop 3D printer

NASA Astrophysics Data System (ADS)

Liu, Yu; Gao, Qing; Du, Song; Chen, Zichen; Fu, Jianzhong; Chen, Bing; Liu, Zhenjie; He, Yong

2017-05-01

Now, more and more patients are suffering cerebral aneurysm. However, long training time limits the rapid growth of cerebrovascular neurosurgeons. Here we developed a novel cerebral aneurysm simulator which can be better represented the dynamic bulging process of cerebral aneurysm The proposed simulator features the integration of a hollow elastic vascular model, a skull model and a brain model, which can be affordably fabricated at the clinic (Fab@Clinic), under $25.00 each with the help of a low-cost desktop 3D printer. Moreover, the clinical blood flow and pulsation pressure similar to the human can be well simulated, which can be used to train the neurosurgical residents how to clip aneurysms more effectively.

Unruptured cerebral aneurysms do not shrink when they rupture: multicenter collaborative aneurysm study group.

PubMed

Rahman, Maryam; Ogilvy, Christopher S; Zipfel, Gregory J; Derdeyn, Colin P; Siddiqui, Adnan H; Bulsara, Ketan R; Kim, Louis J; Riina, Howard A; Mocco, J; Hoh, Brian L

2011-01-01

The International Study of Intracranial Aneurysms found that for patients with no previous history of subarachnoid hemorrhage, small (< 7 mm) anterior circulation and posterior circulation aneurysms had a 0% and 2.5% risk of subarachnoid hemorrhage over 5 years, respectively. To determine whether cerebral aneurysms shrink with rupture. The clinical databases of 7 sites were screened for patients with imaging of cerebral aneurysms before and after rupture. Inclusion criteria included documented subarachnoid hemorrhage by imaging or lumbar puncture and intracranial imaging before and after cerebral aneurysm rupture. The patients were evaluated for aneurysm maximal height, maximal width, neck diameter, and other measurement parameters. Only a change of ≥ 2 mm was considered a true change. Data on 13 patients who met inclusion criteria were collected. The median age was 60, and 11 of the 13 patients (84.6%) were female. Only 5 patients had posterior circulation aneurysms. None of the aneurysms had a significant decrease in size. One aneurysm decreased by 1.8 mm in maximum size after rupture (7.7%). Six aneurysms had an increase in maximum size of at least 2 mm after rupture (46.2%) with a mean increase of 3.5 mm (± 0.5 mm). Unruptured aneurysms do not shrink when they rupture. The large percentage of ruptured small aneurysms in previous studies were likely small before they ruptured.

Biomechanical Simulation to Compare the Blood Hemodynamics and Cerebral Aneurysm Rupture Risk in Patients with Different Aneurysm Necks

NASA Astrophysics Data System (ADS)

Hajirayat, K.; Gholampour, S.; Sharifi, I.; Bizari, D.

2017-11-01

In this study, one normal subject and two patients suffering from a cerebral aneurysm with circular and elliptical necks are analyzed by using the fluid-structure interaction (FSI) method. Although the blood hemodynamics parameters increase after the occurrence of the disease, the largest increase is in the wall shear stress (by a factor of 4.1-6.5) as compared to the normal subject. The increase in these parameters for patients with a circular neck is more pronounced than that with an elliptical neck. The blood flow becomes slightly more turbulent after the occurrence of the cerebral aneurysm, though it still remains in the range of the laminar flow and the pulsatility of the blood flow in patients is 28-45% greater than that of the normal subject. Finally, the results show that the risk of vessel rupture in the cerebral aneurysm with a circular neck is 40.8% higher than that in the case of the cerebral aneurysm with an elliptical neck.

Aneurysm treatment practice patterns for newly appointed dual-trained cerebrovascular/endovascular neurosurgeons: Comparison of open surgical to neuroendovascular procedures in the first 2 years of academic practice

PubMed Central

Jiang, Bowen; Bender, Matthew T.; Hasjim, Bima; Hsu, Frank P. K.; Tamargo, Rafael J.; Huang, Judy; Colby, Geoffrey P.; Coon, Alexander L.; Lin, Li-Mei

2017-01-01

Background: The practice patterns of a hybrid open cerebrovascular/neuroendovascular (CVNV) neurosurgeon in early academic practice is unknown. Methods: We performed a multi-institutional retrospective cohort study of patients with cerebral aneurysms that were treated within the first 24 months of the neurosurgeon’s practice. Results: A total of 533 aneurysms were treated by the three senior authors within the first 24 months of their academic practice. Of these aneurysms, 172 were treated with microsurgical clipping, 191 with coiling, and 170 with flow diversion. Treatment in the setting of acute subarachnoid hemorrhage (SAH) occurred in 23% (122/533) of the aneurysms. Majority of the clipped aneurysms (70%, 121/172) were anterior cerebral artery (ACA), anterior communicating artery (ACOM), or middle cerebral artery (MCA) in location. In comparison, only 23% (82/361) of aneurysms treated with coiling or flow diversion therapy were ACA, ACOM, or MCA in location (P < 0.05). Additionally, majority of the flow diverted aneurysm (65%, 111/170) were cavernous or ophthalmic/paraophthalmic in location. During the second year of practice, there appeared to be a trend towards more aneurysms treated with neuroendovascular techniques (22% increase), particularly in flow diversion. Conclusion: Although the CVNV neurosurgeon treats cerebral aneurysms more commonly with neuroendovascular techniques, a third of the cerebral aneurysms are still selected for microsurgical clipping. Aneurysms located along the ACA/ACOM or MCA are the most frequent aneurysms reserved for microsurgical clipping. The CVNV neurosurgeon must be prepared to manage a high percentage of ACA/ACOM or MCA aneurysms microsurgically. PMID:28808603

[Analysis on Clinical Characteristic and Risk Factors of Patients Coexistence of Cerebral Artery Stenosis with Unruptured Intracranial Aneurysm].

PubMed

Zhao, Hai-Yan; Han, Jin-Tao; Fan, Dong-Sheng

2017-09-01

To analyze the incidence of intracranial unruptured aneurysms in patients with intracranial artery stenosis,clinical features,and investigate the risk factors for unruptured intracranial aneurysms. Medical records from all patients performed with digital subtraction angiography (DSA) who had been treated at Peking University Third Hospital,China,from January 2012 to December 2015 were retrospectively reviewed to identify cases coexistence with cerebral artery stenosis and unruptured intracranial aneurysm. Of 273 patients with cerebral artery stenosis (≥50%),intracranial unruptured aneurysms was observed in 17 cases (6.23%) from age of 45 to 78,among them 8 (47.06%) were female and 9 (52.94%) were male. The incidence of unruptured intracranial aneurysm in male patients was 4.17% (9/216),and that of female was 14.4% (8/57). There was statistically significant difference between the male and female incidence of intracranial aneurysm ( P <0.05). Of these 17 patients,16 (94.12%) aneurysms were located in the internal carotid artery (ICA) system,1 (5.88%) aneurysm was located at the tip of the basilar artery. In 11 cases (64.71%),aneurysms were located at the distal of the stenotic vessels,2 (11.76%) were located at the proximal of the stenotic vessels,and 4 cases (23.53%) of which the aneurysm and stenosis were not in the same artery. Logistic multivariate analysis showed that gender was an independent risk factor for aneurysms in patients with cerebral arterial stenosis. In the intracranial artery stenosis atients,the possibility of the occurrence of the aneurysm is much higher than the general population,and women were more prominent than man. Sex is an independent risk factor for aneurysms in patients with cerebral arterial stenosis.

Developmental deficits in adult patients with arteriovenous malformations.

PubMed

Lazar, R M; Connaire, K; Marshall, R S; Pile-Spellman, J; Hacein-Bey, L; Solomon, R A; Sisti, M B; Young, W L; Mohr, J P

1999-01-01

Cerebral arteriovenous malformations (AVMs) are congenital masses of arteries and veins that appear to undergo an unclear "maturation" for many years. Using structured interviews, we compared developmental history of adult patients with AVM with a comparison group of patients with cerebral tumor or aneurysm. To determine whether a remote history of developmental abnormality in adult patients with AVM might be an early marker of cerebral status. Adult patients with AVM and a comparison group of patients with cerebral aneurysm or low-grade tumor participated in a survey. Urban medical school-based tertiary care center. Forty-four randomly selected patients with AVM from the Columbia-Presbyterian AVM Database. There were 32 comparison patients:15 randomly chosen patients from the institution's Cerebral Aneurysm Database and all 17 patients who underwent a biopsy from 1990 to 1995 with a diagnosis of low-grade tumor and who could be contacted. A brief, structured interview adapted from the Centers for Disease Control and Prevention for its 1994 study of the prevalence of learning disabilities in American children. We defined the positive occurrence of a condition as an affirmative answer to the question, " Did have (condition) during his/her school-age years?" Each patient was also asked if there had been any problems in the following skill areas: reading, writing, listening, speaking, attention, impulsivity, organization, mathematics, or drawing. The AVM size was calculated on the angiographic film by measuring its longest diameter in any dimension. Patients with AVM were significantly more likely to report a positive occurrence to any survey question (P<.05). Two thirds of all patients with AVM (66%) reported at least 1 skill difficulty during their school years, significantly more than the comparison group (P<.001). Neither the maximum AVM diameter nor the occurrence of hemorrhage as an adult differed between patients with AVM with and without early skill difficulty. Patients with AVM are more likely to report a developmental learning disorder than patients with tumor or aneurysm despite the absence of other neurologic symptoms of diseases not diagnosed for another 20 years. These data support the notion that disorders of behavioral and intellectual function are sensitive markers of early cerebral status.

Fabrication of cerebral aneurysm simulator with a desktop 3D printer

PubMed Central

Liu, Yu; Gao, Qing; Du, Song; Chen, ZiChen; Fu, JianZhong; Chen, Bing; Liu, ZhenJie; He, Yong

2017-01-01

Now, more and more patients are suffering cerebral aneurysm. However, long training time limits the rapid growth of cerebrovascular neurosurgeons. Here we developed a novel cerebral aneurysm simulator which can be better represented the dynamic bulging process of cerebral aneurysm The proposed simulator features the integration of a hollow elastic vascular model, a skull model and a brain model, which can be affordably fabricated at the clinic (Fab@Clinic), under $25.00 each with the help of a low-cost desktop 3D printer. Moreover, the clinical blood flow and pulsation pressure similar to the human can be well simulated, which can be used to train the neurosurgical residents how to clip aneurysms more effectively. PMID:28513626

Predicting inpatient complications from cerebral aneurysm clipping: the Nationwide Inpatient Sample 2005-2009.

PubMed

Bekelis, Kimon; Missios, Symeon; MacKenzie, Todd A; Desai, Atman; Fischer, Adina; Labropoulos, Nicos; Roberts, David W

2014-03-01

Precise delineation of individualized risks of morbidity and mortality is crucial in decision making in cerebrovascular neurosurgery. The authors attempted to create a predictive model of complications in patients undergoing cerebral aneurysm clipping (CAC). The authors performed a retrospective cohort study of patients who had undergone CAC in the period from 2005 to 2009 and were registered in the Nationwide Inpatient Sample (NIS) database. A model for outcome prediction based on preoperative individual patient characteristics was developed. Of the 7651 patients in the NIS who underwent CAC, 3682 (48.1%) had presented with unruptured aneurysms and 3969 (51.9%) with subarachnoid hemorrhage. The respective inpatient postoperative risks for death, unfavorable discharge, stroke, treated hydrocephalus, cardiac complications, deep vein thrombosis, pulmonary embolism, and acute renal failure were 0.7%, 15.3%, 5.3%, 1.5%, 1.3%, 0.6%, 2.0%, and 0.1% for those with unruptured aneurysms and 11.5%, 52.8%, 5.5%, 39.2%, 1.7%, 2.8%, 2.7%, and 0.8% for those with ruptured aneurysms. Multivariate analysis identified risk factors independently associated with the above outcomes. A validated model for outcome prediction based on individual patient characteristics was developed. The accuracy of the model was estimated using the area under the receiver operating characteristic curve, and it was found to have good discrimination. The featured model can provide individualized estimates of the risks of postoperative complications based on preoperative conditions and can potentially be used as an adjunct in decision making in cerebrovascular neurosurgery.

A Less Invasive Strategy for Ruptured Cerebral Aneurysms with Intracerebral Hematomas: Endovascular Coil Embolization Followed by Stereotactic Aspiration of Hematomas Using Urokinase

PubMed Central

Kim, Sang Heum; Kong, Min Ho

2017-01-01

Objective Aneurysm clipping and simultaneous hematoma evacuation through open craniotomy is traditionally recommended for ruptured cerebral aneurysms accompanied by intracerebral or intrasylvian hemorrhages. We report our experience of adapting a less invasive treatment strategy in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms, where the associated ruptured cerebral aneurysms were managed by endovascular coil embolization, followed by stereotactic aspiration of hematomas (SRH) using urokinase. Materials and Methods We retrospectively analyzed 112 patients with ruptured cerebral aneurysms. There were accompanying intracerebral or intrasylvian hemorrhages in 36 patients (32.1%). The most common site for these ruptured aneurysms was the middle cerebral artery (MCA) (n = 15; 41.6%). Endovascular coil embolization followed by SRH using urokinase was performed in 9 patients (25%). Results In these 9 patients, the most common site of aneurysms was the MCA (n = 3; 33.4%); the hematoma volume ranged from 19.24 to 61.68 mL. Four patients who were World Federation of Neurological Surgeons (WFNS) grade-IV on admission, achieved favorable outcomes (Glasgow Outcome Score [GOS] 4 or 5) at 6-months postoperatively. In the five patients who were WFNS grade-V on admission, one achieved a favorable outcome, whereas 4 achieved GOS scores of 2 or 3, 6-months postoperatively. There was no mortality. Conclusion If immediate hematoma evacuation is not mandated by clinical or radiological signs of brain herniation, a less invasive strategy, such as endovascular coil embolization followed by SRH using urokinase, may be a good alternative in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms. PMID:29152466

Blood free Radicals Concentration Determined by Electron Paramagnetic Resonance Spectroscopy and Delayed Cerebral Ischemia Occurrence in Patients with Aneurysmal Subarachnoid Hemorrhage.

PubMed

Ewelina, Grzywna; Krzysztof, Stachura; Marek, Moskala; Krzysztof, Kruczala

2017-12-01

Pathophysiology of delayed cerebral ischemia and cerebral vasospasm following aneurysmal subarachnoid hemorrhage is still poorly recognized, however free radicals are postulated as one of the crucial players. This study was designed to scrutinize whether the concentration of free radicals in the peripheral venous blood is related to the occurrence of delayed cerebral ischemia associated with cerebral vasospasm. Twenty-four aneurysmal subarachnoid hemorrhage patients and seven patients with unruptured intracranial aneurysm (control group) have been studied. Free radicals in patients' blood have been detected by the electron paramagnetic resonance (CMH.HCl spin probe, 150 K, ELEXSYS E500 spectrometer) on admission and at least 72 h from disease onset. Delayed cerebral ischemia monitoring was performed by daily neurological follow-up and transcranial color coded Doppler. Delayed cerebral ischemia observed in six aneurysmal subarachnoid hemorrhage patients was accompanied by cerebral vasospasm in all six cases. No statistically significant difference in average free radicals concentration between controls and study subgroups was noticed on admission (p = .3; Kruskal-Wallis test). After 72 h free radicals concentration in delayed cerebral ischemia patients (3.19 ± 1.52 mmol/l) differed significantly from the concentration in aneurysmal subarachnoid hemorrhage patients without delayed cerebral ischemia (0.65 ± 0.37 mmol/l) (p = .012; Mann-Whitney test). These findings are consistent with our assumptions and seem to confirm the role of free radicals in delayed cerebral ischemia development. Preliminary results presented above are promising and we need perform further investigation to establish whether blood free radicals concentration may serve as the biomarker of delayed cerebral ischemia associated with cerebral vasospasm.

Application of Micromirror in Microsurgical Clipping to the Intracranial Aneurysms.

PubMed

Zhao, Chao; Ma, Zhiguo; Zhang, Yuhai; Mou, Shanling; Yang, Yunxue; Yang, Yonglin; Sun, Guoqing; Yao, Weicheng

2018-05-01

The aim of the study was to explore the values and disadvantages of micromirror in the intracranial aneurysm clipping surgery. Micromirror was used to assist microsurgical clipping to 36 intracranial aneurysms in 31 patients, of which 3 were carotid-ophthalmic artery aneurysms, 3 were anterior choroidal artery aneurysms, 11 were posterior communicating artery aneurysms, 7 were middle cerebral artery aneurysms, 10 were anterior communicating artery or anterior cerebral artery aneurysms, and the rest were a posterior cerebral artery aneurysm and a posterior inferior cerebellar artery aneurysm. The micromirror was used before and after clipping to observe the anatomic features of necks hidden behind and medial to aneurysms, to visualize surrounding neurovascular structures, and to verify the optimal clipping position. Intraoperative indocyanine green fluorescein angiography, postoperative computerized tomography angiography, and digital subtraction angiography confirmed the success of sufficient clipping. Intraoperative indocyanine green angiography, postoperative computerized tomography angiography , or digital subtraction angiography were performed and showed no case of wrong or insufficient clipping of aneurysm. Micromirror-assisted microsurgical clipping to the intracranial aneurysm is safe, sufficient, convenient, and practical.

Initial experience of coiling cerebral aneurysms using the new Comaneci device

PubMed Central

Lawson, Aimee Louise Deborah; Chandran, Arun; Puthuran, Mani; Goddard, Tony; Nahser, Hans; Patankar, Tufail

2015-01-01

We present our initial patient experience with an innovative temporary bridging device, the Comaneci (Rapid Medical, Israel), to assist in the coiling of cerebral aneurysms. The Comaneci device confers the same benefits as balloon remodeling but without the risks of parent artery occlusion. This alleviates time pressure on the clinician, and could reduce the risk of parent artery thrombosis. Three patients were treated with the Comaneci device. Two patients had acute ruptured posterior communicating aneurysms and one patient was treated electively for a carotico-ophthalmic aneurysm. Excellent occlusion of all three aneurysms was obtained. One patient developed a distal middle cerebral artery clot, that was treated with intravenous aspirin, with minor neurological consequences. These early results show that the Comaneci device can be used to achieve good cerebral aneurysm occlusion. Vessel patency is maintained throughout the procedure with potential advantages over conventional balloon assisted coiling. PMID:26123460

Complicated Sporadic Cardiac Myxomas: A Second Recurrence and Myxomatous Cerebral Aneurysms in One Patient

PubMed Central

Iskandar, Mazen E.; Dimitrova, Kamellia; Geller, Charles M.; Hoffman, Darryl M.; Tranbaugh, Robert F.

2013-01-01

A second recurrence of an excised nonfamilial cardiac myxoma is rare. Myxomatous cerebral aneurysms as a complication of cardiac myxomas are equally rare. A unique case of a patient with a total of 4 myxomas over a 20-year interval is presented. Her most recent presentation was a second recurrence of a left atrial myxoma, a de novo right atrial myxoma, and multiple cerebral myxomatous aneurysms. The challenging reconstruction of the normal anatomy was achieved with the use of porcine extracellular matrix patches. A diagnostic cerebral angiogram was later performed, and the aneurysms will be monitored for growth and possible intervention. PMID:24455387

Complicated sporadic cardiac myxomas: a second recurrence and myxomatous cerebral aneurysms in one patient.

PubMed

Iskandar, Mazen E; Dimitrova, Kamellia; Geller, Charles M; Hoffman, Darryl M; Tranbaugh, Robert F

2013-01-01

A second recurrence of an excised nonfamilial cardiac myxoma is rare. Myxomatous cerebral aneurysms as a complication of cardiac myxomas are equally rare. A unique case of a patient with a total of 4 myxomas over a 20-year interval is presented. Her most recent presentation was a second recurrence of a left atrial myxoma, a de novo right atrial myxoma, and multiple cerebral myxomatous aneurysms. The challenging reconstruction of the normal anatomy was achieved with the use of porcine extracellular matrix patches. A diagnostic cerebral angiogram was later performed, and the aneurysms will be monitored for growth and possible intervention.

Brain protection in aortic arch aneurysm: antegrade or retrograde?

PubMed

Harky, Amer; Fok, Matthew; Bashir, Mohamad; Estrera, Anthony L

2018-01-03

During open aortic arch repair, there is an interruption of cerebral perfusion and to prevent neurological sequelae, the hypothermic circulatory arrest has been established to provide sufficient brain protection coupled with adjuncts including retrograde and antegrade cerebral perfusion. To date, brain protection during open aortic arch repair is a contested topic as to which provides superior brain protection with little evidence existing to suggest supremacy of one modality over the other. This article reviews current literature reflecting on key and emerging studies in brain protection and their associated outcomes in patients undergoing open aortic arch surgery.

Computational fluid dynamics modeling of intracranial aneurysms: effects of parent artery segmentation on intra-aneurysmal hemodynamics.

PubMed

Castro, M A; Putman, C M; Cebral, J R

2006-09-01

The purpose of this study is to show the influence of the upstream parent artery geometry on intraaneurysmal hemodynamics of cerebral aneurysms. Patient-specific models of 4 cerebral aneurysms (1 posterior communicating artery [PcomA], 2 middle cerebral artery [MCA], and 1 anterior communicating artery [AcomA]) were constructed from 3D rotational angiography images. Two geometric models were constructed for each aneurysm. One model had the native parent vessel geometry; the second model was truncated approximately 1 cm upstream from the aneurysm, and the parent artery replaced with a straight cylinder. Corresponding finite element grids were generated and computational fluid dynamics simulations were carried out under pulsatile flow conditions. The intra-aneurysmal flow patterns and wall shear stress (WSS) distributions were visualized and compared. Models using the truncated parent vessel underestimated the WSS in the aneurysms in all cases and shifted the impaction zone to the neck compared with the native geometry. These effects were more pronounced in the PcomA and AcomA aneurysms where upstream curvature was substantial. The MCA aneurysm with a long M1 segment was the least effected. The more laminar flow pattern within the parent vessel in truncated models resulted in a less complex intra-aneurysmal flow patterns with fewer vortices and less velocity at the dome. Failure to properly model the inflow stream contributed by the upstream parent artery can significantly influence the results of intra-aneurysmal hemodynamic models. The upstream portion of the parent vessel of cerebral aneurysms should be included to accurately represent the intra-aneurysmal hemodynamics.

Nickel-related adverse reactions in the treatment of cerebral aneurysms: a literature review.

PubMed

Tsang, Anderson Chun On; Nicholson, Patrick; Pereira, Vitor Mendes

2018-04-20

Nickel is the most common metal allergen and predominantly affects women. It is also the ubiquitous component in the alloys used to manufacture intracranial devices for aneurysm treatments, including aneurysm clips, self-expanding stents, flow-diverting stents and endosaccular occlusion devices. Adverse events related to nickel-allergy after deployment of such devices are uncommon but can be severe, resulting in dilemmas in the choice of treatment strategies and devices in managing nickel-sensitive patients with intracranial aneurysms. A literature search in accordance with the PRISMA guidelines was performed to identify studies reporting on nickel-related adverse events in cerebral aneurysm treatment. The material of the culprit devices, clinical presentation, histological feature and treatment were reviewed. The clinical consideration and management options for nickel allergy patients were discussed. Nickel is a major component of the cobalt-alloy used in aneurysm clips, and of nitinol which is commonly used in flow-diverters and intracranial stents. There were 9 papers reporting 10 unique cases of nickel-related adverse events after aneurysm treatment. Half of the cases occurred after aneurysm clipping and the remaining 5 was attributed to endovascular devices. Two presented with dermatological and 8 with neurological manifestations including cerebral edema and cerebritis. Neurological complication related to nickel in cerebral aneurysm treatments is rare but remains a concern due to the high prevalence of nickel allergy in the population. Surgeons and interventionists should consider the metal-allergy history and its potential clinical significance in managing nickel-allergic patients with aneurysms. Copyright © 2018 Elsevier Inc. All rights reserved.

In vitro strain measurements in cerebral aneurysm models for cyber-physical diagnosis.

PubMed

Shi, Chaoyang; Kojima, Masahiro; Anzai, Hitomi; Tercero, Carlos; Ikeda, Seiichi; Ohta, Makoto; Fukuda, Toshio; Arai, Fumihito; Najdovski, Zoran; Negoro, Makoto; Irie, Keiko

2013-06-01

The development of new diagnostic technologies for cerebrovascular diseases requires an understanding of the mechanism behind the growth and rupture of cerebral aneurysms. To provide a comprehensive diagnosis and prognosis of this disease, it is desirable to evaluate wall shear stress, pressure, deformation and strain in the aneurysm region, based on information provided by medical imaging technologies. In this research, we propose a new cyber-physical system composed of in vitro dynamic strain experimental measurements and computational fluid dynamics (CFD) simulation for the diagnosis of cerebral aneurysms. A CFD simulation and a scaled-up membranous silicone model of a cerebral aneurysm were completed, based on patient-specific data recorded in August 2008. In vitro blood flow simulation was realized with the use of a specialized pump. A vision system was also developed to measure the strain at different regions on the model by way of pulsating blood flow circulating inside the model. Experimental results show that distance and area strain maxima were larger near the aneurysm neck (0.042 and 0.052), followed by the aneurysm dome (0.023 and 0.04) and finally the main blood vessel section (0.01 and 0.014). These results were complemented by a CFD simulation for the addition of wall shear stress, oscillatory shear index and aneurysm formation index. Diagnosis results using imaging obtained in August 2008 are consistent with the monitored aneurysm growth in 2011. The presented study demonstrates a new experimental platform for measuring dynamic strain within cerebral aneurysms. This platform is also complemented by a CFD simulation for advanced diagnosis and prediction of the growth tendency of an aneurysm in endovascular surgery. Copyright © 2013 John Wiley & Sons, Ltd.

Volumetric PIV in Patient-Specific Cerebral Aneurysm

NASA Astrophysics Data System (ADS)

Brindise, Melissa; Dickerhoff, Ben; Saloner, David; Rayz, Vitaliy; Vlachos, Pavlos

2016-11-01

Cerebral aneurysms impose a unique challenge in which neurosurgeons must assess and decide between the risk of rupture and risk of treatment for each patient. Risk of rupture is often difficult to determine and most commonly assessed using geometric data including the size and shape of the aneurysm and parent vessel. Hemodynamics is thought to play a major role in the growth and rupture of a cerebral aneurysm, but its specific influence is largely unknown due to the inability of in vivo modalities to characterize detailed flow fields and limited in vitro studies. In this work, we use a patient-specific basilar tip aneurysm model and volumetric particle image velocimetry (PIV). In vivo, 4-D PC-MRI measurements were obtained for this aneurysm and the extracted pulsatile waveform was used for the in vitro study. Clinically relevant metrics including wall shear stress (WSS), oscillatory shear index (OSI), relative residence time (RRT), 3-D pressure contours, and pressure wave speed were subsequently computed. This is the first study to investigate in vitro 3-D pressure fields within a cerebral aneurysm. The results of this study demonstrate how these metrics influence the biomechanics of the aneurysm and ultimately their affect on the risk of rupture.

Thrombosis in Cerebral Aneurysms and the Computational Modeling Thereof: A Review

PubMed Central

Ngoepe, Malebogo N.; Frangi, Alejandro F.; Byrne, James V.; Ventikos, Yiannis

2018-01-01

Thrombosis is a condition closely related to cerebral aneurysms and controlled thrombosis is the main purpose of endovascular embolization treatment. The mechanisms governing thrombus initiation and evolution in cerebral aneurysms have not been fully elucidated and this presents challenges for interventional planning. Significant effort has been directed towards developing computational methods aimed at streamlining the interventional planning process for unruptured cerebral aneurysm treatment. Included in these methods are computational models of thrombus development following endovascular device placement. The main challenge with developing computational models for thrombosis in disease cases is that there exists a wide body of literature that addresses various aspects of the clotting process, but it may not be obvious what information is of direct consequence for what modeling purpose (e.g., for understanding the effect of endovascular therapies). The aim of this review is to present the information so it will be of benefit to the community attempting to model cerebral aneurysm thrombosis for interventional planning purposes, in a simplified yet appropriate manner. The paper begins by explaining current understanding of physiological coagulation and highlights the documented distinctions between the physiological process and cerebral aneurysm thrombosis. Clinical observations of thrombosis following endovascular device placement are then presented. This is followed by a section detailing the demands placed on computational models developed for interventional planning. Finally, existing computational models of thrombosis are presented. This last section begins with description and discussion of physiological computational clotting models, as they are of immense value in understanding how to construct a general computational model of clotting. This is then followed by a review of computational models of clotting in cerebral aneurysms, specifically. Even though some progress has been made towards computational predictions of thrombosis following device placement in cerebral aneurysms, many gaps still remain. Answering the key questions will require the combined efforts of the clinical, experimental and computational communities. PMID:29670533

Thrombosis in Cerebral Aneurysms and the Computational Modeling Thereof: A Review.

PubMed

Ngoepe, Malebogo N; Frangi, Alejandro F; Byrne, James V; Ventikos, Yiannis

2018-01-01

Thrombosis is a condition closely related to cerebral aneurysms and controlled thrombosis is the main purpose of endovascular embolization treatment. The mechanisms governing thrombus initiation and evolution in cerebral aneurysms have not been fully elucidated and this presents challenges for interventional planning. Significant effort has been directed towards developing computational methods aimed at streamlining the interventional planning process for unruptured cerebral aneurysm treatment. Included in these methods are computational models of thrombus development following endovascular device placement. The main challenge with developing computational models for thrombosis in disease cases is that there exists a wide body of literature that addresses various aspects of the clotting process, but it may not be obvious what information is of direct consequence for what modeling purpose (e.g., for understanding the effect of endovascular therapies). The aim of this review is to present the information so it will be of benefit to the community attempting to model cerebral aneurysm thrombosis for interventional planning purposes, in a simplified yet appropriate manner. The paper begins by explaining current understanding of physiological coagulation and highlights the documented distinctions between the physiological process and cerebral aneurysm thrombosis. Clinical observations of thrombosis following endovascular device placement are then presented. This is followed by a section detailing the demands placed on computational models developed for interventional planning. Finally, existing computational models of thrombosis are presented. This last section begins with description and discussion of physiological computational clotting models, as they are of immense value in understanding how to construct a general computational model of clotting. This is then followed by a review of computational models of clotting in cerebral aneurysms, specifically. Even though some progress has been made towards computational predictions of thrombosis following device placement in cerebral aneurysms, many gaps still remain. Answering the key questions will require the combined efforts of the clinical, experimental and computational communities.

Duplicated middle cerebral artery

PubMed Central

Perez, Jesus; Machado, Calixto; Scherle, Claudio; Hierro, Daniel

2009-01-01

Duplicated middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery. The incidence DMCA is relatively law, and an association between this anomaly and cerebral aneurysms has been documented. There is a controversy whether DMCA may have perforating arteries. This is an important fact to consider in aneurysm surgery. We report the case of a 34-year-old black woman who suffered a subarachnoid hemorrhage and the angiography a left DMCA, and an aneurysm in an inferior branch of the main MCA. The DMCA and the MCA had perforating arteries. The aneurysm was clipped without complications. The observation of perforating arteries in our patient confirms that the DMCA may have perforating arteries. This is very important to be considered in cerebral aneurysms surgery. Moreover, the DMCA may potentially serve as a collateral blood supply to the MCA territory in cases of MCA occlusion. PMID:22140405

Intracranial aneurysmal pulsatility as a new individual criterion for rupture risk evaluation: biomechanical and numeric approach (IRRAs Project).

PubMed

Sanchez, M; Ecker, O; Ambard, D; Jourdan, F; Nicoud, F; Mendez, S; Lejeune, J-P; Thines, L; Dufour, H; Brunel, H; Machi, P; Lobotesis, K; Bonafe, A; Costalat, V

2014-09-01

The present study follows an experimental work based on the characterization of the biomechanical behavior of the aneurysmal wall and a numerical study where a significant difference in term of volume variation between ruptured and unruptured aneurysm was observed in a specific case. Our study was designed to highlight by means of numeric simulations the correlation between aneurysm sac pulsatility and the risk of rupture through the mechanical properties of the wall. In accordance with previous work suggesting a correlation between the risk of rupture and the material properties of cerebral aneurysms, 12 fluid-structure interaction computations were performed on 12 "patient-specific" cases, corresponding to typical shapes and locations of cerebral aneurysms. The variations of the aneurysmal volume during the cardiac cycle (ΔV) are compared by using wall material characteristics of either degraded or nondegraded tissues. Aneurysms were located on 6 different arteries: middle cerebral artery (4), anterior cerebral artery (3), internal carotid artery (1), vertebral artery (1), ophthalmic artery (1), and basilar artery (1). Aneurysms presented different shapes (uniform or multilobulated) and diastolic volumes (from 18 to 392 mm3). The pulsatility (ΔV/V) was significantly larger for a soft aneurysmal material (average of 26%) than for a stiff material (average of 4%). The difference between ΔV, for each condition, was statistically significant: P=.005. The difference in aneurysmal pulsatility as highlighted in this work might be a relevant patient-specific predictor of aneurysm risk of rupture. © 2014 by American Journal of Neuroradiology.

[Cerebral aneurysms complicating bacterial endocarditis. Seven cases (author's transl)].

PubMed

Pecker, J; Vallée, B; Camuzet, J P; Faivre, J; Javalet, A

The authors report seven cases of cerebral aneurysms complicating bacterial endocarditis. The evolution was good in three cases, two of which without sequelae. The bacteries involved were staphylococcus, streptococcus, and enterobacter. The cardiopathy was mitral in four cases. Two patients presented an isolated focal neurological impairment, while the other five presented a severe coma either isolated (one case) or associated with focal neurological deficits (four cases). An intracerebral hematoma was diagnosed in five cases (four died). Only one patient was not operated. The surgical treatment was as follows: one carotid ligation (good result), two evacuations of intracerebral hematomas (both died), two evacuations of intracerebral hematomas with clipping of the aneurysms (one died, one had a fair result in despite of residual hemiplegia), one clipping of aneurysm (good result). Repeated cerebral angiographies should be systematically performed in cases of bacterial endocarditis in order to disclose and follow up cerebral aneurysms which may occur in this condition. Except in cases of emergency, surgery should be differed, in particular, in cases of proximal or multiple aneurysms. Aneurysms of the peripheral cortical arteries are more accessible to treatment and may be operated in the acute phase.

The dynamic natural history of cerebral aneurysms from cardiac myxomas: A review of the natural history of myxomatous aneurysms.

PubMed

Flores, Paloma Largo; Haglund, Felix; Bhogal, Pervinder; Yeo Leong Litt, Leonard; Södermann, Michael

2018-06-01

We describe two contrasting patients with multiple cerebral aneurysms and a previous history of resected cardiac myxomas with no cardiac recurrence on follow-up echocardiography. Both patients presented with stroke- like symptoms; one with a left visual defect and the other with right hemiplegia. Magnetic resonance imaging of the brain of both patients showed the presence of multiple cerebral aneurysms that was later confirmed on conventional angiography. Both patients' aneurysms were managed conservatively. Serial angiograms were performed during their follow-up, which spanned several years. One patient's aneurysms remained static while the evolution of the other patient's aneurysms displayed a dynamic quality with some increasing in size while others diminished. This is the first description in which some aneurysms progressed while others regressed simultaneously in the same patient. Aneurysms in patients with a history of cardiac myxoma can be active years after primary tumor resection and it is difficult to predict how they will develop. We reviewed the literature of all patients with multiple myxomatous aneurysms who were treated conservatively to better understand the natural history of this rare disease. Long-term follow-up of these patients may be necessary.

Safety and efficacy of flow re-direction endoluminal device (FRED) in the treatment of cerebral aneurysms: a single center experience.

PubMed

Briganti, Francesco; Leone, Giuseppe; Ugga, Lorenzo; Marseglia, Mariano; Solari, Domenico; Caranci, Ferdinando; Mariniello, Giuseppe; Maiuri, Francesco; Cappabianca, Paolo

2016-09-01

Experience with the endovascular treatment of cerebral aneurysms by the Flow Re-Direction Endoluminal Device (FRED) is still limited. The aim of this study is to discuss the results and complications of this new flow diverter device (FDD). Between November 2013 and April 2015, 20 patients (15 female and five male) harboring 24 cerebral aneurysms were treated with FRED FDD in a single center. Complete occlusion was obtained in 20/24 aneurysms (83 %) and partial occlusion in four (17 %). Intraprocedural technical complication occurred in one case (4 %) and post-procedural complications in three (12 %). None reported neurological deficits (mRS = 0). All FRED were patent at follow-up. No early or delayed aneurysm rupture, no subarachnoid (SAH) or intraparenchymal hemorrhage (IPH) no ischemic complications and no deaths occurred. Endovascular treatment with FRED FDD is a safe treatment for unruptured cerebral aneurysms, resulting in a high rate of occlusion. The FRED is substantially equivalent to the other known FDDs, which show similar functions and technical profiles.

Cigarette Smoke and Inflammation: Role in Cerebral Aneurysm Formation and Rupture

PubMed Central

Chalouhi, Nohra; Ali, Muhammad S.; Starke, Robert M.; Jabbour, Pascal M.; Tjoumakaris, Stavropoula I.; Gonzalez, L. Fernando; Rosenwasser, Robert H.; Koch, Walter J.; Dumont, Aaron S.

2012-01-01

Smoking is an established risk factor for subarachnoid hemorrhage yet the underlying mechanisms are largely unknown. Recent data has implicated a role of inflammation in the development of cerebral aneurysms. Inflammation accompanying cigarette smoke exposure may thus be a critical pathway underlying the development, progression, and rupture of cerebral aneurysms. Various constituents of the inflammatory response appear to be involved including adhesion molecules, cytokines, reactive oxygen species, leukocytes, matrix metalloproteinases, and vascular smooth muscle cells. Characterization of the molecular basis of the inflammatory response accompanying cigarette smoke exposure will provide a rational approach for future targeted therapy. In this paper, we review the current body of knowledge implicating cigarette smoke-induced inflammation in cerebral aneurysm formation/rupture and attempt to highlight important avenues for future investigation. PMID:23316103

Physiologically-relevant measurements of flow through coils and stents: towards improved modeling of endovascular treatment of intracranial aneurysms

NASA Astrophysics Data System (ADS)

Barbour, Michael; Levitt, Michael; Geindreau, Christian; Rolland Du Roscoat, Sabine; Johnson, Luke; Chivukula, Keshav; Aliseda, Alberto

2016-11-01

The hemodynamic environment in cerebral aneurysms undergoing flow-diverting stent (FDS) or coil embolization treatment plays a critical role in long-term outcomes. Standard modeling approaches to endovascular coils and FDS simplify the complex geometry into a homogenous porous volume or surface through the addition of a Darcy-Brinkman pressure loss term in the momentum equation. The inertial and viscous loss coefficients are typically derived from published in vitro studies of pressure loss across FDS and coils placed in a straight tube, where the only fluid path is across the treatment - an unrealistic representation of treatment apposition in vivo. The pressure drop across FDS and coils in side branch aneurysms located on curved parent vessels is measured. Using PIV, the velocity at the aneurysm neck plane is reconstructed and used to determine loss coefficients for better models of endovascular coils or FDS that account for physiological placement and vessel curvature. These improved models are incorporated into CFD simulations and validated against in vitro model PIV velocity, as well as compared to microCT-based coil/stent-resolving CFD simulations of patient-specific treated aneurysm flow.

Radio aneurysm coils for noninvasive detection of cerebral embolization failures: a preliminary study.

PubMed

Mohammadi, Abdolreza Rashidi; Chen, Keqin; Ali, Mohamed Sultan Mohamed; Takahata, Kenichi

2011-12-15

The rupture of a cerebral aneurysm is the most common cause of subarachnoid hemorrhage. Endovascular embolization of the aneurysms by implantation of Guglielmi detachable coils (GDC) has become a major treatment approach in the prevention of a rupture. Implantation of the coils induces formation of tissues over the coils, embolizing the aneurysm. However, blood entry into the coiled aneurysm often occurs due to failures in the embolization process. Current diagnostic methods used for aneurysms, such as X-ray angiography and computer tomography, are ineffective for continuous monitoring of the disease and require extremely expensive equipment. Here we present a novel technique for wireless monitoring of cerebral aneurysms using implanted embolization coils as radiofrequency resonant sensors that detect the blood entry. The experiments show that commonly used embolization coils could be utilized as electrical inductors or antennas. As the blood flows into a coil-implanted aneurysm, parasitic capacitance of the coil is modified because of the difference in permittivity between the blood and the tissues grown around the coil, resulting in a change in the coil's resonant frequency. The resonances of platinum GDC-like coils embedded in aneurysm models are detected to show average responses of 224-819 MHz/ml to saline injected into the models. This preliminary demonstration indicates a new possibility in the use of implanted GDC as a wireless sensor for embolization failures, the first step toward realizing long-term, noninvasive, and cost-effective remote monitoring of cerebral aneurysms treated with coil embolization. Copyright © 2011 Elsevier B.V. All rights reserved.

Epidemiology, genetic, natural history and clinical presentation of giant cerebral aneurysms.

PubMed

Lonjon, M; Pennes, F; Sedat, J; Bataille, B

2015-12-01

Giant cerebral aneurysms represent 5% of intracranial aneurysms, and become symptomatic between 40 and 70 years with a female predominance. In the paediatric population, the giant aneurysm rate is higher than in the adult population. Classified as saccular, fusiform and serpentine, the natural history of giant cerebral aneurysms is characterized by thrombosis, growth and rupture. The pathogenesis of these giant aneurysms is influenced by a number of risk factors, including genetic variables. Genome-wide association studies have identified some chromosomes highlighting candidate genes. Although these giant aneurysms can occur at the same locations as their smaller counterparts, a predilection for the cavernous location has been observed. Giant aneurysms present with symptoms caused by a mass effect depending on their location or by rupture; ischemic manifestations rarely reveal the aneurysm. If the initial clinical descriptions have been back up by imagery, the clinical context with a pertinent analysis of the risk factors remain the cornerstone for the management decisions of these lesions. Five year cumulative rupture rates for patients with giant aneurysm were 40% for those located on the anterior part of circle of Willis and 50% for those on the posterior part. The poor outcome of untreated patients justifies the therapeutic risks. Copyright © 2015. Published by Elsevier Masson SAS.

Clinical value of homodynamic numerical simulation applied in the treatment of cerebral aneurysm.

PubMed

Zhang, Hailin; Li, Li; Cheng, Chongjie; Sun, Xiaochuan

2017-12-01

Our objective was to evaluate the clinical value of numerical simulation in diagnosing cerebral aneurysm based on the analysis of numerical simulation of hemodynamic model. The experimental method used was the numerical model of cerebral aneurysm hemodynamic, and the numerical value of blood flow at each point was analyzed. The results showed that, the wall shear stress (WSS) value on the top of CA1 was significantly lower than that of the top (P<0.05), the WSS value of each point on the CA2 tumor was significantly lower than that of tumor neck (P<0.05); the pressure value on the tumor top and tumor neck between CA1 and CA2 had no significant difference (P>0.05); the unsteady index of shear (UIS) value at the points of 20 had distinctly changed, the wave range was 0.6-1.5; the unsteady index of pressure value of every point was significantly lower than UIS value, the wave range was 0.25-0.40. In conclusion, the application of cerebral aneurysm hemodynamic research can help doctors to diagnose cerebral aneurysm more precisely and to grasp the opportunity of treatment during the formulating of the treatment strategies.

Two cases of cerebral aneurysms in HIV+ children.

PubMed

Fulmer, B B; Dillard, S C; Musulman, E M; Palmer, C A; Oakes, J

1998-01-01

Two cases of fusiform cerebral aneurysms in human immunodeficiency virus (HIV) positive children are presented. To our knowledge, only 9 patients with this association have been reported. One of our patients represents the first report of a patient with an aneurysm associated with varicella-zoster vasculitis. One patient presented with a subarachnoid hemorrhage, Hunt-Hess grade IV, and posed difficult surgical management. The other patient suffered a cerebral infarct with a resulting hemiparesis. The first patient had a ventriculostomy placed, initially improved, and subsequently died from rebleeding. The second patient improved with medical management. AIDS arteriopathy, and specifically fusiform aneurysms, are being increasingly reported. The various presentations of this surgically challenging entity in light of other AIDS-related syndromes pose difficult management decisions. On occasion, the intracranial aneurysm may be the initial form of presentation as was present in our first patient.

The Biochemical Basis of Hydroxymethylglutaryl-CoA Reductase Inhibitors as Neuroprotective Agents in Aneurysmal Subarachnoid Hemorrhage

PubMed Central

Wong, George Kwok Chu; Poon, Wai Sang

2010-01-01

Aneurysmal subarachnoid hemorrhage (SAH) has the highest morbidity and mortality rates of all types of stroke. Many aneurysmal SAH patients continue to suffer from significant neurological morbidity and mortality directly related to delayed cerebral ischemia. Pilot clinical studies of the use of Hydroxymethylglutaryl-CoA Reductase Inhibitors (statins) in aneurysmal SAH patients have reported a reduction in delayed cerebral ischemia and better clinical outcomes. We review the biochemical effects of statins on endothelium vascular function, glutamate-mediated neurotoxicity, inflammatory changes, and oxidative injuries, with reference to their possible neuroprotective effects in aneurysmal SAH.

Coadjuvant Treatment of Vasospasm in Ruptured Unsecured Cerebral Aneurysms with Aggressive Angioplasty, Intra-Arterial Nimodipine, and Aneurysm Embolization.

PubMed

Chen, Ching-Chang; Yi-Chou Wang, Alvin; Chen, Chun-Ting; Hsieh, Po-Chuan

2018-05-16

Vasospasm is a major cause of morbidity and mortality in patients after aneurysmal subarachnoid hemorrhage. Early treatment of ruptured aneurysms is advocated; delayed intervention complicates the treatment strategy leading to significant vasospasm and poor prognosis. We report an endovascular protocol for occlusion of the unsecured aneurysm and angioplasty for vasospasm in a single session. Between January 2011 and May 2017, among 660 patients with aneurysmal subarachnoid hemorrhage, 24 patients with significant vasospasm and unsecured ruptured cerebral aneurysm were reviewed. Continuous nimodipine drip through a pressure line of the guiding catheter was set up. Aggressive angioplasty with a compliant balloon catheter either before or after embolization of the aneurysm in the major branches of vasospastic territory was performed. The goal was complete embolization of the aneurysm. Of 24 patients, 17 had ischemic symptoms at presentation, and the average delay from aneurysm rupture to presentation was 7.58 days. Angioplasty and nimodipine drip were performed on all patients. Severity of vasospasm was significantly reduced, and outcome improved in each patient. Two patients required a second angioplasty. In 20 patients, embolization of aneurysms was achieved without any aneurysmal sac or residual neck. Clinical outcome was good recovery (modified Rankin Scale score 0-2) in 23 patients (95.8%) and moderate disability in 1 patient (modified Rankin Scale score 3). Aggressive endovascular treatment of patients with unsecured ruptured cerebral aneurysm and associated vasospasm is safe and effective. Copyright © 2018 Elsevier Inc. All rights reserved.

Aneurysm flow characteristics in realistic carotid artery aneurysm models induced by proximal virtual stenotic plaques: a computational hemodynamics study

NASA Astrophysics Data System (ADS)

Castro, Marcelo A.; Peloc, Nora L.; Chien, Aichi; Goldberg, Ezequiel; Putman, Christopher M.; Cebral, Juan R.

2015-03-01

Cerebral aneurysms may rarely coexist with a proximal artery stenosis. In that small percent of patients, such coexistence poses a challenge for interventional neuroradiologists and neurosurgeons to make the best treatment decision. According to previous studies, the incidence of cerebral aneurysms in patients with internal carotid artery stenosis is no greater than five percent, where the aneurysm is usually incidentally detected, being about two percent for aneurysms and stenoses in the same cerebral circulation. Those cases pose a difficult management decision for the physician. Case reports showed patients who died due to aneurysm rupture months after endarterectomy but before aneurysm clipping, while others did not show any change in the aneurysm after plaque removal, having optimum outcome after aneurysm coiling. The aim of this study is to investigate the intra-aneurysmal hemodynamic changes before and after treatment of stenotic plaque. Virtually created moderate stenoses in vascular models of internal carotid artery aneurysm patients were considered in a number of cases reconstructed from three dimensional rotational angiography images. The strategy to create those plaques was based on parameters analyzed in a previous work where idealized models were considered, including relative distance and stenosis grade. Ipsilateral and contralateral plaques were modeled. Wall shear stress and velocity pattern were computed from finite element pulsatile blood flow simulations. The results may suggest that wall shear stress changes depend on relative angular position between the aneurysm and the plaque.

'Mirror image' distal anterior cerebral artery aneurysms. A case report of two patients with review of literature.

PubMed

Sousa, J; Iyer, V; Roberts, G

2002-09-01

We report two cases of patients with bilateral 'mirror image' or 'kissing' aneurysms at the distal anterior cerebral arteries who presented with subarachnoid haemorrhage and frontal intracerebral haematoma.

Fluid structure interaction model for biological systems in the presence of magnetic field

NASA Astrophysics Data System (ADS)

Aziz, Asim; Shoaib, Muhammad

2016-06-01

In the present paper a one-dimensional mathematical model of a cerebral aneurysm is considered. The model combines the interaction between the arterial wall structure, blood pressure and the cerebral spinal fluid (CSF) that is around the aneurysm. CSF is considered electrically conducting in the presence of a uniform magnetic field. Therefore, it may be possible to control pressure and its flow behavior by using an appropriate magnetic field. Hence, such studies have potential for the treatment of Cerebral aneurysms, diseases of heart and blood vessels. The modeled mathematical equations are solved algebraically and the displacement of the arterial wall is plotted to visualize the wall movement. It is evident from the graphs the inclusion of magnetic field reduce the movement of the arterial wall and in turn prevent the rupture of the cerebral aneurysm. The solution is also investigated using computational tools for various other parameters involve in the model.

Cerebral aneurysms: relations between geometry, hemodynamics and aneurysm location in the cerebral vasculature

NASA Astrophysics Data System (ADS)

Passerini, Tiziano; Veneziani, Alessandro; Sangalli, Laura; Secchi, Piercesare; Vantini, Simone

2010-11-01

In cerebral blood circulation, the interplay of arterial geometrical features and flow dynamics is thought to play a significant role in the development of aneurysms. In the framework of the Aneurisk project, patient-specific morphology reconstructions were conducted with the open-source software VMTK (www.vmtk.org) on a set of computational angiography images provided by Ospedale Niguarda (Milano, Italy). Computational fluid dynamics (CFD) simulations were performed with a software based on the library LifeV (www.lifev.org). The joint statistical analysis of geometries and simulations highlights the possible association of certain spatial patterns of radius, curvature and shear load along the Internal Carotid Artery (ICA) with the presence, position and previous event of rupture of an aneurysm in the entire cerebral vasculature. Moreover, some possible landmarks are identified to be monitored for the assessment of a Potential Rupture Risk Index.

Augmented reality in the surgery of cerebral aneurysms: a technical report.

PubMed

Cabrilo, Ivan; Bijlenga, Philippe; Schaller, Karl

2014-06-01

Augmented reality is the overlay of computer-generated images on real-world structures. It has previously been used for image guidance during surgical procedures, but it has never been used in the surgery of cerebral aneurysms. To report our experience of cerebral aneurysm surgery aided by augmented reality. Twenty-eight patients with 39 unruptured aneurysms were operated on in a prospective manner with augmented reality. Preoperative 3-dimensional image data sets (angio-magnetic resonance imaging, angio-computed tomography, and 3-dimensional digital subtraction angiography) were used to create virtual segmentations of patients' vessels, aneurysms, aneurysm necks, skulls, and heads. These images were injected intraoperatively into the eyepiece of the operating microscope. An example case of an unruptured posterior communicating artery aneurysm clipping is illustrated in a video. The described operating procedure allowed continuous monitoring of the accuracy of patient registration with neuronavigation data and assisted in the performance of tailored surgical approaches and optimal clipping with minimized exposition. Augmented reality may add to the performance of a minimally invasive approach, although further studies need to be performed to evaluate whether certain groups of aneurysms are more likely to benefit from it. Further technological development is required to improve its user friendliness.

Identification of the inflow zone of unruptured cerebral aneurysms: comparison of 4D flow MRI and 3D TOF MRA data.

PubMed

Futami, K; Sano, H; Misaki, K; Nakada, M; Ueda, F; Hamada, J

2014-07-01

The hemodynamics of the inflow zone of cerebral aneurysms may be a key factor in coil compaction and recanalization after endovascular coil embolization. We performed 4D flow MR imaging in conjunction with 3D TOF MRA and compared their ability to identify the inflow zone of unruptured cerebral aneurysms. This series comprised 50 unruptured saccular cerebral aneurysms in 44 patients. Transluminal color-coded 3D MRA images were created by selecting the signal-intensity ranges on 3D TOF MRA images that corresponded with both the luminal margin and the putative inflow. 4D flow MR imaging demonstrated the inflow zone and yielded inflow velocity profiles for all 50 aneurysms. In 18 of 24 lateral-projection aneurysms (75%), the inflow zone was located distally on the aneurysmal neck. The maximum inflow velocity ranged from 285 to 922 mm/s. On 4D flow MR imaging and transluminal color-coded 3D MRA studies, the inflow zone of 32 aneurysms (64%) was at a similar location. In 91% of aneurysms whose neck section plane angle was <30° with respect to the imaging section direction on 3D TOF MRA, depiction of the inflow zone was similar on transluminal color-coded 3D MRA and 4D flow MR images. 4D flow MR imaging can demonstrate the inflow zone and provide inflow velocity profiles. In aneurysms whose angle of the neck-section plane is obtuse vis-a-vis the imaging section on 3D TOF MRA scans, transluminal color-coded 3D MRA may depict the inflow zone reliably. © 2014 by American Journal of Neuroradiology.

Particularly interesting Cys-His-rich protein is highly expressed in human intracranial aneurysms and resists aneurysmal rupture

PubMed Central

Peng, Yu-Tao; Shi, Xiang-En; Li, Zhi-Qiang; He, Xin; Sun, Yu-Ming

2016-01-01

Particularly interesting Cys-His-rich protein (PINCH) has several biological functions in cancer development, invasion and metastasis in malignant cells, and the expression of PINCH is upregulated in several cancer types, including breast cancer, gastric adenocarcinoma and rectal cancer. However, the contribution of PINCH to human cerebral aneurysms remains largely unknown. Therefore, the significance of PINCH expression in cerebral aneurysm growth and rupture was examined in the present study. The protein expression levels of alpha-smooth muscle actin, osteopontin (OPN), matrix metalloproteinase (MMP) 9 and PINCH were evaluated using immunohistochemistry and western blot analyses. The results demonstrate that the protein expression levels of OPN, MMP9 and PINCH in the unruptured intracranial aneurysm (UA) and ruptured intracranial aneurysm (RA) groups were markedly higher than those of the control group, whereas OPN and PINCH expression levels were decreased in the RA group compared to those of the UA group. In addition, there was a strong correlation between PINCH and tumor size (r=0.650 and P=0.0026), as well as between PINCH and OPN (r=0.639 and P=0.0033) in the unruptured cerebral aneurysms. However, the correlation between PINCH and tumor size (r=0.450 and P=0.1393) and between PINCH and OPN (r=0.366 and P=0.2426) revealed no obvious difference in the ruptured cerebral aneurysms. In conclusion, PINCH was highly expressed in the UAs, which may be a critical factor for preventing aneurysmal rupture. Moreover, PINCH may facilitate intracranial aneurysm progression, at least partially, through the activation of extracellular signal-regulated kinase signaling and the suppression of c-Jun N-terminal kinase signaling. PMID:28101173

Particularly interesting Cys-His-rich protein is highly expressed in human intracranial aneurysms and resists aneurysmal rupture.

PubMed

Peng, Yu-Tao; Shi, Xiang-En; Li, Zhi-Qiang; He, Xin; Sun, Yu-Ming

2016-12-01

Particularly interesting Cys-His-rich protein (PINCH) has several biological functions in cancer development, invasion and metastasis in malignant cells, and the expression of PINCH is upregulated in several cancer types, including breast cancer, gastric adenocarcinoma and rectal cancer. However, the contribution of PINCH to human cerebral aneurysms remains largely unknown. Therefore, the significance of PINCH expression in cerebral aneurysm growth and rupture was examined in the present study. The protein expression levels of alpha-smooth muscle actin, osteopontin (OPN), matrix metalloproteinase (MMP) 9 and PINCH were evaluated using immunohistochemistry and western blot analyses. The results demonstrate that the protein expression levels of OPN, MMP9 and PINCH in the unruptured intracranial aneurysm (UA) and ruptured intracranial aneurysm (RA) groups were markedly higher than those of the control group, whereas OPN and PINCH expression levels were decreased in the RA group compared to those of the UA group. In addition, there was a strong correlation between PINCH and tumor size ( r =0.650 and P=0.0026), as well as between PINCH and OPN ( r =0.639 and P=0.0033) in the unruptured cerebral aneurysms. However, the correlation between PINCH and tumor size ( r =0.450 and P=0.1393) and between PINCH and OPN ( r =0.366 and P=0.2426) revealed no obvious difference in the ruptured cerebral aneurysms. In conclusion, PINCH was highly expressed in the UAs, which may be a critical factor for preventing aneurysmal rupture. Moreover, PINCH may facilitate intracranial aneurysm progression, at least partially, through the activation of extracellular signal-regulated kinase signaling and the suppression of c-Jun N-terminal kinase signaling.

Impact of the moon on cerebral aneurysm rupture.

PubMed

Kamp, Marcel A; Dibué, Maxine; Slotty, Philipp; Steiger, Hans-Jakob; Hänggi, Daniel

2013-08-01

Several external and internal risk factors for cerebral aneurysm rupture have been identified to date. Recently, it has been reported that moon phases correlate with the incidence of aneurysmal subarachnoid hemorrhage (SAH), however, another author found no such association. Therefore, the present study investigates the influence of the lunar cycle on the incidence of aneurysmal rupture, the initial clinical presentation, and the amount of subarachnoid blood. Lunar phase and the particular day of the lunar cycle were correlated to the date of aneurysm rupture, aneurysm location, initial clinical presentation, and amount of subarachnoid blood assessed from CT scans of all patients treated for basal SAH in our department from 2003 to 2010. We found no correlation between incidence of aneurysmal SAH, location of the aneurysm, initial clinical presentation, or amount of subarachnoid blood and the lunar cycle. The moon influences neither the incidence of aneurysmal SAH nor the grade of initial neurological deterioration or amount of subarachnoid blood.

A failure to communicate: patients with cerebral aneurysms and vascular neurosurgeons

PubMed Central

King, J; Yonas, H; Horowitz, M; Kassam, A; Roberts, M

2005-01-01

Objective: To assess communication between vascular neurosurgeons and their patients with unruptured cerebral aneurysms about treatment options and expected outcomes. Methods: Vascular neurosurgeons and their patients with cerebral aneurysms were surveyed immediately following outpatient appointments in a neurosurgery clinic. Data collected included how well the patient understood their aneurysm treatment options, the risks of a poor outcome from various treatments, and the consensus "best" treatment. Patient and neurosurgeon responses were measured using Likert scales, multiple choice questions, and visual analogue scales. Agreement between patient and neurosurgeon was assessed with kappa scores. The Wilcoxon sign rank test was used to compare visual analogue scale responses. Results: Data for 44 patient–neurosurgeon pairs were collected. Only 61% of patient–neurosurgeon pairs agreed on the best treatment plan for the patient's aneurysm (κ = 0.51, moderate agreement). Among the neurosurgeons, agreement with their patients ranged from 82% (κ = 0.77, almost perfect agreement) to 52% (κ = 0.37, fair agreement). Patients estimated much higher risks of stroke or death from surgical clipping, endovascular embolisation, or no intervention compared with the estimates offered by their neurosurgeons (surgical clipping: patient 36% v neurosurgeon 13%, p<0.001; endovascular embolisation: patient 35% v neurosurgeon 19%, p = 0.040; and no intervention: patient 63% v neurosurgeon 25%, p<0.001). Conclusions: Following consultation with a vascular neurosurgeon, many patients with cerebral aneurysms have an inaccurate understanding of their aneurysm treatment plan and an exaggerated sense of the risks of aneurysmal disease and treatment. PMID:15774444

A failure to communicate: patients with cerebral aneurysms and vascular neurosurgeons.

PubMed

King, J T; Yonas, H; Horowitz, M B; Kassam, A B; Roberts, M S

2005-04-01

To assess communication between vascular neurosurgeons and their patients with unruptured cerebral aneurysms about treatment options and expected outcomes. Vascular neurosurgeons and their patients with cerebral aneurysms were surveyed immediately following outpatient appointments in a neurosurgery clinic. Data collected included how well the patient understood their aneurysm treatment options, the risks of a poor outcome from various treatments, and the consensus "best" treatment. Patient and neurosurgeon responses were measured using Likert scales, multiple choice questions, and visual analogue scales. Agreement between patient and neurosurgeon was assessed with kappa scores. The Wilcoxon sign rank test was used to compare visual analogue scale responses. Data for 44 patient-neurosurgeon pairs were collected. Only 61% of patient-neurosurgeon pairs agreed on the best treatment plan for the patient's aneurysm (kappa = 0.51, moderate agreement). Among the neurosurgeons, agreement with their patients ranged from 82% (kappa = 0.77, almost perfect agreement) to 52% (kappa = 0.37, fair agreement). Patients estimated much higher risks of stroke or death from surgical clipping, endovascular embolisation, or no intervention compared with the estimates offered by their neurosurgeons (surgical clipping: patient 36% v neurosurgeon 13%, p<0.001; endovascular embolisation: patient 35% v neurosurgeon 19%, p = 0.040; and no patient 63% v neurosurgeon 25%, p<0.001). Following consultation with a vascular neurosurgeon, many patients with cerebral aneurysms have an inaccurate understanding of their aneurysm treatment plan and an exaggerated sense of the risks of aneurysmal disease and treatment.

Indocyanine Green Videoangiography for Surgery of a Ruptured Dissecting Aneurysm in the Precommunicating Anterior Cerebral Artery: A Technical Case Report.

PubMed

Nagai, Yasunori; Goto, Masanori; Toda, Hiroki; Nishida, Namiko; Yoshimoto, Naoya; Iwasaki, Koichi

2017-08-01

Indocyanine green videoangiography (ICG-VA) is an important intraoperative adjunct for saccular aneurysm surgery, but its efficacy in surgery for dissecting aneurysms has rarely been reported. The authors describe the usefulness of preclipping ICG-VA in a rare case of a ruptured dissecting aneurysm located at the precommunicating (A1) segment of the anterior cerebral artery. A 52-year-old woman, with no history of connective tissue diseases or vascular disorders, presented with sudden headache and convulsion. The CT scan showed that the patient had subarachnoid hemorrhage. Angiography showed a dissecting aneurysm in the left A1 segment of the anterior cerebral artery. Thus, the patient underwent trapping of the dissecting aneurysm. ICG-VA was used as an intraoperative adjunct before and after clipping. The preclipping ICG-VA showed the heterogeneously bright dissecting aneurysm and branching arteries even in the presence of hematoma. Preclipping ICG-VA may enhance the advantage of direct surgery for dissecting aneurysm by allowing visualization of the extent of the dissected vascular wall and the related branching arteries. ICG-VA can be an indispensable adjunct to minimize the compromise from the surgical treatment for intracranial dissecting aneurysms. Copyright © 2017 by the Congress of Neurological Surgeons

Estrogen Deficiency Promotes Cerebral Aneurysm Rupture by Upregulation of Th17 Cells and Interleukin-17A Which Downregulates E-Cadherin.

PubMed

Hoh, Brian L; Rojas, Kelley; Lin, Li; Fazal, Hanain Z; Hourani, Siham; Nowicki, Kamil W; Schneider, Matheus B; Hosaka, Koji

2018-04-13

Estrogen deficiency is associated with the development of cerebral aneurysms; however, the mechanism remains unknown. We explored the pathway of cerebral aneurysm development by investigating the potential link between estrogen deficiency and inflammatory factors. First, we established the role of interleukin-17 (IL-17)A. We performed a cytokine screen demonstrating that IL-17A is significantly expressed in mouse and human aneurysms ( P =0.03). Likewise, IL-17A inhibition was shown to prevent aneurysm formation by 42% ( P =0.02) and rupture by 34% ( P <0.05). Second, we found that estrogen deficiency upregulates T helper 17 cells and IL-17A and promotes aneurysm rupture. Estrogen-deficient mice had more ruptures than control mice (47% versus 7%; P =0.04). Estradiol supplementation or IL-17A inhibition decreased the number of ruptures in estrogen-deficient mice (estradiol 6% versus 37%; P =0.04; IL-17A inhibition 18% versus 47%; P =0.018). Third, we found that IL-17A-blockade protects against aneurysm formation and rupture by increased E-cadherin expression. IL-17-inhibited mice had increased E-cadherin expression ( P =0.003). E-cadherin inhibition reversed the protective effect of IL-17A inhibition and increased the rate of aneurysm formation (65% versus 28%; P =0.04) and rupture (12% versus 0%; P =0.22). However, E-cadherin inhibition alone does not significantly increase aneurysm formation in normal mice or in estrogen-deficient mice. In cell migration assays, E-cadherin inhibition promoted macrophage infiltration across endothelial cells ( P <0.05), which may be the mechanism for the estrogen deficiency/IL-17/E-cadherin aneurysm pathway. Our data suggest that estrogen deficiency promotes cerebral aneurysm rupture by upregulating IL-17A, which downregulates E-cadherin, encouraging macrophage infiltration in the aneurysm vessel wall. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Stromal Cell-Derived Factor-1 Is Associated with Angiogenesis and Inflammatory Cell Infiltration in Aneurysm Walls

PubMed Central

Hoh, Brian L.; Hosaka, Koji; Downes, Daniel P.; Nowicki, Kamil W.; Wilmer, Erin N.; Velat, Gregory J.; Scott, Edward W.

2013-01-01

Object A small percentage of cerebral aneurysms rupture, but when they do, the effects are devastating. Current management of unruptured aneurysms consist of surgery, endovascular treatment, or watchful waiting. If the biology of how aneurysms grow and rupture were better known, a novel drug could be developed to prevent unruptured aneurysms from rupturing. Ruptured cerebral aneurysms are characterized by inflammation-mediated wall remodeling. We studied the role of stromal cell-derived factor-1 (SDF-1) in inflammation-mediated wall remodeling in cerebral aneurysms. Methods Human aneurysms; murine carotid aneurysms; and murine intracranial aneurysms were studied by immunohistochemistry. Flow cytometry analysis was performed on blood from mice developing carotid aneurysms or intracranial aneurysms. The effect of SDF-1 on endothelial cells and macrophages was studied by chemotaxis cell migration assay and capillary tube formation assay. Anti-SDF-1 blocking antibody was given to mice and compared to control (vehicle)-administered mice for its effects on the walls of carotid aneurysms and the development of intracranial aneurysms. Results Human aneurysms, murine carotid aneurysms, and murine intracranial aneurysms, all express SDF-1; and mice with developing carotid aneurysms or intracranial aneurysms have increased progenitor cells expressing CXCR4, the receptor for SDF-1 (P<0.01 and P<0.001, respectively). Human aneurysms and murine carotid aneurysms have endothelial cells, macrophages, and capillaries in the walls of the aneurysms; and the presence of capillaries in the walls of human aneurysms is associated with presence of macrophages (P=0.01). SDF-1 promotes endothelial cell and macrophage migration (P<0.01 for each), and promotes capillary tube formation (P<0.001). When mice are given anti-SDF-1 blocking antibody, there is a significant reduction in endothelial cells (P<0.05), capillaries (P<0.05), and cell proliferation (P<0.05) in the aneurysm wall. Mice given anti-SDF-1 blocking antibody develop significantly fewer intracranial aneurysms (33% versus 89% in mice given control IgG)(P<0.05). Conclusions These data suggest SDF-1 associated with angiogenesis and inflammatory cell migration and proliferation in the walls of aneurysms, and may have a role in the development of intracranial aneurysms. PMID:24160472

The clinical spectrum of unruptured intracranial aneurysms.

PubMed

Raps, E C; Rogers, J D; Galetta, S L; Solomon, R A; Lennihan, L; Klebanoff, L M; Fink, M E

1993-03-01

A retrospective study was performed to delineate the clinical characteristics of symptomatic unruptured aneurysms. Patient histories, operative reports, and angiograms in 111 patients with 132 unruptured aneurysms were reviewed. Tertiary care university hospital. One hundred eleven patients with 132 unruptured intracranial aneurysms were studied. There were 85 women and 26 men, with a mean age of 51.2 years (age range, 11 to 77 years). Many patients were referred by community neurologists and neurosurgeons for further evaluation and neurosurgical management. Fifty-four symptomatic patients were identified. Group 1 (n = 19; mean aneurysm diameter, 2.1 cm) had acute symptoms: ischemia (n = 7), headache (n = 7), seizure (n = 3), and cranial neuropathy (n = 2). Group 2 (n = 35; mean aneurysm diameter, 2.2 cm) had chronic symptoms attributed to mass effect: headache (n = 18), visual loss (n = 10), pyramidal tract dysfunction (n = 4), and facial pain (n = 3). Group 3 (n = 57; mean aneurysm diameter, 1.1 cm) had asymptomatic aneurysms. Acute severe headache, comparable to subarachnoid hemorrhage headache, but without nuchal rigidity, was associated with the following mechanisms: aneurysm thrombosis, localized meningeal inflammation, and unexplained. Unruptured aneurysms may be misdiagnosed as optic neuritis or migraine, or serve as a nidus for cerebral thromboembolic events. Internal carotid artery and posterior circulation aneurysms were more likely to cause focal symptoms from mass effect than were anterior cerebral artery and middle cerebral artery aneurysms. Weeks to years may elapse before their diagnosis. The absence of subarachnoid blood does not exclude an aneurysm as a cause for acute or chronic neurologic symptoms.

Microembolism after Endovascular Treatment of Unruptured Cerebral Aneurysms: Reduction of its Incidence by Microcatheter Lumen Aspiration

PubMed Central

Kim, Dae Yoon; Park, Jung Cheol; Kim, Jae Kyun; Sung, Yu Sub; Park, Eun Suk; Kwak, Jae Hyuk; Choi, Choong-Gon

2015-01-01

Purpose Diffusion-weighted MR images (DWI) obtained after endovascular treatment of cerebral aneurysms frequently show multiple high-signal intensity (HSI) dots. The purpose of this study was to see whether we could reduce their incidence after embolization of unruptured cerebral aneurysms by modification of our coiling technique, which involves the deliberate aspiration of the microcatheter lumen right after delivery of each detachable coil into the aneurysm sac. Materials and Methods From January 2011 to June 2011, all 71 patients with unruptured cerebral aneurysms were treated using various endovascular methods. During the earlier period, 37 patients were treated using our conventional embolization technique (conventional period). Then 34 patients were treated with a modified coiling technique (modified period). DWI was obtained on the following day. We compared the occurrence of any DWI HSI lesions and the presence of the symptomatic lesions during the two time periods. Results The incidence of the DWI HSI lesions differed significantly at 89.2% (33/37) during the conventional period and 26.5% (9/34) during the modified period (p < 0.0001). The incidence of symptomatic lesions differed between the two periods (29.7% during the conventional period vs. 2.9% during the modified period, p < 0.003). Conclusion Aspiration of the inner content of the microcatheter right after detachable coil delivery was helpful for the reduction of the incidence of microembolisms after endovascular coil embolization for the treatment of unruptured cerebral aneurysms. PMID:26389009

Quantitative comparison of hemodynamics in simulated and 3D angiography models of cerebral aneurysms by use of computational fluid dynamics.

PubMed

Saho, Tatsunori; Onishi, Hideo

2015-07-01

In this study, we evaluated hemodynamics using simulated models and determined how cerebral aneurysms develop in simulated and patient-specific models based on medical images. Computational fluid dynamics (CFD) was analyzed by use of OpenFOAM software. Flow velocity, stream line, and wall shear stress (WSS) were evaluated in a simulated model aneurysm with known geometry and in a three-dimensional angiographic model. The ratio of WSS at the aneurysm compared with that at the basilar artery was 1:10 in simulated model aneurysms with a diameter of 10 mm and 1:18 in the angiographic model, indicating similar tendencies. Vortex flow occurred in both model aneurysms, and the WSS decreased in larger model aneurysms. The angiographic model provided accurate CFD information, and the tendencies of simulated and angiographic models were similar. These findings indicate that hemodynamic effects are involved in the development of aneurysms.

Three distal anterior cerebral artery aneurysms in the same branch associated with five additional intracranial aneurysms

PubMed Central

Kozyrev, Danil A.; Jahromi, Behnam Rezai; Thiarawat, Peeraphong; Choque-Velasquez, Joham; Ludtka, Christopher; Goehre, Felix; Hernesniemi, Juha

2017-01-01

Background: Multiple distal anterior cerebral artery (DACA) aneurysms appear as rare findings. Simultaneous treatment of such lesions can be particularly challenging. A report of three aneurysms on the same parent artery has not been reported before. We report a case of three DACA aneurysms treated within one microsurgical operation in a patient with eight aneurysms. Case Description: A 62-year-old woman incidentally presented with multiple various size saccular aneurysms, including tree on the left DACA. One of the DACA aneurysm was located on the A3 segment, and the other two were on the A4 and A5 segments. Ligation of all three of these aneurysms was planned in one operation. A standard anterior interhemispheric approach was utilized. Three aneurysms were successfully clipped using four clips. Intraoperative angiography confirmed aneurysm occlusion with parent artery patency preservation. The patient showed no new postoperative neurological deficit. Conclusion: Clipping multiple DACA aneurysms within a single microneurosurgical operation is a feasible treatment option. Meticulous analysis of preoperative imaging features is crucial for selecting the best, patient-specific treatment strategy. PMID:28540128

Keyhole Approach Combined With External Ventricular Drainage for Ruptured, Poor-Grade, Anterior Circulation Cerebral Aneurysms

PubMed Central

Zheng, Shu-Fa; Yao, Pei-Sen; Yu, Liang-Hong; Kang, De-Zhi

2015-01-01

Abstract Poor-grade ruptured anterior circulation cerebral aneurysms are frequently associated with severe vasospasm and high morbidity rates despite recent remarkable advances in endovascular coiling. Here, we explored the feasibility of keyhole approach combined with external ventricular drainage for ruptured, poor-grade, anterior circulation cerebral aneurysms. We retrospectively assessed the records of 103 patients with ruptured, Hunt and Hess grade IV or V, anterior circulation cerebral aneurysms. The patients were divided into 2 groups (conservative group and surgical group). In surgical group, patients were divided into 2 subgroups according to surgical time (within 24 hours and at 24–48 hours). Clinical outcome was assessed at the 6-month follow-up and categorized according to modified Rankin Scale (mRS) score. Twenty percent of patients (9/44) in conservative group obtained good outcome, while 54% (32/54) in surgical group (P < 0.05). Mortality was 73% in conservative group and 40% in surgical group, respectively. In surgical group, age, Hunt and Hess grade (IV or V), and timing of intervention (<24 hours or later) influenced the clinical outcome of the patients (P < 0.05), while sex, Fisher grade, hydrocephalus, the location of aneurysms, and cerebral vasospasm (CVS) not (P > 0.05). Furthermore, 65% of patients (22/34) operated within 24 hours after onset of hemorrhage had a good outcome compared with 20% of patients (5/25) operated at 24 to 48 hours in surgical group (P < 0.05). The results indicate that keyhole approach combined with external ventricular drainage is a safe and reliable treatment for ruptured, poor-grade, anterior circulation cerebral aneurysms in early stage, which will reduce mortality. PMID:26705215

Atorvastatin prevents angiotensin II-induced high permeability of human arterial endothelial cell monolayers via ROCK signaling pathway.

PubMed

Yi, Ren; Xiao-Ping, Gao; Hui, Liang

2015-03-27

Intracranial aneurysm, as a common cause of cerebral hemorrhage, is often discovered when the aneurysm ruptures, causing subarachnoid hemorrhage. Unfortunately, the formation of cerebral aneurysm, which is associated with endothelial damage and macrophage migration, still cannot be prevented now. Tight junctions (TJs) open due to the disappearance of TJ proteins occludin and zona occludens-1 (ZO-1) in damaged endothelia, thus allowing macrophage migration and forming cerebral aneurysm. Therefore, cerebral aneurysm formation can be prevented by increasing TJs of the artery endothelium. Interestingly, statin, which can reduce saccular aneurysm, may prevent aneurysm formation through acting on different steps, but the underlying mechanism remains unclear. In this study, angiotensin II (Ang II) significantly increased the permeability of human arterial endothelial cell (HAEC). Moreover, the distribution of ZO-1 in cell-cell junction area and the total expression in HAECs were significantly decreased by Ang II treatment. However, the abnormal distribution and decreased expression of ZO-1 and hyperpermeability of HAECs were significantly reversed by pretreatment with atorvastatin. Furthermore, Ang II-induced phosphorylations of MYPT1, LIMK and MLC2 were significantly inhibited with atorvastatin or Rho kinase (ROCK) inhibitor (H1152) pretreatment. Knockdown of ROCK-II probably abolished Ang II-induced abnormal ZO-1 distribution and expression deficiency and hyperpermeability of HAECs. In conclusion, atorvastatin prevented Ang II-induced rupture of HAEC monolayers by suppressing the ROCK signaling pathway. Our results may explain, at least in part, some beneficial effects of statins on cardiovascular diseases such as intracranial aneurysm. Copyright © 2015 Elsevier Inc. All rights reserved.

Computational fluid dynamics (CFD) using porous media modeling predicts recurrence after coiling of cerebral aneurysms.

PubMed

Umeda, Yasuyuki; Ishida, Fujimaro; Tsuji, Masanori; Furukawa, Kazuhiro; Shiba, Masato; Yasuda, Ryuta; Toma, Naoki; Sakaida, Hiroshi; Suzuki, Hidenori

2017-01-01

This study aimed to predict recurrence after coil embolization of unruptured cerebral aneurysms with computational fluid dynamics (CFD) using porous media modeling (porous media CFD). A total of 37 unruptured cerebral aneurysms treated with coiling were analyzed using follow-up angiograms, simulated CFD prior to coiling (control CFD), and porous media CFD. Coiled aneurysms were classified into stable or recurrence groups according to follow-up angiogram findings. Morphological parameters, coil packing density, and hemodynamic variables were evaluated for their correlations with aneurysmal recurrence. We also calculated residual flow volumes (RFVs), a novel hemodynamic parameter used to quantify the residual aneurysm volume after simulated coiling, which has a mean fluid domain > 1.0 cm/s. Follow-up angiograms showed 24 aneurysms in the stable group and 13 in the recurrence group. Mann-Whitney U test demonstrated that maximum size, dome volume, neck width, neck area, and coil packing density were significantly different between the two groups (P < 0.05). Among the hemodynamic parameters, aneurysms in the recurrence group had significantly larger inflow and outflow areas in the control CFD and larger RFVs in the porous media CFD. Multivariate logistic regression analyses demonstrated that RFV was the only independently significant factor (odds ratio, 1.06; 95% confidence interval, 1.01-1.11; P = 0.016). The study findings suggest that RFV collected under porous media modeling predicts the recurrence of coiled aneurysms.

Comparison of Dexmedetomidine and Remifentanil on Airway Reflex and Hemodynamic Changes during Recovery after Craniotomy

PubMed Central

Kim, Hyunzu; Min, Kyeong Tae; Lee, Jeong Rim; Ha, Sang Hee; Lee, Woo Kyung; Seo, Jae Hee

2016-01-01

Purpose During emergence from anesthesia for a craniotomy, maintenance of hemodynamic stability and prompt evaluation of neurological status is mandatory. The aim of this prospective, randomized, double-blind study was to compare the effects of dexmedetomidine and remifentanil on airway reflex and hemodynamic change in patients undergoing craniotomy. Materials and Methods Seventy-four patients undergoing clipping of unruptured cerebral aneurysm were recruited. In the dexmedetomidine group, patients were administered dexmedetomidine (0.5 µg/kg) for 5 minutes, while the patients of the remifentanil group were administered remifentanil with an effect site concentration of 1.5 ng/mL until endotracheal extubation. The incidence and severity of cough and hemodynamic variables were measured during the recovery period. Hemodynamic variables, respiration rate, and sedation scale were measured after extubation and in the post-anesthetic care unit (PACU). Results The incidence of grade 2 and 3 cough at the point of extubation was 62.5% in the dexmedetomidine group and 53.1% in the remifentanil group (p=0.39). Mean arterial pressure (p=0.01) at admission to the PACU and heart rate (p=0.04 and 0.01, respectively) at admission and at 10 minutes in the PACU were significantly lower in the dexmedetomidine group. Respiration rate was significantly lower in the remifentanil group at 2 minutes (p<0.01) and 5 minutes (p<0.01) after extubation. Conclusion We concluded that a single bolus of dexmedetomidine (0.5 µg/kg) and remifentanil infusion have equal effectiveness in attenuating coughing and hemodynamic changes in patients undergoing cerebral aneurysm clipping; however, dexmedetomidine leads to better preservation of respiration. PMID:27189295

Microsurgical management of a complicated aneurysmal endovascular embolisation with GDC coil: a case report.

PubMed

Pogády, P; Mustafa, H; Wies, W; Lungenschmid, K; Wurm, G; Tomancok, B; Holl, K; Fischer, J

1998-01-01

We present a case involving a microsurgical approach to solving the problem of a medial cerebral artery (MCA) occlusion occurring after GDC coiling of an internal cerebral artery (ICA) bifurcation aneurysm in a 40 year old woman. We describe the clinical course of the case and discuss technical possibilities and risks of clipping a coiled aneurysm. One key to success is awareness of changes in the aneurysm's properties after coiling. With loss of elasticity the aneurysm had the effect of a tumor fixed on the vessel. The apposition of the aneurysm to the wall of the vessel, as well as the aneurysm's rigidity and increase of intracranial pressure after subarachnoideal hemorrhage (SAH), may lead to occlusion of the vessel. In cases of an mandatory operation due to the occlusion of a main arterial stem after coiling, it is primarily crucial to perforate the aneurysm's fundus, remove the coils, and, finally, to clip the slack neck of the aneurysm. An attempt to precisely prepare and clip the aneurysmal neck without removing the coils could result in the rupture of the aneurysm's neck.

Unexpected Rupture of a Giant Lobulated Thrombotic Middle Cerebral Artery Aneurysm and Emergency Surgical Treatment With Thrombectomy: A Case Report and Review of the Literature

PubMed Central

Koksal, Vaner; Kayaci, Selim

2016-01-01

Introduction The treatment of giant intracranial aneurysms is one of the most challenging cerebrovascular problems of neurosurgery. We report the rupture of a giant, lobulated, and almost completely thrombosed middle cerebral artery (MCA) aneurysm that is the ninth such report in the literature. We also investigated additional solutions used in the treatment of this patient. Case Presentation A 58-year-old man had been admitted with headache 8 years previously (in 2005), and a giant MCA aneurysm was detected. Two separate endovascular interventions were performed, and both failed. The patient began to live with the giant aneurysm. As there was a large thrombosis filling the aneurysm lumen during the previous endovascular procedures, the aneurysm was not expected to rupture. However, a rupture eventually occurred, in 2013. Even if an aneurysm is very large, lobulated, old, and almost completely thrombosed, it can suddenly bleed. During surgery on this patient, we observed severe cerebral vasospasm caused by a giant thrombosed aneurysmal rupture. Despite the complications, surgery is a life-saving treatment for this emergency when other strategies are not possible. Thrombectomy and clipping are approaches that require a great deal of courage for the neurosurgeon, in terms of entering the risky area within the aneurysm. Conclusions We believe that it would be more appropriate to plan for combined treatment with surgical and endovascular approaches before the emergency condition could occur. PMID:27781115

Virtual reality cerebral aneurysm clipping simulation with real-time haptic feedback.

PubMed

Alaraj, Ali; Luciano, Cristian J; Bailey, Daniel P; Elsenousi, Abdussalam; Roitberg, Ben Z; Bernardo, Antonio; Banerjee, P Pat; Charbel, Fady T

2015-03-01

With the decrease in the number of cerebral aneurysms treated surgically and the increase of complexity of those treated surgically, there is a need for simulation-based tools to teach future neurosurgeons the operative techniques of aneurysm clipping. To develop and evaluate the usefulness of a new haptic-based virtual reality simulator in the training of neurosurgical residents. A real-time sensory haptic feedback virtual reality aneurysm clipping simulator was developed using the ImmersiveTouch platform. A prototype middle cerebral artery aneurysm simulation was created from a computed tomographic angiogram. Aneurysm and vessel volume deformation and haptic feedback are provided in a 3-dimensional immersive virtual reality environment. Intraoperative aneurysm rupture was also simulated. Seventeen neurosurgery residents from 3 residency programs tested the simulator and provided feedback on its usefulness and resemblance to real aneurysm clipping surgery. Residents thought that the simulation would be useful in preparing for real-life surgery. About two-thirds of the residents thought that the 3-dimensional immersive anatomic details provided a close resemblance to real operative anatomy and accurate guidance for deciding surgical approaches. They thought the simulation was useful for preoperative surgical rehearsal and neurosurgical training. A third of the residents thought that the technology in its current form provided realistic haptic feedback for aneurysm surgery. Neurosurgical residents thought that the novel immersive VR simulator is helpful in their training, especially because they do not get a chance to perform aneurysm clippings until late in their residency programs.

The impact of a highly visible display of cerebral perfusion pressure on outcome in individuals with cerebral aneurysms.

PubMed

Kirkness, Catherine J; Burr, Robert L; Cain, Kevin C; Newell, David W; Mitchell, Pamela H

2008-01-01

Nurses' ability to rapidly detect decreases in cerebral perfusion pressure (CPP), which may contribute to secondary brain injury, may be limited by poor visibility of CPP displays. To evaluate the impact of a highly visible CPP display on the functional outcome in individuals with cerebral aneurysms. Patients with cerebral aneurysms (n = 100) who underwent continuous CPP monitoring were enrolled and randomized to beds with or without the additional CPP display. Six-month outcome was assessed. Functional outcome was not significantly different between control and intervention groups after controlling for initial neurologic condition (odds ratio .904, 95% confidence interval 0.317 to 2.573). However, greater time below CPP thresholds (55 to 70 mm Hg) was significantly associated with poorer outcome (P = .005 to .010). Although the enhanced CPP display was not associated with significantly better outcome, longer periods of CPP below set levels were associated with poorer outcome.

Cerebral aneurysm (image)

MedlinePlus

... loss of nerve function may indicate that an aneurysm may be causing pressure on adjacent brain tissue. ... changes or other neurological changes can indicate the aneurysm has ruptured and is bleeding into the brain. ...

Anatomical Reproducibility of a Head Model Molded by a Three-dimensional Printer

PubMed Central

KONDO, Kosuke; NEMOTO, Masaaki; MASUDA, Hiroyuki; OKONOGI, Shinichi; NOMOTO, Jun; HARADA, Naoyuki; SUGO, Nobuo; MIYAZAKI, Chikao

We prepared rapid prototyping models of heads with unruptured cerebral aneurysm based on image data of computed tomography angiography (CTA) using a three-dimensional (3D) printer. The objective of this study was to evaluate the anatomical reproducibility and accuracy of these models by comparison with the CTA images on a monitor. The subjects were 22 patients with unruptured cerebral aneurysm who underwent preoperative CTA. Reproducibility of the microsurgical anatomy of skull bone and arteries, the length and thickness of the main arteries, and the size of cerebral aneurysm were compared between the CTA image and rapid prototyping model. The microsurgical anatomy and arteries were favorably reproduced, apart from a few minute regions, in the rapid prototyping models. No significant difference was noted in the measured lengths of the main arteries between the CTA image and rapid prototyping model, but errors were noted in their thickness (p < 0.001). A significant difference was also noted in the longitudinal diameter of the cerebral aneurysm (p < 0.01). Regarding the CTA image as the gold standard, reproducibility of the microsurgical anatomy of skull bone and main arteries was favorable in the rapid prototyping models prepared using a 3D printer. It was concluded that these models are useful tools for neurosurgical simulation. The thickness of the main arteries and size of cerebral aneurysm should be comprehensively judged including other neuroimaging in consideration of errors. PMID:26119896

Diffusion-Weighted Imaging-Detected Ischemic Lesions following Endovascular Treatment of Cerebral Aneurysms: A Systematic Review and Meta-Analysis.

PubMed

Bond, K M; Brinjikji, W; Murad, M H; Kallmes, D F; Cloft, H J; Lanzino, G

2017-02-01

Endovascular treatment of intracranial aneurysms is associated with the risk of thromboembolic ischemic complications. Many of these events are asymptomatic and identified only on diffusion-weighted imaging. We performed a systematic review and meta-analysis to study the incidence of DWI positive for thromboembolic events following endovascular treatment of intracranial aneurysms. A comprehensive literature search identified studies published between 2000 and April 2016 that reported postprocedural DWI findings in patients undergoing endovascular treatment of intracranial aneurysms. The primary outcome was the incidence of DWI positive for thromboembolic events. We examined outcomes by treatment type, sex, and aneurysm characteristics. Meta-analyses were performed by using a random-effects model. Twenty-two studies with 2148 patients and 2268 aneurysms were included. The overall incidence of DWI positive for thromboembolic events following endovascular treatment was 49% (95% CI, 42%-56%). Treatment with flow diversion trended toward a higher rate of DWI positive for lesions than coiling alone (67%; 95% CI, 46%-85%; versus 45%; 95% CI, 33%-56%; P = .07). There was no difference between patients treated with coiling alone and those treated with balloon-assisted (44%; 95% CI, 29%-60%; P = .99) or stent-assisted (43%; 95% CI, 24%-63%; P = .89) coiling. Sex, aneurysm rupture status, location, and size were not associated with the rate of DWI positive for lesions. One in 2 patients may have infarcts on DWI following endovascular treatment of intracranial aneurysms. There is a trend toward a higher incidence of DWI-positive lesions following treatment with flow diversion compared with coiling. Patient demographics and aneurysm characteristics were not associated with DWI-positive thromboembolic events. © 2017 by American Journal of Neuroradiology.

Diagnostic Accuracy of Somatosensory Evoked Potential Monitoring in Evaluating Neurological Complications During Endovascular Aneurysm Treatment.

PubMed

Ares, William J; Grandhi, Ramesh M; Panczykowski, David M; Weiner, Gregory M; Thirumala, Parthasarathy; Habeych, Miguel E; Crammond, Donald J; Horowitz, Michael B; Jankowitz, Brian T; Jadhav, Ashutosh; Jovin, Tudor G; Ducruet, Andrew F; Balzer, Jeffrey

2018-02-01

Somatosensory evoked potential (SSEP) monitoring is used extensively for early detection and prevention of neurological complications in patients undergoing many different neurosurgical procedures. However, the predictive ability of SSEP monitoring during endovascular treatment of cerebral aneurysms is not well detailed. To evaluate the performance of intraoperative SSEP in the prediction postprocedural neurological deficits (PPNDs) after coil embolization of intracranial aneurysms. This population-based cohort study included patients ≥18 years of age undergoing intracranial aneurysm embolization with concurrent SSEP monitoring between January 2006 and August 2012. The ability of SSEP to predict PPNDs was analyzed by multiple regression analyses and assessed by the area under the receiver operating characteristic curve. In a population of 888 patients, SSEP changes occurred in 8.6% (n = 77). Twenty-eight patients (3.1%) suffered PPNDs. A 50% to 99% loss in SSEP waveform was associated with a 20-fold increase in risk of PPND; a total loss of SSEP waveform, regardless of permanence, was associated with a greater than 200-fold risk of PPND. SSEPs displayed very good predictive ability for PPND, with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.76-0.92). This study supports the predictive ability of SSEPs for the detection of PPNDs. The magnitude and persistence of SSEP changes is clearly associated with the development of PPNDs. The utility of SSEP monitoring in detecting ischemia may provide an opportunity for neurointerventionalists to respond to changes intraoperatively to mitigate the potential for PPNDs. Copyright © 2017 by the Congress of Neurological Surgeons

Postprocedural, midterm, and long-term results of cerebral aneurysms treated with flow-diverter devices: 7-year experience at a single center.

PubMed

Briganti, Francesco; Leone, Giuseppe; Cirillo, Luigi; de Divitiis, Oreste; Solari, Domenico; Cappabianca, Paolo

2017-06-01

OBJECTIVE Flow diversion has emerged as a viable treatment option for selected intracranial aneurysms and recently has been gaining traction. The aim of this study was to evaluate the safety and effectiveness of flow-diverter devices (FDDs) over a long-term follow-up period. METHODS The authors retrospectively reviewed all cerebral aneurysm cases that had been admitted to the Division of Neurosurgery of the Università degli Studi di Napoli between November 2008 and November 2015 and treated with an FDD. The records of 60 patients (48 females and 12 males) harboring 69 cerebral aneurysms were analyzed. The study end points were angiographic evidence of complete aneurysm occlusion, recanalization rate, occlusion of the parent artery, and clinical and radiological evidence of brain ischemia. The occlusion rate was evaluated according to the O'Kelly-Marotta (OKM) Scale for flow diversion, based on the degree of filling (A, total filling; B, subtotal filling; C, entry remnant; D, no filling). Postprocedural, midterm, and long-term results were strictly analyzed. RESULTS Complete occlusion (OKM D) was achieved in 63 (91%) of 69 aneurysms, partial occlusion (OKM C) in 4 (6%), occlusion of the parent artery in 2 (3%). Intraprocedural technical complications occurred in 3 patients (5%). Postprocedural complications occurred in 6 patients (10%), without neurological deficits. At the 12-month follow-up, 3 patients (5%) experienced asymptomatic cerebral infarction. No further complications were observed at later follow-up evaluations (> 24 months). There were no reports of any delayed aneurysm rupture, subarachnoid or intraparenchymal hemorrhage, ischemic complications, or procedure- or device-related deaths. CONCLUSIONS Endovascular treatment with an FDD is a safe treatment for unruptured cerebral aneurysms, resulting in a high rate of occlusion. In the present study, the authors observed effective and stable aneurysm occlusion, even at the long-term follow-up. Data in this study also suggest that ischemic complications can occur at a later stage, particularly at 12-18 months. On the other hand, no other ischemic or hemorrhagic complications occurred beyond 24 months.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hentschke, Clemens M., E-mail: clemens.hentschke@gmail.com; Tönnies, Klaus D.; Beuing, Oliver

Purpose: The early detection of cerebral aneurysms plays a major role in preventing subarachnoid hemorrhage. The authors present a system to automatically detect cerebral aneurysms in multimodal 3D angiographic data sets. The authors’ system is parametrizable for contrast-enhanced magnetic resonance angiography (CE-MRA), time-of-flight magnetic resonance angiography (TOF-MRA), and computed tomography angiography (CTA). Methods: Initial volumes of interest are found by applying a multiscale sphere-enhancing filter. Several features are combined in a linear discriminant function (LDF) to distinguish between true aneurysms and false positives. The features include shape information, spatial information, and probability information. The LDF can either be parametrized bymore » domain experts or automatically by training. Vessel segmentation is avoided as it could heavily influence the detection algorithm. Results: The authors tested their method with 151 clinical angiographic data sets containing 112 aneurysms. The authors reach a sensitivity of 95% with CE-MRA data sets at an average false positive rate per data set (FP{sub DS}) of 8.2. For TOF-MRA, we achieve 95% sensitivity at 11.3 FP{sub DS}. For CTA, we reach a sensitivity of 95% at 22.8 FP{sub DS}. For all modalities, the expert parametrization led to similar or better results than the trained parametrization eliminating the need for training. 93% of aneurysms that were smaller than 5 mm were found. The authors also showed that their algorithm is capable of detecting aneurysms that were previously overlooked by radiologists. Conclusions: The authors present an automatic system to detect cerebral aneurysms in multimodal angiographic data sets. The system proved as a suitable computer-aided detection tool to help radiologists find cerebral aneurysms.« less

Endovascular treatment of a true posterior communicating artery aneurysm.

PubMed

Munarriz, Pablo M; Castaño-Leon, Ana M; Cepeda, Santiago; Campollo, Jorge; Alén, Jose F; Lagares, Alfonso

2014-01-01

Posterior communicating artery (PCoA) aneurysms are most commonly located at the junction of the internal carotid artery and the PCoA. "True" PCoA aneurysms, which originate from the PCoA itself, are rarely encountered. Most previously reported cases were treated surgically mainly before the endovascular option became available. A 53-year-old male presented with sudden onset of right hemiparesis and aphasia. Left middle cerebral artery stroke was diagnosed. Further studies revealed a 3 mm left PCoA aneurysm arising from the PCoA itself, attached to neither the internal carotid artery nor the posterior cerebral artery. Endovascular treatment was performed and the aneurysm was coiled completely. Technical advances in endovascular interventional technology have permitted an additional approach to these lesions. The possible endovascular significance of the treatment of true PCoA aneurysms is discussed.

Computational fluid dynamics (CFD) using porous media modeling predicts recurrence after coiling of cerebral aneurysms

PubMed Central

Ishida, Fujimaro; Tsuji, Masanori; Furukawa, Kazuhiro; Shiba, Masato; Yasuda, Ryuta; Toma, Naoki; Sakaida, Hiroshi; Suzuki, Hidenori

2017-01-01

Objective This study aimed to predict recurrence after coil embolization of unruptured cerebral aneurysms with computational fluid dynamics (CFD) using porous media modeling (porous media CFD). Method A total of 37 unruptured cerebral aneurysms treated with coiling were analyzed using follow-up angiograms, simulated CFD prior to coiling (control CFD), and porous media CFD. Coiled aneurysms were classified into stable or recurrence groups according to follow-up angiogram findings. Morphological parameters, coil packing density, and hemodynamic variables were evaluated for their correlations with aneurysmal recurrence. We also calculated residual flow volumes (RFVs), a novel hemodynamic parameter used to quantify the residual aneurysm volume after simulated coiling, which has a mean fluid domain > 1.0 cm/s. Result Follow-up angiograms showed 24 aneurysms in the stable group and 13 in the recurrence group. Mann-Whitney U test demonstrated that maximum size, dome volume, neck width, neck area, and coil packing density were significantly different between the two groups (P < 0.05). Among the hemodynamic parameters, aneurysms in the recurrence group had significantly larger inflow and outflow areas in the control CFD and larger RFVs in the porous media CFD. Multivariate logistic regression analyses demonstrated that RFV was the only independently significant factor (odds ratio, 1.06; 95% confidence interval, 1.01–1.11; P = 0.016). Conclusion The study findings suggest that RFV collected under porous media modeling predicts the recurrence of coiled aneurysms. PMID:29284057

Frequency of Atrial Septal Aneurysms in Patients with Cerebral Ischemic Events

NASA Technical Reports Server (NTRS)

Agmon, Yoram; Khandheria, Bijoy K.; Meissner, Irene; Gentile, Federico; Whisnant, Jack P.; Sicks, JoRean D.; O'Fallon, W. Michael; Covalt, Jody L.; Wiebers, David O.; Seward, James B.

1999-01-01

Background-Atrial septal aneurysm (ASA) is a putative risk factor for cardioembolism. However, the frequency of ASA in the general population has not been adequately determined. Therefore, the frequency in patients with cerebral ischemic events, compared with the frequency in the general population, is poorly defined. We sought to determine the frequency of ASA in the general population and to compare the frequency of ASA in patients with cerebral ischemic events with the frequency in the general population. Methods and Results-The frequency of ASA in the population was determined in 363 subjects, a sample of the participants in the Stroke Prevention: Assessment of Risk in a Community study (control subjects), and was compared with the frequency in 355 age- and sex-matched patients undergoing transesophageal echocardiography in search of a cardiac source of embolism after a focal cerebral ischemic event. The proportion with ASA was 7.9% in patients versus 2.2% in control subjects (P=0.002; odds ratio of ASA, 3.65; 95% CI, 1.64 to 8.13, in patients versus control subjects). Patent foramen ovale (PFO) was detected with contrast injections in 56% of subjects with ASA. The presence of ASA predicted the presence of PFO (odds ratio of PFO, 4.57; 95% CI, 2.18 to 9.57, in subjects with versus those without ASA). In 86% of subjects with ASA and cerebral ischemia, transesophageal echocardiography did not detect an alternative source of cardioembolism other than an associated PFO. Conclusions-The prevalence of ASA based on this population-based study is 2.2%. The frequency of ASA is relatively higher in patients evaluated with transesophageal echocardiography after a cerebral ischemic event. ASA is frequently associated with PFO, suggesting paradoxical embolism as a mechanism of cardioembolism. In patients with cerebral ischemia and ASA, ASA (with or without PFO) commonly is the only potential cardioembolic source detected with transesophageal echocardiography.

Relationships and redundancies of selected hemodynamic and structural parameters for characterizing virtual treatment of cerebral aneurysms with flow diverter devices.

PubMed

Karmonik, C; Anderson, J R; Beilner, J; Ge, J J; Partovi, S; Klucznik, R P; Diaz, O; Zhang, Y J; Britz, G W; Grossman, R G; Lv, N; Huang, Q

2016-07-26

To quantify the relationship and to demonstrate redundancies between hemodynamic and structural parameters before and after virtual treatment with a flow diverter device (FDD) in cerebral aneurysms. Steady computational fluid dynamics (CFD) simulations were performed for 10 cerebral aneurysms where FDD treatment with the SILK device was simulated by virtually reducing the porosity at the aneurysm ostium. Velocity and pressure values proximal and distal to and at the aneurysm ostium as well as inside the aneurysm were quantified. In addition, dome-to-neck ratios and size ratios were determined. Multiple correlation analysis (MCA) and hierarchical cluster analysis (HCA) were conducted to demonstrate dependencies between both structural and hemodynamic parameters. Velocities in the aneurysm were reduced by 0.14m/s on average and correlated significantly (p<0.05) with velocity values in the parent artery (average correlation coefficient: 0.70). Pressure changes in the aneurysm correlated significantly with pressure values in the parent artery and aneurysm (average correlation coefficient: 0.87). MCA found statistically significant correlations between velocity values and between pressure values, respectively. HCA sorted velocity parameters, pressure parameters and structural parameters into different hierarchical clusters. HCA of aneurysms based on the parameter values yielded similar results by either including all (n=22) or only non-redundant parameters (n=2, 3 and 4). Hemodynamic and structural parameters before and after virtual FDD treatment show strong inter-correlations. Redundancy of parameters was demonstrated with hierarchical cluster analysis. Copyright © 2015 Elsevier Ltd. All rights reserved.

Virtual Reality Cerebral Aneurysm Clipping Simulation With Real-time Haptic Feedback

PubMed Central

Alaraj, Ali; Luciano, Cristian J.; Bailey, Daniel P.; Elsenousi, Abdussalam; Roitberg, Ben Z.; Bernardo, Antonio; Banerjee, P. Pat; Charbel, Fady T.

2014-01-01

Background With the decrease in the number of cerebral aneurysms treated surgically and the increase of complexity of those treated surgically, there is a need for simulation-based tools to teach future neurosurgeons the operative techniques of aneurysm clipping. Objective To develop and evaluate the usefulness of a new haptic-based virtual reality (VR) simulator in the training of neurosurgical residents. Methods A real-time sensory haptic feedback virtual reality aneurysm clipping simulator was developed using the Immersive Touch platform. A prototype middle cerebral artery aneurysm simulation was created from a computed tomography angiogram. Aneurysm and vessel volume deformation and haptic feedback are provided in a 3-D immersive VR environment. Intraoperative aneurysm rupture was also simulated. Seventeen neurosurgery residents from three residency programs tested the simulator and provided feedback on its usefulness and resemblance to real aneurysm clipping surgery. Results Residents felt that the simulation would be useful in preparing for real-life surgery. About two thirds of the residents felt that the 3-D immersive anatomical details provided a very close resemblance to real operative anatomy and accurate guidance for deciding surgical approaches. They believed the simulation is useful for preoperative surgical rehearsal and neurosurgical training. One third of the residents felt that the technology in its current form provided very realistic haptic feedback for aneurysm surgery. Conclusion Neurosurgical residents felt that the novel immersive VR simulator is helpful in their training especially since they do not get a chance to perform aneurysm clippings until very late in their residency programs. PMID:25599200

Virtual Cerebral Aneurysm Clipping with Real-Time Haptic Force Feedback in Neurosurgical Education.

PubMed

Gmeiner, Matthias; Dirnberger, Johannes; Fenz, Wolfgang; Gollwitzer, Maria; Wurm, Gabriele; Trenkler, Johannes; Gruber, Andreas

2018-04-01

Realistic, safe, and efficient modalities for simulation-based training are highly warranted to enhance the quality of surgical education, and they should be incorporated in resident training. The aim of this study was to develop a patient-specific virtual cerebral aneurysm-clipping simulator with haptic force feedback and real-time deformation of the aneurysm and vessels. A prototype simulator was developed from 2012 to 2016. Evaluation of virtual clipping by blood flow simulation was integrated in this software, and the prototype was evaluated by 18 neurosurgeons. In 4 patients with different medial cerebral artery aneurysms, virtual clipping was performed after real-life surgery, and surgical results were compared regarding clip application, surgical trajectory, and blood flow. After head positioning and craniotomy, bimanual virtual aneurysm clipping with an original forceps was performed. Blood flow simulation demonstrated residual aneurysm filling or branch stenosis. The simulator improved anatomic understanding for 89% of neurosurgeons. Simulation of head positioning and craniotomy was considered realistic by 89% and 94% of users, respectively. Most participants agreed that this simulator should be integrated into neurosurgical education (94%). Our illustrative cases demonstrated that virtual aneurysm surgery was possible using the same trajectory as in real-life cases. Both virtual clipping and blood flow simulation were realistic in broad-based but not calcified aneurysms. Virtual clipping of a calcified aneurysm could be performed using the same surgical trajectory, but not the same clip type. We have successfully developed a virtual aneurysm-clipping simulator. Next, we will prospectively evaluate this device for surgical procedure planning and education. Copyright © 2018 Elsevier Inc. All rights reserved.

Risk factors and consequences of unexpected trapping for ruptured anterior communicating artery aneurysms

PubMed Central

Fukuda, Hitoshi; Iwasaki, Koichi; Murao, Kenichi; Yamagata, Sen; Lo, Benjamin W.Y.; Macdonald, R. Loch

2014-01-01

Background: While clipping cerebral aneurysms at the neck is optimal, in some cases this is not possible and other strategies are necessary. The purpose of this study was to describe the incidence, risk factors, and outcomes for inability to clip reconstruct ruptured anterior communicating artery (ACoA) aneurysms. Methods: Of the 70 cases of ruptured ACoA aneurysms between January 2006 and December 2013, our institutional experience revealed four cases of small ACoA aneurysms that had been considered clippable prior to operation but required trapping. When a unilateral A2 segment of anterior cerebral artery (ACA) was compromised by trapping, revascularization was performed by bypass surgery. Clinical presentation, angiographic characteristics, operative approach, intraoperative findings, and treatment outcomes were assessed. Results: Very small aneurysm under 3 mm was a risk factor for unexpected trapping. The reason for unexpected trapping was laceration of the aneurysmal neck in two cases, and lack of clippaple component due to disintegration of entire aneurysmal wall at the time of rupture in the others. Aneurysms with bilateral A1 were treated with sole trapping through pterional approach in two cases. The other two cases had hypoplastic unilateral A1 segment of ACA and were treated with combination of aneurysm trapping and revascularization of A2 segment of ACA through interhemispheric approach. No patients had new cerebral infarctions of cortical ACA territory from surgery. Cognitive dysfunction was observed in three cases, but all patients became independent at 12-month follow up. Conclusions: Unexpected trapping was performed when ruptured ACoA aneurysms were unclippable. Trapping with or without bypass can result in reasonable outcomes, with acceptable risk of cognitive dysfunction. PMID:25101201

Flow Diversion for Treatment of Growing A2 Aneurysm in a Child: Case Report and Review of Flow Diversion for Intracranial Aneurysms in Pediatric Patients.

PubMed

Vachhani, Jay Ashok; Nickele, Christopher Michael; Elijovich, Lucas; Klimo, Paul; Arthur, Adam Stephen

2016-12-01

Intracranial flow diversion has gained increasing popularity since the approval of the Pipeline Embolization Device (PED). Although it is only approved for use in adult patients, the PED has been used to treat aneurysms in pediatric patients. We present the first reported case of the use of a PED in a pediatric patient to treat an unusual fusiform distal anterior cerebral artery aneurysm. A 12-year-old girl presented with new onset seizures and was found to have a distal left anterior cerebral artery aneurysm. Initially, this was managed conservatively, but follow-up imaging performed 4 months after presentation demonstrated enlargement of the aneurysm. The patient underwent endovascular embolization of her aneurysm with PED. This was successfully performed and the patient recovered from the procedure with no neurologic deficits. Follow-up digital subtraction angiography and magnetic resonance angiography at 6 and 12 months, respectively, showed complete occlusion of the aneurysm. We also reviewed the literature on flow diversion for treatment of pediatric intracranial aneurysms. Copyright © 2016 Elsevier Inc. All rights reserved.

Influence of different computational approaches for stent deployment on cerebral aneurysm haemodynamics

PubMed Central

Bernardini, Annarita; Larrabide, Ignacio; Morales, Hernán G.; Pennati, Giancarlo; Petrini, Lorenza; Cito, Salvatore; Frangi, Alejandro F.

2011-01-01

Cerebral aneurysms are abnormal focal dilatations of artery walls. The interest in virtual tools to help clinicians to value the effectiveness of different procedures for cerebral aneurysm treatment is constantly growing. This study is focused on the analysis of the influence of different stent deployment approaches on intra-aneurysmal haemodynamics using computational fluid dynamics (CFD). A self-expanding stent was deployed in an idealized aneurysmatic cerebral vessel in two initial positions. Different cases characterized by a progression of simplifications on stent modelling (geometry and material) and vessel material properties were set up, using finite element and fast virtual stenting methods. Then, CFD analysis was performed for untreated and stented vessels. Haemodynamic parameters were analysed qualitatively and quantitatively, comparing the cases and the two initial positions. All the cases predicted a reduction of average wall shear stress and average velocity of almost 50 per cent after stent deployment for both initial positions. Results highlighted that, although some differences in calculated parameters existed across the cases based on the modelling simplifications, all the approaches described the most important effects on intra-aneurysmal haemodynamics. Hence, simpler and faster modelling approaches could be included in clinical workflow and, despite the adopted simplifications, support clinicians in the treatment planning. PMID:22670204

Electrophysiological monitoring during basilar aneurysm operation.

PubMed

Little, J R; Lesser, R P; Luders, H

1987-03-01

Intraoperative brain stem auditory evoked potential (BAEP) and somatosensory evoked potential (SEP) monitoring was evaluated in 16 patients each undergoing intracranial operation for basilar artery aneurysm. The 16 patients had 18 posterior circulation aneurysms, including 2 patients with 2 aneurysms. Fourteen aneurysms arose from the rostral basilar artery, 2 arose from the midbasilar artery, 1 arose from the vertebrobasilar junction, and 1 arose from the proximal segment of the posterior cerebral artery. Five aneurysms were classified as giant (i.e., greater than 25 mm), and 5 aneurysms were large (i.e., 15 to 25 mm). Ten patients had BAEP and SEP monitoring, 4 had BAEP monitoring only, and 2 had SEP monitoring only. Two patients showed significant abnormalities during operation, including 1 patient with transient changes in the BAEP when the lower pons and the 8th cranial nerve were retracted. Another patient had progressive increases in latency and decreases in amplitude and subsequent loss of the SEP cortical components during a period of intermittent temporary rostral basilar artery occlusion. Wave P13 was also lost during that period. The cortical components as well as Wave P13 returned after circulation was restored. The BAEPs were unchanged in the same patient during the period of temporary basilar artery occlusion. Fourteen patients had no significant abnormalities. There were no consistent changes during the various stages of operation. BAEP and SEP monitoring failed to identify ischemic events in 4 patients with neurological findings of brain stem ischemia immediately after operation (i.e., 25% false-negative studies).(ABSTRACT TRUNCATED AT 250 WORDS)

Subarachnoid Aneurysmal Hemorrhage Associated with Coarctation of the Aorta: Case Report and Review of the Literature.

PubMed

Nakae, Ryuta; Fujiki, Yu; Yokobori, Shoji; Naoe, Yasutaka; Yokota, Hiroyuki

2017-01-01

Intracranial aneurysms (IAs) that undergo rupture causing subarachnoid hemorrhage (SAH), are common in young patients with coarctation of the aorta (CoA), but rarer in middle-aged and elderly patients. The pathogenesis of IAs associated with CoA remains unclear. We report the case of a 50-year-old woman who presented with SAH. On evaluation, six IAs were distributed among the anterior communicating artery (ACoA) (ruptured), distal segments of both anterior cerebral arteries (ACA), the left internal carotid artery (ICA), the bifurcation of the left middle cerebral artery (MCA)/MCA early branch, and the inferior trunk of the left MCA. CoA was also diagnosed. The ruptured ACoA IA, and two other unruptured IAs, were successfully clipped during emergency surgery. Postoperative intensive care was instituted to avoid cerebral vasospasm and renal or spinal cord ischemia. During the same hospitalization, the remaining three IAs were clipped at a second surgery. She was discharged with slight cognitive impairment eighty days after admission. Subsequently, she underwent elective treatment for the CoA. According to the literature, IAs associated with CoA have a higher tendency to involve the ACoA than IAs without CoA. Moreover, adult CoA patients tend to have multiple IAs, considered to be due to hypertension associated with CoA, as well as genetic predisposition. In CoA patients, ruptured IAs should be treated as early as possible before correction of the CoA. Close postoperative observation with management of cerebral vasospasm, renal or spinal cord ischemia, and respiratory compromise in the perioperative period is vital.

An outcomes-based grading scale for the evaluation of cerebral aneurysms treated with flow diversion.

PubMed

Park, Min S; Mazur, Marcus D; Moon, Karam; Nanaszko, Michael J; Kestle, John R W; Shah, Lubdha M; Winegar, Blair; Albuquerque, Felipe C; Taussky, Philipp; McDougall, Cameron G

2017-11-01

Despite the popularity of flow-diverting stents for the treatment of cerebral aneurysms, there is no widely accepted scale for the characterization of results. We present an outcomes-based grading scale that considers factors related to failure of flow diversion. The grading scale was developed using the results from consecutive patients at two institutions who were treated with flow diversion for a cerebral aneurysm. The initial treatment results were graded on patient, aneurysm, and treatment characteristics. A 6-point grading scale was developed based on these data. One hundred and seventy-one patients were included in the patient cohort. When compared by multivariate analysis with patients without residuals, patients with aneurysm residuals were found to be older (age ≥60 years, p=0.01, OR 1.17, 95% CI 1.03 to 1.33), to have larger aneurysms (size ≥15 mm, p<0.01, OR 1.38, 95% CI 1.17 to 1.62), to have aneurysms with associated side branches (p=0.02, OR 1.17, 95% CI 1.03 to 1.33), and to have a post-treatment Raymond score of 2 or 3 (p=0.01, OR 1.28, 95% CI 1.06 to 1.56). Using the Raymond score (1-3) as the foundation for the grading scale, additional points (0 or 1) were given for the other three identified factors, creating a 6-point scale. We found that patients with residual aneurysms had statistically higher final tabulated scores (p<0.01). We propose a novel straightforward outcomes-based scale to characterize results after flow diversion treatment of cerebral aneurysms. This scale may provide the basis for the common reporting of results in future studies. 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/.

[Rapid 3-Dimensional Models of Cerebral Aneurysm for Emergency Surgical Clipping].

PubMed

Konno, Takehiko; Mashiko, Toshihiro; Oguma, Hirofumi; Kaneko, Naoki; Otani, Keisuke; Watanabe, Eiju

2016-08-01

We developed a method for manufacturing solid models of cerebral aneurysms, with a shorter printing time than that involved in conventional methods, using a compact 3D printer with acrylonitrile-butadiene-styrene(ABS)resin. We further investigated the application and utility of this printing system in emergency clipping surgery. A total of 16 patients diagnosed with acute subarachnoid hemorrhage resulting from cerebral aneurysm rupture were enrolled in the present study. Emergency clipping was performed on the day of hospitalization. Digital Imaging and Communication in Medicine(DICOM)data obtained from computed tomography angiography(CTA)scans were edited and converted to stereolithography(STL)file formats, followed by the production of 3D models of the cerebral aneurysm by using the 3D printer. The mean time from hospitalization to the commencement of surgery was 242 min, whereas the mean time required for manufacturing the 3D model was 67 min. The average cost of each 3D model was 194 Japanese Yen. The time required for manufacturing the 3D models shortened to approximately 1 hour with increasing experience of producing 3D models. Favorable impressions for the use of the 3D models in clipping were reported by almost all neurosurgeons included in this study. Although 3D printing is often considered to involve huge costs and long manufacturing time, the method used in the present study requires shorter time and lower costs than conventional methods for manufacturing 3D cerebral aneurysm models, thus making it suitable for use in emergency clipping.

Comparison of clipping and coiling in elderly patients with unruptured cerebral aneurysms

PubMed Central

Bekelis, Kimon; Gottlieb, Daniel J.; Su, Yin; O’Malley, A. James; Labropoulos, Nicos; Goodney, Philip; Lawton, Michael T.; MacKenzie, Todd A.

2016-01-01

OBJECTIVE The comparative effectiveness of the 2 treatment options—surgical clipping and endovascular coiling—for unruptured cerebral aneurysms remains an issue of debate and has not been studied in clinical trials. The authors investigated the association between treatment method for unruptured cerebral aneurysms and outcomes in elderly patients. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who had treatment for unruptured cerebral aneurysms between 2007 and 2012. To control for measured confounding, the authors used propensity score conditioning and inverse probability weighting with mixed effects to account for clustering at the level of the hospital referral region (HRR). An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding and to create pseudo-randomization on the treatment method. RESULTS During the study period, 8705 patients underwent treatment for unruptured cerebral aneurysms and met the study inclusion criteria. Of these patients, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular coiling. Instrumental variable analysis demonstrated no difference between coiling and clipping in 1-year postoperative mortality (OR 1.25, 95% CI 0.68–2.31) or 90-day readmission rate (OR 1.04, 95% CI 0.66–1.62). However, clipping was associated with a greater likelihood of discharge to rehabilitation (OR 6.39, 95% CI 3.85–10.59) and 3.6 days longer length of stay (LOS; 95% CI 2.90–4.71). The same associations were present in propensity score–adjusted and inverse probability– weighted models. CONCLUSIONS In a cohort of Medicare patients, there was no difference in mortality and the readmission rate between clipping and coiling of unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to a rehabilitation facility and a longer LOS. PMID:27203150

Patient-reported outcome measures for patients with cerebral aneurysms acquired via social media: data from a large nationwide sample.

PubMed

Chen, Michael; Mangubat, Erwin; Ouyang, Bichun

2016-01-01

With greater survival rates, patient-reported outcome measures (PROMs) among survivors of ruptured cerebral aneurysm should be an increasing concern among neurointerventionalists. Prior studies were limited in scale and generalizability. Our study aims were to (1) evaluate the validity of cerebral aneurysm PROMs obtained from social media; (2) determine the persistence of PROMs over time; and (3) determine what PROMs still exist in those with no physical impairments. By engaging national brain aneurysm support groups and using an online questionnaire modeled after the generic EQ-5D instrument, we asked respondents to classify their health in five dimensions including mobility, self-care, usual activities, pain/discomfort, and anxiety/depression using a 3-point Likert scale. In 2 months we received 604 responses from 46 states in the USA. Our cohort of ruptured aneurysm respondents reported PROMs similar to previously published series. Over time, headache and anxiety improved while depression, level of exercise, and return to work remained unchanged. We found that memory worsened after 2 years. Among those without any physical impairment, rates of 20.6%, 14.9%, 12.6%, and 23% were seen for significant headaches, significant memory loss, significant depression, and sense of life being negatively affected, respectively. Despite this novel study design, we obtained results comparable to prior studies. These results suggest that many patients with ruptured cerebral aneurysms, regardless of whether they are >2 years after the event and/or free of physical impairment, struggle with a poor quality of life. The latency, scale, and low cost of this study design may accelerate future cerebral aneurysm PROM research. 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/

Endovascular treatment of a true posterior communicating artery aneurysm

PubMed Central

Munarriz, Pablo M.; Castaño-Leon, Ana M.; Cepeda, Santiago; Campollo, Jorge; Alén, Jose F.; Lagares, Alfonso

2014-01-01

Background: Posterior communicating artery (PCoA) aneurysms are most commonly located at the junction of the internal carotid artery and the PCoA. “True” PCoA aneurysms, which originate from the PCoA itself, are rarely encountered. Most previously reported cases were treated surgically mainly before the endovascular option became available. Case Description: A 53-year-old male presented with sudden onset of right hemiparesis and aphasia. Left middle cerebral artery stroke was diagnosed. Further studies revealed a 3 mm left PCoA aneurysm arising from the PCoA itself, attached to neither the internal carotid artery nor the posterior cerebral artery. Endovascular treatment was performed and the aneurysm was coiled completely. Conclusion: Technical advances in endovascular interventional technology have permitted an additional approach to these lesions. The possible endovascular significance of the treatment of true PCoA aneurysms is discussed. PMID:25422786

Cerebral Aneurysm from Cardiobacterium hominis Endocarditis.

PubMed

Glucksman, Aaron; Naut, Edgar

2016-05-01

A 43-year-old male with a history of bioprosthetic aortic valve replacement and tricuspid valve annuloplasty presented with vertigo and was found to have an acute infarct in the left superior cerebellum, as well as a left-middle cerebral artery mycotic aneurysm. Blood cultures grew Cardiobacterium hominis and bioprosthetic aortic valve vegetation was found on transthoracic echocardiogram.

Deep neural network-based computer-assisted detection of cerebral aneurysms in MR angiography.

PubMed

Nakao, Takahiro; Hanaoka, Shouhei; Nomura, Yukihiro; Sato, Issei; Nemoto, Mitsutaka; Miki, Soichiro; Maeda, Eriko; Yoshikawa, Takeharu; Hayashi, Naoto; Abe, Osamu

2018-04-01

The usefulness of computer-assisted detection (CAD) for detecting cerebral aneurysms has been reported; therefore, the improved performance of CAD will help to detect cerebral aneurysms. To develop a CAD system for intracranial aneurysms on unenhanced magnetic resonance angiography (MRA) images based on a deep convolutional neural network (CNN) and a maximum intensity projection (MIP) algorithm, and to demonstrate the usefulness of the system by training and evaluating it using a large dataset. Retrospective study. There were 450 cases with intracranial aneurysms. The diagnoses of brain aneurysms were made on the basis of MRA, which was performed as part of a brain screening program. Noncontrast-enhanced 3D time-of-flight (TOF) MRA on 3T MR scanners. In our CAD, we used a CNN classifier that predicts whether each voxel is inside or outside aneurysms by inputting MIP images generated from a volume of interest (VOI) around the voxel. The CNN was trained in advance using manually inputted labels. We evaluated our method using 450 cases with intracranial aneurysms, 300 of which were used for training, 50 for parameter tuning, and 100 for the final evaluation. Free-response receiver operating characteristic (FROC) analysis. Our CAD system detected 94.2% (98/104) of aneurysms with 2.9 false positives per case (FPs/case). At a sensitivity of 70%, the number of FPs/case was 0.26. We showed that the combination of a CNN and an MIP algorithm is useful for the detection of intracranial aneurysms. 4 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:948-953. © 2017 International Society for Magnetic Resonance in Medicine.

Intrinsic, Transitional, and Extrinsic Morphological Factors Associated With Rupture of Intracranial Aneurysms.

PubMed

Ho, Allen L; Lin, Ning; Frerichs, Kai U; Du, Rose

2015-09-01

As diagnosis and treatment of unruptured intracranial aneurysms continues to increase, management principles remain largely based on size. This is despite mounting evidence that aneurysm location and other morphologic variables could play a role in predicting overall risk of rupture. Morphological parameters can be divided into 3 main groups, those that are intrinsic to the aneurysm, those that are extrinsic to the aneurysm, and those that involve both the aneurysm and surrounding vasculature (transitional). We present an evaluation of intrinsic, transitional, and extrinsic factors and their association with ruptured aneurysms. Using preoperative computed tomographic angiography, we generated 3-dimensional models of aneurysms and their surrounding vasculature with Slicer software. Using univariate and multivariate analyses, we examined the association of intrinsic, transitional, and extrinsic aspects of aneurysm morphology with rupture. Between 2005 and 2013, 227 cerebral aneurysms in 4 locations were evaluated/treated at a single institution, and computed tomographic angiographies of 218 patients (97 unruptured and 130 ruptured) were analyzed. Ruptured aneurysms analyzed were associated with clinical factors of absence of multiple aneurysms and history of no prior rupture, and morphologic factors of greater aspect ratio. On multivariate analysis, aneurysm rupture remained associated with history of no prior rupture, greater flow angle, greater daughter-daughter vessel angle, and smaller parent-daughter vessel angle. By studying the morphology of aneurysms and their surrounding vasculature, we identified several parameters associated with ruptured aneurysms that include intrinsic, transitional, and extrinsic factors of cerebral aneurysms and their surrounding vasculature.

Physical Factors Effecting Cerebral Aneurysm Pathophysiology

PubMed Central

Sadasivan, Chander; Fiorella, David J.; Woo, Henry H.; Lieber, Baruch B.

2013-01-01

Many factors that are either blood-, wall-, or hemodynamics-borne have been associated with the initiation, growth, and rupture of intracranial aneurysms. The distribution of cerebral aneurysms around the bifurcations of the circle of Willis has provided the impetus for numerous studies trying to link hemodynamic factors (flow impingement, pressure, and/or wall shear stress) to aneurysm pathophysiology. The focus of this review is to provide a broad overview of such hemodynamic associations as well as the subsumed aspects of vascular anatomy and wall structure. Hemodynamic factors seem to be correlated to the distribution of aneurysms on the intracranial arterial tree and complex, slow flow patterns seem to be associated with aneurysm growth and rupture. However, both the prevalence of aneurysms in the general population and the incidence of ruptures in the aneurysm population are extremely low. This suggests that hemodynamic factors and purely mechanical explanations by themselves may serve as necessary, but never as necessary and sufficient conditions of this disease’s causation. The ultimate cause is not yet known, but it is likely an additive or multiplicative effect of a handful of biochemical and biomechanical factors. PMID:23549899

De novo giant A2 aneurysm following anterior communicating artery occlusion.

PubMed

Ibrahim, Tarik F; Hafez, Ahmad; Andrade-Barazarte, Hugo; Raj, Rahul; Niemela, Mika; Lehto, Hanna; Numminen, Jussi; Jarvelainen, Juha; Hernesniemi, Juha

2015-01-01

De novo intracranial aneurysms are reported to occur with varying incidence after intracranial aneurysm treatment. They are purported to be observed, however, with increased incidence after Hunterian ligation; particularly in cases of carotid artery occlusion for giant or complex aneurysms deemed unclippable. We report a case of right-sided de novo giant A2 aneurysm 6 years after an anterior communicating artery (ACoA) aneurysm clipping. We believe this de novo aneurysm developed in part due to patient-specific risk factors but also a significant change in cerebral hemodynamics. The ACoA became occluded after surgery that likely altered the cerebral hemodynamics and contributed to the de novo aneurysm. We believe this to be the first reported case of a giant de novo aneurysm in this location. Following parent vessel occlusion (mostly of the carotid artery), there are no reports of any de novo aneurysms in the pericallosal arteries let alone a giant one. The patient had a dominant right A1 and the sudden increase in A2 blood flow likely resulted in increased wall shear stress, particularly in the medial wall of the A2 where the aneurysm occurred 2 mm distal to the A1-2 junction. ACoA preservation is a key element of aneurysm surgery in this location. Suspected occlusion of this vessel may warrant closer radiographic follow-up in patients with other risk factors for aneurysm development.

Surgical flow modification of the anterior cerebral artery-anterior communicating artery complex in the management of giant aneurysms of internal carotid artery bifurcation: An alternative for a difficult clip reconstruction

PubMed Central

Pahl, Felix Hendrik; de Oliveira, Matheus Fernandes; Beer-Furlan, André Luiz; Rotta, José Marcus

2016-01-01

Background: Internal carotid artery bifurcation (ICAb) aneurysms account for about 2–15% of all intracranial aneurysms. In giant and complex cases, treatment may be difficult and dangerous, once some aneurysms have wide neck and anterior cerebral artery (ACA) and middle cerebral artery (MCA) may arise from the aneurysm itself. Clip reconstruction may be difficult in such cases. Whenever possible, the occlusion of ACA transform the bifurcation in a single artery reconstruction (ICA to MCA), much easier than a bifurcation reconstruction. Methods: In patients with giant and complex ICAb aneurysms, we propose routine preoperative angiography with anatomical evaluation of anterior communicating artery (ACoA) patency during cervical common carotid compression with concomitant contralateral carotid artery injection. This allowed visualization of the expected reversal of flow in the A1 segment–ACoA complex. When test is positive, we can perform ipsilateral ACA (A1 segment) clip occlusion and flow modification of the ACA-ACoA complex transforming a three vessel (ICA, ACA, and MCA) reconstruction into a two vessel (ICA and MCA) reconstruction. Results: Two patients were treated, with 100% of occlusion and good outcome. Conclusions: Surgical treatment of giant and complex ICAb may be achieved with acceptable morbidity. PMID:27313968

Blood flow characteristics in a terminal basilar tip aneurysm prior to its fatal rupture

PubMed Central

Sforza, D.M.; Putman, C.M.; Scrivano, E.; Lylyk, P.; Cebral, J.R.

2010-01-01

Background and Purpose The development and validation of methods to stratify the risk of rupture of cerebral aneurysms is highly desired since current treatment risks can exceed the natural risk of rupture. Because unruptured aneurysms are typically treated before they rupture, it is very difficult to connect the proposed risk indices to the rupture of an individual aneurysm. The purpose of this case study was to analyze the hemodynamic environment of a saccular aneurysm of the terminal morphology sub-type that was imaged just prior to its rupture and to test whether the hemodynamic characteristics would designate this particular aneurysm as at high risk. Methods A patient-specific computational fluid dynamics model was constructed from 3D rotational angiography images acquired just hours before the aneurysm ruptured. A pulsatile flow calculation was performed and hemodynamic characteristics previously connected to rupture were analyzed. Results It was found that the aneurysm had a concentrated inflow stream, small impingement region, complex intra-aneurysmal flow structure, asymmetric flow split from the parent vessel to the aneurysm and daughter branches, and high levels of aneurysmal wall shear stress near the impaction zone. Conclusions The hemodynamics characteristics observed in this aneurysm right before its rupture are consistent with previous studies correlating aneurysm rupture and hemodynamic patterns in saccular and terminal aneurysms. This study supports the notion that hemodynamic information may be used to help stratify the rupture risk of cerebral aneurysms. PMID:20150312

A case of acute subdural hematoma due to ruptured aneurysm detected by postmortem angiography.

PubMed

Inokuchi, Go; Makino, Yohsuke; Yajima, Daisuke; Motomura, Ayumi; Chiba, Fumiko; Torimitsu, Suguru; Hoshioka, Yumi; Iwase, Hirotaro

2016-03-01

Acute subdural hematoma (ASDH) is mostly caused by head trauma, but intrinsic causes also exist such as aneurysm rupture. We describe here a case involving a man in his 70s who was found lying on the bedroom floor by his family. CT performed at the hospital showed ASDH and a forensic autopsy was requested. Postmortem cerebral angiography showed dilatation of the bifurcation of the middle cerebral artery, which coincided with the dilated part of the Sylvian fissure. Extravasation of contrast medium into the subdural hematoma from this site was suggestive of a ruptured aneurysm. Autopsy revealed a fleshy hematoma (total weight 110 g) in the right subdural space and findings of brain herniation. As indicated on angiography, a ruptured saccular aneurysm was confirmed at the bifurcation of the middle cerebral artery. Obvious injuries to the head or face could not be detected on either external or internal examination, and intrinsic ASDH due to a ruptured middle cerebral artery aneurysm was determined as the cause of death. One of the key points of forensic diagnosis is the strict differentiation between intrinsic and extrinsic onset for conditions leading to death. Although most subdural hematomas (SDH) are caused by extrinsic factors, forensic pathologists should consider the possibility of intrinsic SDH. In addition, postmortem angiography can be useful for identifying vascular lesions in such cases.

Intracerebral haemorrhage and drug abuse in young adults.

PubMed

McEvoy, A W; Kitchen, N D; Thomas, D G

2000-10-01

The epidemic of abuse of the so-called 'designer drugs' amphetamine, cocaine and ecstasy--is fast replacing traditional aetiological factors as the largest cause of intracerebral haemorrhage among young adults. Traditional teaching is that these represent hypertensive haemorrhages. Recent reports, however, have indicated that these patients may harbour underlying vascular malformations. We review 13 patients with a positive history of drug abuse preceding the onset of intracerebral haemorrhage. These patients presented to the National Hospital for Neurology and Neurosurgery in central London over a 7-month period. Of the 13 patients (eight male, five female), average age 31 years (19-43) years), 10 were well enough to undergo cerebral angiography. Intracranial aneurysms were demonstrated in six patients and arteriovenous malformations in three patients. In only one of the patients was the angiogram normal. A further patient was subsequently shown to have a middle cerebral artery aneurysm at autopsy. The epidemiology, pharmacology and systemic effects of these drugs are considered. The mechanisms by which these compounds cause intracerebral complications and their influence on prognosis are discussed. The incidence of intracerebral haemorrhage (ICH), ischaemic cerebral infarctions and subarachnoid haemorrhage (SAH) following drug abuse is increasing. Contrary to historical opinion, drug-related ICH is frequently related to an underlying vascular malformation. Arteriography should be part of the evaluation of most young patients with nontraumatic ICH. A thorough history focusing on the use of illicit substances and toxicological screening of urine and serum should be part of the evaluation of any young patient with a stroke.

EC-IC bypass for cavernous carotid aneurysms: An initial experience with twelve patients

PubMed Central

Menon, G.; Jayanand, Sudhir; Krishnakumar, K.; Nair, S.

2014-01-01

Aims: Need for performing a bypass procedure prior to parent artery occlusion in patients with good cerebral vascular reserve is controversial. We analyze our experience of 12 giant internal carotid artery aneurysms treated with extracranial-intracranial (EC-IC) bypass and proximal artery occlusion. Materials and Methods: Retrospective analysis of the case records of all complex carotid aneurysms operated in our institute since January 2009. Results: The study included eleven cavernous carotid aneurysms and one large fusiform cervical carotid aneurysm reaching the skull base. Preoperative assessment of cerebral vascular reserve was limited to Balloon test occlusion with hypotensive challenge. Eleven patients who successfully completed a Balloon test occlusion (BTO) underwent low flow superficial temporal artery to middle cerebral artery (STA-MCA) bypass, while one patient with a failed BTO underwent a high flow bypass using a saphenous vein graft. Parent artery ligation was performed in all patients following the bypass procedure. Check angiogram revealed thrombosis of the aneurysm in all patients with a graft patency rate of 81.8%. We had one operative mortality, probably related to a leak from the anastomotic site. The only patient who had a high flow bypass developed contralateral hemispheric infarcts and remained vegetative. All the other patients had a good recovery and with a Glasgow outcome score of 5 at last follow-up. Conclusion: We feel that combining EC-IC bypass prior to parent vessel occlusion helps in reducing the risk of post operative ischemic complications especially in situations where a complete mandated cerebral blood flow studies are not feasible. PMID:25126123

Microsurgery Simulator of Cerebral Aneurysm Clipping with Interactive Cerebral Deformation Featuring a Virtual Arachnoid.

PubMed

Shono, Naoyuki; Kin, Taichi; Nomura, Seiji; Miyawaki, Satoru; Saito, Toki; Imai, Hideaki; Nakatomi, Hirofumi; Oyama, Hiroshi; Saito, Nobuhito

2018-05-01

A virtual reality simulator for aneurysmal clipping surgery is an attractive research target for neurosurgeons. Brain deformation is one of the most important functionalities necessary for an accurate clipping simulator and is vastly affected by the status of the supporting tissue, such as the arachnoid membrane. However, no virtual reality simulator implementing the supporting tissue of the brain has yet been developed. To develop a virtual reality clipping simulator possessing interactive brain deforming capability closely dependent on arachnoid dissection and apply it to clinical cases. Three-dimensional computer graphics models of cerebral tissue and surrounding structures were extracted from medical images. We developed a new method for modifiable cerebral tissue complex deformation by incorporating a nonmedical image-derived virtual arachnoid/trabecula in a process called multitissue integrated interactive deformation (MTIID). MTIID made it possible for cerebral tissue complexes to selectively deform at the site of dissection. Simulations for 8 cases of actual clipping surgery were performed before surgery and evaluated for their usefulness in surgical approach planning. Preoperatively, each operative field was precisely reproduced and visualized with the virtual brain retraction defined by users. The clear visualization of the optimal approach to treating the aneurysm via an appropriate arachnoid incision was possible with MTIID. A virtual clipping simulator mainly focusing on supporting tissues and less on physical properties seemed to be useful in the surgical simulation of cerebral aneurysm clipping. To our knowledge, this article is the first to report brain deformation based on supporting tissues.

Balloon-Assisted Coil Embolization for Large-Necked Renal Artery Aneurysms

DOE Office of Scientific and Technical Information (OSTI.GOV)

Mounayer, Charbel; Aymard, Armand; Saint-Maurice, Jean-Pierre

2000-03-15

An aneurysm of the right renal artery was discovered in a patient suffering from cerebral arterial angiodysplasia and arterial hypertension. The aneurysm was large necked, which made selective endovascular treatment very difficult. To perform the embolization of the aneurysm, a balloon remodelling technique was used. This prevented migration of coils within the arterial lumen.

Combination Superficial Temporal Artery-Middle Cerebral Artery Bypass and M2-M2 Reanastomosis With Trapping of a Stented Distal Middle Cerebral Artery Aneurysm: 3-Dimensional Operative Video.

PubMed

Burkhardt, Jan-Karl; Yousef, Sonia; Tabani, Halima; Benet, Arnau; Rubio, Roberto Rodriguez; Lawton, Michael T

2018-05-12

Distal middle cerebral artery (MCA) aneurysms often have non-saccular morphology and cannot be clipped, requiring revascularization and trapping instead. Combination bypasses are needed when 2 arteries exit the aneurysm, and extracranial-intracranial and intracranial-intracranial bypasses can be used. This video demonstrates a combination bypass used to treat a previously stented distal MCA aneurysm with both a superficial temporal artery (STA)-to-MCA bypass and an M2-to-M2 reanastomosis. This 56-yr-old man presented with distal left-sided MCA aneurysm 2 years earlier and attempted stent-assisted coiling was aborted after the aneurysm was perforated with stenting alone. Follow-up angiography demonstrated progressive aneurysm enlargement, and he was referred for surgery. The patient consented for the procedure and a pterional craniotomy extended posteriorly exposed the distal Sylvian fissure and efferent M4-cortical arteries. After splitting the Sylvian fissure, the "flash fluorescence" technique with indocyanine green (ICG) videoangiography identified an M4 recipient artery from the deeper of 2 exiting branches for STA-MCA bypass.1 The aneurysm was then trapped, and inflow and the more superficial outflow arteries were anastomosed end to end (M2-M2 in-situ bypass). A platelet plug that developed at the reanastomosis site was broken apart with mechanical manipulation, and ICG videoangiography demonstrated patency of both bypasses. The patient recovered without any neurological deficits, and postoperative computed tomography angiography confirmed bypass patency. Combination bypasses are needed when unclippable bifurcation aneurysms require revascularization. Careful intraoperative evaluation of patency of the bypass is imperative and helps identifying and addressing any potential early bypass occlusion.

Rescue Therapy for Refractory Vasospasm after Subarachnoid Hemorrhage

PubMed Central

Durrant, Julia C.; Hinson, Holly E.

2014-01-01

Vasospasm and delayed cerebral ischemia remain to be the common causes of increased morbidity and mortality after aneurysmal subarachnoid hemorrhage. The majority of clinical vasospasm responds to hemodynamic augmentation and direct vascular intervention; however, a percentage of patients continue to have symptoms and neurological decline. Despite suboptimal evidence, clinicians have several options in treating refractory vasospasm in aneurysmal subarachnoid hemorrhage (aSAH), including cerebral blood flow enhancement, intra-arterial manipulations, and intra-arterial and intrathecal infusions. This review addresses standard treatments as well as emerging novel therapies aimed at improving cerebral perfusion and ameliorating the neurologic deterioration associated with vasospasm and delayed cerebral ischemia. PMID:25501582

Tetrahedral and polyhedral mesh evaluation for cerebral hemodynamic simulation--a comparison.

PubMed

Spiegel, Martin; Redel, Thomas; Zhang, Y; Struffert, Tobias; Hornegger, Joachim; Grossman, Robert G; Doerfler, Arnd; Karmonik, Christof

2009-01-01

Computational fluid dynamic (CFD) based on patient-specific medical imaging data has found widespread use for visualizing and quantifying hemodynamics in cerebrovascular disease such as cerebral aneurysms or stenotic vessels. This paper focuses on optimizing mesh parameters for CFD simulation of cerebral aneurysms. Valid blood flow simulations strongly depend on the mesh quality. Meshes with a coarse spatial resolution may lead to an inaccurate flow pattern. Meshes with a large number of elements will result in unnecessarily high computation time which is undesirable should CFD be used for planning in the interventional setting. Most CFD simulations reported for these vascular pathologies have used tetrahedral meshes. We illustrate the use of polyhedral volume elements in comparison to tetrahedral meshing on two different geometries, a sidewall aneurysm of the internal carotid artery and a basilar bifurcation aneurysm. The spatial mesh resolution ranges between 5,119 and 228,118 volume elements. The evaluation of the different meshes was based on the wall shear stress previously identified as a one possible parameter for assessing aneurysm growth. Polyhedral meshes showed better accuracy, lower memory demand, shorter computational speed and faster convergence behavior (on average 369 iterations less).

Experimental Study of Flow Through Carotid Aneurysms

NASA Astrophysics Data System (ADS)

Masoomi, Faezeh; Mejia-Alvarez, Ricardo

2017-11-01

There is evidence that traditional endovascular techniques like coiling are not effective for treatment of wide-neck cerebral aneurysms. Flow Diverter Stents (FDS) have emerged as promising devices for treating complex aneurysms since they enable treatment of aneurysms that were considered untreatable before. Recent studies suggest a number of associated risks with FDS, including in-stent thrombosis, perianeurysmal edema, delayed hemorrhage, and perforator occlusions. Chong et al. simulated hemodynamic behavior using patient-specific data. From their study, it is possible to infer that the standard deviation of energy loss could be a good predictor for intervention success. The aim of this study is to investigate the flow in models of cerebral aneurysms before and after FDS insertion using PIV. These models will be based on actual clinical studies and will be fabricated with advanced additive manufacturing techniques. These data will then be used to explore flow parameters that could inform the likelihood of post-intervention aneurysm rupture, and help determine FDS designs that better suit any particular patient before its procedure.

A marked decrease in bispectral index with elevation of suppression ratio by cervical haematoma reducing cerebral perfusion pressure.

PubMed

Umegaki, N; Hirota, K; Kitayama, M; Yatsu, Y; Ishihara, H; Mtasuki, A

2003-11-01

A 77-year-old man with a ruptured abdominal aortic aneurysm undergoing aneurysmectomy were anaesthetised with ketamine under bispectral index (BIS) monitoring, which is a clinical EEG monitor for measurement of depth of anaesthesia/sedation. First marked BIS reduction with elevation of suppression ratio (SR) was observed following severe hypotension by deflation of the aortic occlusion balloon. The re-inflation and rapid blood transfusion improved haemodyanamics and BIS and SR. At second marked BIS reduction with SR elevation, a heavy cervical swelling due to a massive subcutaneous haematoma around the previously mis-punctured right carotid artery extending throughout the whole neck was observed without hypotension. Cervical relief incision improved the BIS and SR. The present case suggests that BIS monitor may be a simple and convenient monitor for cerebral ischaemia detection.

Long-Term Follow-Up for a Giant Basilar Trunk Aneurysm Surgically Treated by Proximal Occlusion and External Carotid Artery to Posterior Cerebral Artery Bypass Using a Saphenous Vein Graft.

PubMed

Yanagisawa, Toshiharu; Kinouchi, Hiroyuki; Sasajima, Toshio; Shimizu, Hiroaki

2016-11-01

The authors describe a case of a basilar trunk aneurysm with long-term follow-up after successful bypass and proximal occlusion. A 64-year-old woman had a giant aneurysm of the basilar trunk and underwent external carotid artery-to-posterior cerebral artery vein graft bypass surgery and proximal clipping of the basilar artery, which was followed by low-dose aspirin (100 mg/d) treatment. No ischemic symptoms and lesions developed and the thrombosed aneurysm was stable during 11 years of follow-up. An extracranial-intracranial high flow bypass combined with immediate proximal occlusion and aspirin administration may be an acceptable treatment option for patients with giant posterior circulation aneurysms. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Endovascular Broad-Neck Aneurysm Creation in a Porcine Model Using a Vascular Plug

DOE Office of Scientific and Technical Information (OSTI.GOV)

Muehlenbruch, Georg, E-mail: gmuehlenbruch@ukaachen.de; Nikoubashman, Omid; Steffen, Bjoern

2013-02-15

Ruptured cerebral arterial aneurysms require prompt treatment by either surgical clipping or endovascular coiling. Training for these sophisticated endovascular procedures is essential and ideally performed in animals before their use in humans. Simulators and established animal models have shown drawbacks with respect to degree of reality, size of the animal model and aneurysm, or time and effort needed for aneurysm creation. We therefore aimed to establish a realistic and readily available aneurysm model. Five anticoagulated domestic pigs underwent endovascular intervention through right femoral access. A total of 12 broad-neck aneurysms were created in the carotid, subclavian, and renal arteries usingmore » the Amplatzer vascular plug. With dedicated vessel selection, cubic, tubular, and side-branch aneurysms could be created. Three of the 12 implanted occluders, two of them implanted over a side branch of the main vessel, did not induce complete vessel occlusion. However, all aneurysms remained free of intraluminal thrombus formation and were available for embolization training during a surveillance period of 6 h. Two aneurysms underwent successful exemplary treatment: one was stent-assisted, and one was performed with conventional endovascular coil embolization. The new porcine aneurysm model proved to be a straightforward approach that offers a wide range of training and scientific applications that might help further improve endovascular coil embolization therapy in patients with cerebral aneurysms.« less

Computational study for the effects of coil configuration on blood flow characteristics in coil-embolized cerebral aneurysm.

PubMed

Otani, Tomohiro; Ii, Satoshi; Shigematsu, Tomoyoshi; Fujinaka, Toshiyuki; Hirata, Masayuki; Ozaki, Tomohiko; Wada, Shigeo

2017-05-01

Coil embolization of cerebral aneurysms with inhomogeneous coil distribution leads to an incomplete occlusion of the aneurysm. However, the effects of this factor on the blood flow characteristics are still not fully understood. This study investigates the effects of coil configuration on the blood flow characteristics in a coil-embolized aneurysm using computational fluid dynamics (CFD) simulation. The blood flow analysis in the aneurysm with coil embolization was performed using a coil deployment (CD) model, in which the coil configuration was constructed using a physics-based simulation of the CD. In the CFD results, total flow momentum and kinetic energy in the aneurysm gradually decayed with increasing coil packing density (PD), regardless of the coil configuration attributed to deployment conditions. However, the total shear rate in the aneurysm was relatively high and the strength of the local shear flow varied based on the differences in coil configuration, even at adequate PDs used in clinical practice (20-25 %). Because the sufficient shear rate reduction is a well-known factor in the blood clot formation occluding the aneurysm inside, the present study gives useful insight into the effects of coil configuration on the treatment efficiency of coil embolization.

Gemstone spectral imaging reduced artefacts from metal coils or clips after treatment of cerebral aneurysms: a retrospective study of 35 patients.

PubMed

Jia, Yulin; Zhang, Jinling; Fan, Jinyu; Li, Chao; Sun, Yuanyuan; Li, Di; Xiao, Xigang

2015-01-01

This study aimed to evaluate the effect of gemstone spectral imaging (GSI) for metal artefact reduction in cerebral artery CT angiography (CTA) after metal coils or clips treatment. 35 patients with cerebral aneurysms were treated with metal coils or clips and underwent CTA using gemstone spectral CT between February and December 2013. The data were reconstructed into three image groups including Group A (quality check images with 140 kVp), Group B (monochromatic image sets in the range of 40-140 keV) and Group C [monochromatic image sets with metal artefacts reduction software (MARS GE Medical Systems, Waukesha, WI)]. CT attenuation value of cerebral artery, contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR) and the subjective score of all images were measured and compared statistically. CT attenuation value of cerebral artery decreased in Groups B and C as the photon energy increased. The average energy levels of 60.05 ± 5.37 and 59.93 ± 5.57 keV presented the best CNR in Groups B and C, respectively. CNR values, SNR values and the subjective scores of the image quality of the two sets were higher than those of Group A. GSI reduced metal artefact and improved the image quality of CTA after metal coils or clips treatment in patients with cerebral aneurysm. The monochromatic images at the average energy level of 60.05 ± 5.37 keV with MARS and 59.93 ± 5.57 keV without MARS were suggested to be the optimal parameters. GSI could reduce metal artefact after metal coils or clips treatment in patients with cerebral aneurysm.

Phase-contrast MRI versus numerical simulation to quantify hemodynamical changes in cerebral aneurysms after flow diverter treatment

PubMed Central

Frolov, Sergey; Prothmann, Sascha; Liepsch, Dieter; Balasso, Andrea; Berg, Philipp; Kaczmarz, Stephan; Kirschke, Jan Stefan

2018-01-01

Cerebral aneurysms are a major risk factor for intracranial bleeding with devastating consequences for the patient. One recently established treatment is the implantation of flow-diverters (FD). Methods to predict their treatment success before or directly after implantation are not well investigated yet. The aim of this work was to quantitatively study hemodynamic parameters in patient-specific models of treated cerebral aneurysms and its correlation with the clinical outcome. Hemodynamics were evaluated using both computational fluid dynamics (CFD) and phase contrast (PC) MRI. CFD simulations and in vitro MRI measurements were done under similar flow conditions and results of both methods were comparatively analyzed. For preoperative and postoperative distribution of hemodynamic parameters, CFD simulations and PC-MRI velocity measurements showed similar results. In both cases where no occlusion of the aneurysm was observed after six months, a flow reduction of about 30-50% was found, while in the clinically successful case with complete occlusion of the aneurysm after 6 months, the flow reduction was about 80%. No vortex was observed in any of the three models after treatment. The results are in agreement with recent studies suggesting that CFD simulations can predict post-treatment aneurysm flow alteration already before implantation of a FD and PC-MRI could validate the predicted hemodynamic changes right after implantation of a FD. PMID:29304062

Case of Subarachnoid Hemorrhage Caused by Tuberculous Aneurysm.

PubMed

Liu, Wei; Li, Chuanfeng; Liu, Xianming; Xu, Zhiming; Kong, Lu

2018-02-01

Subarachnoid hemorrhage caused by rupture of tuberculosis associated aneurysm is a rare complication. In this paper, we report a case of intracranial tuberculum with adjacent intracerebral inflammatory aneurysm which caused subarachnoid hemorrhage and brain abscess formation. A 28-year-old man presented with sudden onset of severe headache. He was diagnosed with pulmonary tuberculosis 8 years ago, and had been treated with antituberculosis medications for 6 months. Head computed tomography showed a small hematoma in the left sylvian fissure with subarachnoid hemorrhage. Cerebral digital subtraction angiography was performed and no aneurysm was found. He was discharged after nonsurgical treatment. Three weeks later, he came back to our department with complaint of aphasia. Magnetic resonance images showed a cystic lesion with mass effect. During operation, we encounter the brain abscess and were surprised to find a middle cerebral artery aneurysm while dissecting. The abscess was totally removed, and the aneurysm was secured by clipping. The aneurysm was suspected of being inflammatory in nature and associated with the patient's tuberculosis. Tuberculosis in the central nervous system may present as tuberculoma and tuberculous meningitis. Vasculitis secondary to tuberculous meningitis can cause infarcts, and, rarely, aneurysm formation. This case report illustrated a rare case of intracranial infectious aneurysm related to tuberculosis and complicated by hemorrhage and brain abscess. Copyright © 2017 Elsevier Inc. All rights reserved.

EARLYDRAIN- outcome after early lumbar CSF-drainage in aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial.

PubMed

Bardutzky, Jürgen; Witsch, Jens; Jüttler, Eric; Schwab, Stefan; Vajkoczy, Peter; Wolf, Stefan

2011-09-14

Aneurysmal subarachnoid hemorrhage (SAH) may be complicated by delayed cerebral ischemia, which is a major cause of unfavorable clinical outcome and death in SAH-patients. Delayed cerebral ischemia is presumably related to the development of vasospasm triggered by the presence of blood in the basal cisterns. To date, oral application of the calcium antagonist nimodipine is the only prophylactic treatment for vasospasm recognized under international guidelines.In retrospective trials lumbar drainage of cerebrospinal fluid has been shown to be a safe and feasible measure to remove the blood from the basal cisterns and decrease the incidence of delayed cerebral ischemia and vasospasm in the respective study populations. However, the efficacy of lumbar drainage has not been evaluated prospectively in a randomized controlled trial yet. This is a protocol for a 2-arm randomized controlled trial to compare an intervention group receiving early continuous lumbar CSF-drainage and standard neurointensive care to a control group receiving standard neurointensive care only. Adults suffering from a first aneurysmal subarachnoid hemorrhage whose aneurysm has been secured by means of coiling or clipping are eligible for trial participation. The effect of early CSF drainage (starting < 72 h after securing the aneurysm) will be measured in the following ways: the primary endpoint will be disability after 6 months, assessed by a blinded investigator during a personal visit or standardized telephone interview using the modified Rankin Scale. Secondary endpoints include mortality after 6 months, angiographic vasospasm, transcranial Doppler sonography (TCD) mean flow velocity in both middle cerebral arteries and rate of shunt insertion at 6 months after hospital discharge. Here, we present the study design of a multicenter prospective randomized controlled trial to investigate whether early application of a lumbar drainage improves clinical outcome after aneurysmal subarachnoid hemorrhage.

Indocyanine Green Videoangiography Transoptic Visualization and Clipping Confirmation of an Optic Splitting Ophthalmic Artery Aneurysm.

PubMed

Rustemi, Oriela; Cester, Giacomo; Causin, Francesco; Scienza, Renato; Della Puppa, Alessandro

2016-06-01

Ophthalmic artery aneurysms with medial and superior projection in exceptionally rare cases can split the optic nerve. Treatment of these aneurysms is challenging, because the aneurysm dome is hidden from the optic nerve, rendering its visualization and clipping confirmation difficult. In addition, optic nerve function should be preserved during surgical maneuvers. Preoperative detection of this growing feature is usually missing. We illustrate the first case of indocyanine green videoangiography (ICG-VA) application in an optic penetrating ophthalmic artery aneurysm treatment. A 57-year-old woman presented with temporal hemianopsia, slight right visual acuity deficit, and new onset of headache. The cerebral angiography detected a right ophthalmic artery aneurysm medially and superiorly projecting. The A1 tract of the ipsilateral anterior cerebral artery was elevated and curved, being suspicious for an under optic aneurysm growth. Surgery was performed. Initially the aneurysm was not visible. ICG-VA permitted the transoptic aneurysm visualization. After optic canal opening, the aneurysm was clipped and transoptic ICG-VA confirmed the aneurysm occlusion. ICG-VA showed also the slight improvement of the optic nerve pial vascularization. Postoperatively, the visual acuity was 10/10 and the hemianopsia did not worsen. The elevation and curve of the A1 tract in medially and superiorly projecting ophthalmic aneurysms may be an indirect sign of under optic growth, or optic splitting aneurysms. ICG-VA transoptic aneurysm detection and occlusion confirmation reduces the surgical maneuvers on the optic nerve, contributing to function preservation. Copyright © 2016 Elsevier Inc. All rights reserved.

Assessment of Pre- and Post-Operative Cerebral Perfusion in Anterior Circulation Intracranial Aneurysm Clipping Patients at Hospital Sungai Buloh Using CT Perfusion Scan and Correlations to Fisher, Navarro and WFNS Scores.

PubMed

Ghani, Ailani Ab; Nayan, Saiful Azli Mat; Kandasamy, Regunath; Ghani, Abdul Rahman Izani; Rosman, Azmin Kass

2017-02-01

Intracranial aneurysms may rupture and are typically associated with high morbidity and mortality, commonly due to vasospasm after rupture. Once the aneurysm ruptures, the patient's cerebral blood flow may be disturbed during the acute phase, affecting cerebral circulation and thus cerebral perfusion prior to the onset of vasospasm. Fisher and Navarro scores are used to predict vasospasm, while World Federation of Neurosurgical Societies (WFNS) scores are used to predict patient outcomes. Several score modifications are available to obtain higher sensitivity and specificity for the prediction of vasospasm development, but these scores are still unsuccessful. Alternatively, cerebral CT perfusion scan (CTP) is a non-invasive method for measuring cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) in regions of interests (ROI) to obtain the cerebral perfusion status as well as detecting vasospasm. A total of 30 patients' data with clipped anterior circulation intracranial aneurysms admitted to the hospital between 1 January 2013 and 30 June 2014, were collected from the hospital's electronic database. The data collected included patients' admissions demographic profiles, Fisher, Navarro and WFNS scores; and their immediate pre- and post-operative CTP parameters. This study found a significant increase in post-operative MTT (pre- and post-operative MTT) were 9.75 (SD = 1.31) and 10.44 (SD = 1.56) respectively, ( P < 0.001)) as well as a significant reduction in post-operative CBF (pre- and post-operative mean CBF were 195.29 (SD = 24.92) and 179.49 (SD = 31.17) respectively ( P < 0.001)). There were no significant differences in CBV. There were no significant correlations between the pre- and post-operative CTP parameters and Fisher, Navarro or WFNS scores. Despite the interest in using Fisher, Navarro and WFNS scores to predict vasospasm and patient outcomes for ruptured intracranial aneurysms, this study found no significant correlations between these scores in either pre- or post-operative CTP parameters. These results explain the disagreement in the field regarding the multiple proposed grading systems for vasospasm prediction. CTP measures more than just anatomical structures; therefore, it is more sensitive towards minor changes in cerebral perfusion that would not be detected by WFNS, Fisher or Navarro scores.

Microsurgical subtemporal approach to aneurysms on the P(2) segment of the posterior cerebral artery.

PubMed

Zhitao, Jing; Yibao, Wang; Anhua, Wu; Shaowu, Ou; Yunchao, Ban; Renyi, Zhou; Yunjie, Wang

2010-01-01

Aneurysms arising from the P(2) segment of the posterior cerebral artery (PCA) are rare, accounting for less than 1% of all intracranial aneurysms. To date, few studies concerning the management of P(2) segment aneurysms have been reported. To review the microsurgical techniques and clinical outcomes of microsurgical treatment by different approaches in patients with aneurysms on the P(2) segment of the PCA. Forty-two patients with P2 segment aneurysms had microsurgical treatment by subtemporal approach. All the patients had drainage of cerebrospinal fluid for decompression, and indocyanine green (ICG) angiography was used in 20 patients to assess the effect of clipping. Of the 42 patients, 16 were operated by combined pterional-subtemporal approach. In 40 patients aneurysms were successfully treated by clipping the P(2) aneurysmal neck while preserving the parent artery. Two patients with giant aneurysms were treated using surgical trapping. Postoperatively, 41 patients had a good recovery. One patient after aneurysm trapping had ischemic infarction in the PCA tertiary and presented with hemiparesis and homonymous hemianopia. However, this patient recovered after three weeks of treatment. Subtemporal approach is the most appropriate approach to clip the aneurysms of the P(2) segment. It allows the neurosurgeon to operate on the aneurysms while preserving the patency of the parent artery. Gaint P(2) segment aneurysms can safely be treated by rapping of the aneurysm by combined subtemporal or pterional-subtemporal approach in experienced hands. ICG angiography will be an important tool in monitoring for the presence of residual aneurysm or perforating artery occlusion during aneurysm clipping. Preoperative lumbar drainage of cerebrospinal fluid may help to avoid temporal lobe damage.

A coil placement technique to treat intracranial aneurysm with incorporated artery.

PubMed

Luo, Chao-Bao; Chang, Feng-Chi; Lin, Chung-Jung; Guo, Wan-Yuo

2018-03-01

Endovascular coil embolization is an accepted treatment option for intracranial aneurysms. However, the coiling of aneurysms with an incorporated artery (IA) poses a high risk of IA occlusion. Here we report our experience of endovascular coil placement using a technique that avoids IA occlusion in aneurysms with IAs. Over a 6-year period, 185 patients harboring 206 intracranial aneurysms underwent endosaccular coiling. Forty-two of these patients with 45 aneurysms were treated by coil placement to avoid IAs occlusion. We assessed the anatomy of the aneurysms and IAs, technical feasibility of the procedure, and degree of aneurysm occlusion. Clinical and angiographic outcomes were assessed as well. Aneurysms were located in the supra-clinoid intracranial internal carotid artery (n = 24), anterior cerebral artery (n = 6), middle cerebral artery (n = 7), and vertebrobasilar artery (n = 8). The IA was at the aneurysm neck in 34 patients, body in 10, and dome in 1. Immediate post-coiling angiogram showed preservation of blood flow through the IA in all aneurysms. Coil compaction with aneurysmal regrowth was found in 7 of 36 patients having follow-up conventional angiography. One patient had an IA territory infarction after embolization. All 42 patients were followed up (mean: 21 months) and showed no re-bleeding. This technique is effective and safe in managing intracranial aneurysms with IAs. Although aneurysmal recurrence may occur in some aneurysms because of insufficient coiling, this technique is simpler to perform and requires less skill than other techniques. It can be an alternative option for treating some selected intracranial aneurysms with IAs. Copyright © 2017. Published by Elsevier Taiwan LLC.

Treatment of cerebral aneurysms in children: analysis of the Kids' Inpatient Database.

PubMed

Alawi, Aws; Edgell, Randall C; Elbabaa, Samer K; Callison, R Charles; Khalili, Yasir Al; Allam, Hesham; Alshekhlee, Amer

2014-07-01

OBJECT.: Endovascular coiling and surgical clipping are viable treatment options of cerebral aneurysms. Outcome data of these treatments in children are limited. The objective of this study was to determine hospital mortality and complication rates associated with surgical clipping and coil embolization of cerebral aneurysms in children, and to evaluate the trend of hospitals' use of these treatments. The authors identified a cohort of children admitted with the diagnoses of cerebral aneurysms and aneurysmal subarachnoid hemorrhage from the Kids' Inpatient Database for the years 1998 through 2009. Hospital-associated complications and in-hospital mortality were compared between the treatment groups and stratified by aneurysmal rupture status. A multivariate regression analysis was used to identify independent variables associated with in-hospital mortality. The Cochrane-Armitage test was used to assess the trend of hospital use of these operations. A total of 1120 children were included in this analysis; 200 (18%) underwent aneurysmal clipping and 920 (82%) underwent endovascular coiling. Overall in-hospital mortality was higher in the surgical clipping group compared with the coil embolization group (6.09% vs 1.65%, respectively; adjusted odds ratio [OR] 2.52, 95% CI 0.97-6.53, p = 0.05). The risk of postoperative stroke or hemorrhage was similar between the two treatment groups (p = 0.86). Pulmonary complications and systemic infection were higher in the surgical clipping population (p < 0.05). The rate of US hospitals' use of endovascular coiling has significantly increased over the years included in this study (p < 0.0001). Teaching hospitals were associated with a lower risk of death (OR 0.13, 95% CI 0.03-0.46; p = 0.001). Although both treatments are valid, endovascular coiling was associated with fewer deaths and shorter hospital stays than clip placement. The trend of hospitals' use of coiling operations has increased in recent years.

Impact of routine cerebral CT angiography on treatment decisions in infective endocarditis.

PubMed

Meshaal, Marwa Sayed; Kassem, Hussein Heshmat; Samir, Ahmad; Zakaria, Ayman; Baghdady, Yasser; Rizk, Hussein Hassan

2015-01-01

Infective endocarditis (IE) is commonly complicated by cerebral embolization and hemorrhage secondary to intracranial mycotic aneurysms (ICMAs). These complications are associated with poor outcome and may require diagnostic and therapeutic plans to be modified. However, routine screening by brain CT and CT angiography (CTA) is not standard practice. We aimed to study the impact of routine cerebral CTA on treatment decisions for patients with IE. From July 2007 to December 2012, we prospectively recruited 81 consecutive patients with definite left-sided IE according to modified Duke's criteria. All patients had routine brain CTA conducted within one week of admission. All patients with ICMA underwent four-vessel conventional angiography. Invasive treatment was performed for ruptured aneurysms, aneurysms ≥ 5 mm, and persistent aneurysms despite appropriate therapy. Surgical clipping was performed for leaking aneurysms if not amenable to intervention. The mean age was 30.43 ± 8.8 years and 60.5% were males. Staph aureus was the most common organism (32.3%). Among the patients, 37% had underlying rheumatic heart disease, 26% had prosthetic valves, 23.5% developed IE on top of a structurally normal heart and 8.6% had underlying congenital heart disease. Brain CT/CTA revealed that 51 patients had evidence of cerebral embolization, of them 17 were clinically silent. Twenty-six patients (32%) had ICMA, of whom 15 were clinically silent. Among the patients with ICMAs, 11 underwent endovascular treatment and 2 underwent neurovascular surgery. The brain CTA findings prompted different treatment choices in 21 patients (25.6%). The choices were aneurysm treatment before cardiac surgery rather than at follow-up, valve replacement by biological valve instead of mechanical valve, and withholding anticoagulation in patients with prosthetic valve endocarditis for fear of aneurysm rupture. Routine brain CT/CTA resulted in changes in the treatment plan in a significant proportion of patients with IE, even those without clinically evident neurological disease. Routine brain CT/CTA may be indicated in all hospitalized patients with IE.

Investigating Flow-Structure Interactions in Cerebral Aneurysms

ScienceCinema

None

2018-06-05

Visualization of blood flow in a cerebral aneurysm. Streamlines (colored by fluid velocity magnitude) reveal the complexity of the flow, isocontours of vorticity show blood vortex structures (colored by pressure), and the flexible arterial wall is colored by the stress magnitude, where regions in red indicate areas of high stress. Credits: Science: Paris Perdikaris, Yue Yu, George Em. Karniadakis and Leopold Grinberg Visualization: Joseph A. Insley and Michael E. Papka

Flow Diverter Stents for the Treatment of Anterior Cerebral Artery Aneurysms: Safety and Effectiveness.

PubMed

Clarençon, F; Di Maria, F; Gabrieli, J; Shotar, E; Zeghal, C; Nouet, A; Chiras, J; Sourour, N-A

2017-03-01

Flow diverter stents (FDSs) are increasingly used for the treatment of intracranial aneurysms. Initially developed for the management of giant and large aneurysms, their indications have progressively expanded. The purpose of our study was to evaluate the safety and effectiveness of FDSs for the treatment of anterior cerebral artery (ACA) aneurysms. Among the 94 consecutive patients treated for 100 intracranial aneurysms by means of FDSs in our institution from October 2010 to January 2015, eight aneurysms (8 %) in seven patients were located on the ACA. Three aneurysms were located on the A1 segment, three aneurysms on the anterior communicating artery (ACom) and two on the A2-A3 junction. In three cases, FDS was used for angiographic recurrence after coiling. Five patients were treated with a Pipeline embolization device, one with a NeuroEndograft and the last one with a Silk FDS. Treatment was feasible in all cases. No technical difficulty was reported. No acute or delayed clinical complication was recorded. Modified Rankin Scale was 0 for six patients and one for one patient. Mean angiographic follow-up was 9.7 ± 3.9 months (range 6-15). Total exclusion was observed in five aneurysms (71.4 %) and neck remnant in two (28.6 %) cases. One patient refused the control DSA. Our series shows the safety and effectiveness of FDSs for the treatment of ACA aneurysms.

Morphological and clinical risk factors for posterior communicating artery aneurysm rupture.

PubMed

Matsukawa, Hidetoshi; Fujii, Motoharu; Akaike, Gensuke; Uemura, Akihiro; Takahashi, Osamu; Niimi, Yasunari; Shinoda, Masaki

2014-01-01

Recent studies have shown that posterior circulation aneurysms, specifically posterior communicating artery (PCoA) aneurysms, are more likely to rupture than other aneurysms. To date, few studies have investigated the factors contributing to PCoA aneurysm rupture. The authors aimed to identify morphological and clinical characteristics predisposing to PCoA aneurysm rupture. The authors retrospectively reviewed 134 consecutive patients with PCoA aneurysms managed at their facility between July 2003 and December 2012. The authors divided patients into groups of those with aneurysmal rupture (n = 39) and without aneurysmal rupture (n = 95) and compared morphological and clinical characteristics. Morphological characteristics were mainly evaluated by 3D CT angiography and included diameter of arteries (anterior cerebral artery, middle cerebral artery, and internal carotid artery), size of the aneurysm, dome-to-neck ratio, neck direction of the aneurysmal dome around the PCoA (medial, lateral, superior, inferior, and posterior), aneurysm bleb formation, whether the PCoA was fetal type, and the existence of other intracranial unruptured aneurysm(s). Patients with ruptured PCoA aneurysms were significantly younger (a higher proportion were < 60 years of age) and a significantly higher proportion of patients with ruptured PCoA aneurysms showed a lateral direction of the aneurysmal dome around the PCoA, had bleb formation, and the aneurysm was > 7 mm in diameter and/or the dome-to-neck ratio was > 2.0. Multivariate logistic regression analysis showed age < 60 years (OR 4.3, p = 0.011), history of hypertension (OR 5.1, p = 0.008), lateral direction of the aneurysmal dome around the PCoA (OR 6.7, p = 0.0001), and bleb formation (OR 11, p < 0.0001) to be significantly associated with PCoA aneurysm rupture. The present results demonstrated that lateral projection of a PCoA aneurysm may be related to rupture.

Fluid Structural Analysis of Human Cerebral Aneurysm Using Their Own Wall Mechanical Properties

PubMed Central

Valencia, Alvaro; Burdiles, Patricio; Ignat, Miguel; Mura, Jorge; Rivera, Rodrigo; Sordo, Juan

2013-01-01

Computational Structural Dynamics (CSD) simulations, Computational Fluid Dynamics (CFD) simulation, and Fluid Structure Interaction (FSI) simulations were carried out in an anatomically realistic model of a saccular cerebral aneurysm with the objective of quantifying the effects of type of simulation on principal fluid and solid mechanics results. Eight CSD simulations, one CFD simulation, and four FSI simulations were made. The results allowed the study of the influence of the type of material elements in the solid, the aneurism's wall thickness, and the type of simulation on the modeling of a human cerebral aneurysm. The simulations use their own wall mechanical properties of the aneurysm. The more complex simulation was the FSI simulation completely coupled with hyperelastic Mooney-Rivlin material, normal internal pressure, and normal variable thickness. The FSI simulation coupled in one direction using hyperelastic Mooney-Rivlin material, normal internal pressure, and normal variable thickness is the one that presents the most similar results with respect to the more complex FSI simulation, requiring one-fourth of the calculation time. PMID:24151523

[Giant aneurysm of posterior comunicating artery (PCoA) in cerebral panarteriography and CT angiography (CTA)].

PubMed

Jaźwiec, Przemysław; Chwiszczuk, Luiza; Sasiadek, Marek; Całka, Karol; Kuniej, Tomasz; Plucińska, Irena

2008-01-01

We present a case of 32-year-old woman, who was admitted to the Department of Neurology in the emergency mode, due to: instantaneous pupillary dilation (mydriasis), ptosis of the left eyeball and double vision. We performed plain CT, panarteriography of cerebral vessels, CT angiography with RT3D (volume-rendered three-dimensional) reconstruction images. On the base of imaging studies the diagnosis of giant saccular aneurysm of the left posterior communicating artery was established. The patient was operated on and the giant aneurysm of left posterior communicating artery was clipped, confirming radiological diagnosis. During operation and postoperative period no complications were noted.

Numerous Fusiform and Saccular Cerebral Aneurysms in Central Nervous System Lupus Presenting with Ischemic Stroke.

PubMed

Majidi, Shahram; Leon Guerrero, Christopher R; Gandhy, Shreya; Burger, Kathleen M; Sigounas, Dimitri

2017-07-01

Central nervous system (CNS) involvement occurs in up to 50% of patients with systemic lupus erythematosus (SLE). Cerebral aneurysm formation is a rare complication of CNS lupus. The majority of these patients present with subarachnoid hemorrhage. We report a patient with an active SLE flare who presented with a recurrent ischemic stroke and was found to have numerous unruptured fusiform and saccular aneurysms in multiple vascular territories. He was treated with high-dose steroid and rituximab along with aspirin and blood pressure control for stroke prevention. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Endovascular Treatment of Posterior Cerebral Artery Aneurysms With Flow Diversion: Case Series and Systematic Review.

PubMed

Wallace, Adam N; Grossberg, Jonathan A; Almandoz, Josser E Delgado; Kamran, Mudassar; Roy, Anil K; Kayan, Yasha; Austin, Matthew J; Howard, Brian M; Moran, Christopher J; Cawley, C Michael; Cross, DeWitte T; Dion, Jacques E; Kansagra, Akash P; Osbun, Joshua W

2018-03-08

Flow diversion of posterior cerebral artery (PCA) aneurysms has not been widely reported, possibly owing to concerns regarding parent vessel size and branch vessel coverage. To examine the safety and effectiveness of PCA aneurysm flow diverter treatment. Retrospective review of PCA aneurysms treated with the Pipeline Embolization Device (PED; Medtronic Inc, Dublin, Ireland) at 3 neurovascular centers, including periprocedural complications and clinical and angiographic outcomes. Systematic review of the literature identified published reports of PCA aneurysms treated with flow diversion. Rates of aneurysm occlusion and complications were calculated, and outcomes of saccular and fusiform aneurysm treatments were compared. Ten PCA aneurysms in 9 patients were treated with the PED. There were 2 intraprocedural thromboembolic events (20%), including 1 symptomatic infarction and 1 delayed PED thrombosis. Eight of 10 patients returned to or improved from their baseline functional status. Complete aneurysm occlusion with parent vessel preservation was achieved in 75% (6/8) of cases at mean follow-up of 16.7 mo. Eleven of 12 (92%) major branch vessels covered by a PED remained patent. Including the present study, systematic review of 15 studies found a complete aneurysm occlusion rate of 88% (30/34) and complication rate of 26% (10/38), including 5 symptomatic ischemic strokes (13%; 5/38). Fusiform aneurysms more frequently completely occluded compared with saccular aneurysms (100% vs 70%; P = .03) but were associated with a higher complication rate (43% vs 9%; P = .06). The safety and effectiveness profile of flow diverter treatment of PCA aneurysms may be acceptable in select cases.

[Congenital anomalies of cerebral artery and intracranial aneurysm].

PubMed

Nakajima, K; Ito, Z; Hen, R; Uemura, K; Matsuoka, S

1976-02-01

It is well known that congenital anomalies such as polycystic kidney, aortic coarctation, Marfan syndrome, Ehler-Danlos syndrome are apt to be complicated by intracranial aneurysms. In this report we attempt to reveal the relation and incidence between cerebrovascular anomalies and intracranial aneurysms. The etiology of aneurysms has been discussed, too. 12 cases of persistent trigeminl artery, 2 cases of persistent hypoglossal artery and 11 cases of fenestration were obtained from 3841 patients who were angiographically examined in our clinic for 5 years. The incidence is 0.31%, 0.05% and 0.29%, respectively. Persistent trigeminal arteries were complicated by 2 cases of intracranial aneurysms and one case of arterivenous malformations (AVM), persistent hypoglossal arteries were complicated by one case of aneurysm, and fenestrations were complicated by 2 cases of aneurysms and one case of AVM. One case of congenital agenesis of right internal carotid artery was obtained which was complicated by aneurysm of anterior communicating artery. Totally, 8 cases of aneurysms and AVM were obtained from 26 cases of cerebrovascular anomalies (incidence 30.8%). On the other hand, thalamic or caudate hemorrhage revealed the highest incidence of complication of intracranial aneurysms among intracerebral hematomas (10.7%). Compared with the incidence of aneurysms between cerebro vascular anomalies (30.8%) and thalamic or caudate hemorrhage (10.7%), the difference is statistically signigicant (P less than 0.05). The cause of intracranial aneurysm has not yet been clarified. But it is well accepted that the defect of tunica media vasorum is most responsible factor as to the occurrence of intracranial aneurysms. We concluded that the genetic error of cerebral vessels including defect of media caused intracranial aneurysms, and this result was supported from the evidence that cerebrovascular anomalies showed statistically high incidence of complication of intracranial aneurysms.

Stent-Assisted Endovascular Treatment of Anterior Communicating Artery Aneurysms - Literature Review.

PubMed

Kocur, Damian; Ślusarczyk, Wojciech; Przybyłko, Nikodem; Bażowski, Piotr; Właszczuk, Adam; Kwiek, Stanisław

2016-01-01

The anterior cerebral artery is a common location of intracranial aneurysms. The standard coil embolization technique is limited by its inability to occlude wide-neck aneurysms. Stent deployment across the aneurysm neck supports the coil mass inside the aneurysmal sac, and furthermore, has an effect on local hemodynamic and biologic changes. In this article, various management strategies and techniques as well as angiographic outcomes and complications related to stent-assisted endovascular treatment of anterior communicating artery aneurysms are presented. This treatment method is safe and associated with low morbidity and mortality rates.

Prevalence of Incidental Clinoid Segment Saccular Aneurysms.

PubMed

Revilla-Pacheco, Francisco; Escalante-Seyffert, María Cecilia; Herrada-Pineda, Tenoch; Manrique-Guzman, Salvador; Perez-Zuniga, Irma; Rangel-Suarez, Sergio; Rubalcava-Ortega, Johnatan; Loyo-Varela, Mauro

2018-04-12

Clinoid segment aneurysms are cerebral vascular lesions recently described in the neurosurgical literature. They arise from the clinoid segment of the internal carotid artery, which is the segment limited rostrally by the dural carotid ring and caudally, by the carotid-oculomotor membrane. Even although clinoid segment aneurysms represent a common incidental finding in magnetic resonance studies, its prevalence has not been yet reported. To determine the prevalence of incidental clinoid segment saccular aneurysms diagnosed by magnetic resonance imaging as well as their anatomic architecture and their association with smoking, arterial hypertension, age, and sex of patients. A total of 500 patients were prospectively studied with magnetic resonance imaging time-of-flight sequence and angioresonance with contrast material, to search for incidental saccular intracranial aneurysms. The site of primary interest was the clinoid segment, but the presence of aneurysms in any other location was determined for comparison. The relation among the presence of clinoid segment aneurysms, demographic factors, and secondary diagnosis of arterial hypertension, smoking, and other vascular/neoplastic cerebral lesions was analyzed. We found a global prevalence of incidental aneurysms of 7% (95% confidence interval, 5-9), with a prevalence of clinoid segment aneurysms of 3% (95% confidence interval, 2-4). Univariate logistic regression analysis showed a statistically significant relationship among incidental aneurysms, systemic arterial hypertension (P = 0.000), and smoking (P = 0.004). In the studied population, incidental clinoid segment aneurysms constitute the variety with highest prevalence. Copyright © 2018 Elsevier Inc. All rights reserved.

Play dough as an educational tool for visualization of complicated cerebral aneurysm anatomy.

PubMed

Eftekhar, Behzad; Ghodsi, Mohammad; Ketabchi, Ebrahim; Ghazvini, Arman Rakan

2005-05-10

Imagination of the three-dimensional (3D) structure of cerebral vascular lesions using two-dimensional (2D) angiograms is one of the skills that neurosurgical residents should achieve during their training. Although ongoing progress in computer software and digital imaging systems has facilitated viewing and interpretation of cerebral angiograms enormously, these facilities are not always available. We have presented the use of play dough as an adjunct to the teaching armamentarium for training in visualization of cerebral aneurysms in some cases. The advantages of play dough are low cost, availability and simplicity of use, being more efficient and realistic in training the less experienced resident in comparison with the simple drawings and even angiographic views from different angles without the need for computers and similar equipment. The disadvantages include the psychological resistance of residents to the use of something in surgical training that usually is considered to be a toy, and not being as clean as drawings or computerized images. Although technology and computerized software using the patients' own imaging data seems likely to become more advanced in the future, use of play dough in some complicated cerebral aneurysm cases may be helpful in 3D reconstruction of the real situation.

Surgical approach to giant aneurysms of the anterior circulation.

PubMed

Giombini, S; Solero, C L; Ferraresi, S; Melcarne, A; Broggi, G; Pluchino, F

1988-01-01

The surgical approach to cerebral giant aneurysms is still a source of great concern. We describe our experience with giant aneurysms of the anterior circulation and discuss the different surgical techniques adopted. During the period January 1972-December 1985, a total of 33 patients were operated upon at the Istituto Neurologico "C. Besta" of Milan for a giant aneurysm of the anterior circulation. Nineteen cases had suffered subarachnoid haemorrhage before admission; in 14 cases the hospitalization was due to evidence of mass effect on the surrounding neurovascular structures. All aneurysms were directly approached: in 24 cases the neck was occluded by a suitable clip, in 4 cases intramural thrombosis was attempted, in 3 cases the aneurysms were definitively trapped and in one case aneurysmorrhaphy was performed after resection of the sac. Operative mortality was 12%. Long-term follow-up shows good results whenever exclusion of the aneurysm from cerebral circulation had been achieved, either after removal of the sac or not; on the contrary, only fair or poor results were evident when other surgical techniques were adopted, either electively or out of necessity. The importance of intraoperative protection and monitoring of brain function is stressed.

[Neurologic complications of subarachnoid hemorrhage due to intracranial aneurysm rupture].

PubMed

Rama-Maceiras, P; Fàbregas Julià, N; Ingelmo Ingelmo, I; Hernández-Palazón, J

2010-12-01

The high rates of morbidity and mortality after subarachnoid hemorrhage due to spontaneous rupture of an intracranial aneurysm are mainly the result of neurologic complications. Sixty years after cerebral vasospasm was first described, this problem remains unsolved in spite of its highly adverse effect on prognosis after aneurysmatic rupture. Treatment is somewhat empirical, given that uncertainties remain in our understanding of the pathophysiology of this vascular complication, which involves structural and biochemical changes in the endothelium and smooth muscle of vessels. Vasospasm that is refractory to treatment leads to cerebral infarction. Prophylaxis, early diagnosis, and adequate treatment of neurologic complications are key elements in the management of vasospasm if neurologic damage, lengthy hospital stays, and increased use of health care resources are to be avoided. New approaches to early treatment of cerebral lesions and cortical ischemia in cases of subarachnoid hemorrhage due to aneurysm rupture should lead to more effective, specific management.

Neurosurgical Issues in Pregnancy.

PubMed

Can, Anil; Du, Rose

2017-12-01

Although rare, intracranial hemorrhage due to rupture of cerebral vascular malformations or intracranial aneurysms during pregnancy is a potentially devastating and life-threatening disorder, posing a diagnostic and therapeutic challenge to a multidisciplinary team of neurosurgeons, neurologists, obstetricians, and anesthesiologists. Despite the significant risk of morbidity and mortality affecting both the mother and the unborn child, knowledge of the natural history, epidemiology, and appropriate management of cerebral vascular malformations and intracranial aneurysms in pregnant women is limited. Although emergent neurosurgical concerns usually outweigh obstetric considerations, and treatment of these disorders is generally similar in pregnant and nonpregnant women, any necessary and feasible modifications to protect the unborn child should be made. This article reviews the management of ruptured intracranial aneurysms and cerebral vascular malformations, including arteriovenous malformations, cavernous malformations, and moyamoya disease, in women during pregnancy, partus, and puerperium. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Surgical Treatment of Large or Giant Fusiform Middle Cerebral Artery Aneurysms: A Case Series.

PubMed

Xu, Feng; Xu, Bin; Huang, Lei; Xiong, Ji; Gu, Yuxiang; Lawton, Michael T

2018-04-14

Management of large or giant fusiform middle cerebral artery (MCA) aneurysms represents a significant challenge. To describe the authors' experience in the treatment of large or giant fusiform MCA aneurysm by using various surgical techniques. We retrospectively reviewed a database of aneurysms treated at our division between 2015 and 2017. Overall, 20 patients (11 males, 9 females) were identified, with a mean age of 40.7 years (range, 13-65 years; median, 43 years). Six patients (30%) had ruptured aneurysms and 14 (70%) had unruptured aneurysms. The mean aneurysm size was 19 mm (range, 10-35 mm). The aneurysms involved the prebifurcation in 5 cases, bifurcation in 4 cases, and postbifurcation in 11 cases. The aneurysms were treated by clip reconstruction (n = 5), clip wrapping (n = 1), proximal occlusion or trapping (n = 4), and bypass revascularization (n = 10). Bypasses included 7 low-flow superficial temporal artery-MCA bypasses, 2 high-flow extracranial-intracranial bypasses, and 1 intracranial-intracranial bypass (reanastomosis). Bypass patency was 90%. Nineteen aneurysms (95%) were completely obliterated, and no rehemorrhage occurred during follow-up. There was no procedural-related mortality. Clinical outcomes were good (modified Rankin Scale score ≤2) in 18 of 20 patients (90%) at the last follow-up. Surgical treatment strategy for large or giant fusiform MCA aneurysms should be determined on an individual basis, based on aneurysm morphology, location, size, and clinical status. Favorable outcomes can be achieved by various surgical techniques, including clip reconstruction, wrap clipping, aneurysm trapping, aneurysm excision followed by reanastomosis, and partial trapping with bypass revascularization. Copyright © 2018 Elsevier Inc. All rights reserved.

What You Should Know about Cerebral Aneurysms

MedlinePlus

... produce cerebrospinal fluid), difficulty breathing that requires a mechanical ventilator, and infection. Heart and lung problems may ... stay within the aneurysm and act as a mechanical barrier to blood flow, thus sealing it off. ...

Morphological Variables Associated With Ruptured Middle Cerebral Artery Aneurysms.

PubMed

Zhang, Jian; Can, Anil; Mukundan, Srinivasan; Steigner, Michael; Castro, Victor M; Dligach, Dmitriy; Finan, Sean; Yu, Sheng; Gainer, Vivian; Shadick, Nancy A; Savova, Guergana; Murphy, Shawn; Cai, Tianxi; Wang, Zhong; Weiss, Scott T; Du, Rose

2018-05-30

Geometric factors of intracranial aneurysms and surrounding vasculature could affect the risk of aneurysm rupture. However, large-scale assessments of morphological parameters correlated with intracranial aneurysm rupture in a location-specific manner are scarce. To investigate the morphological characteristics associated with ruptured middle cerebral artery (MCA) aneurysms. Five hundred sixty-one patients with 638 MCA aneurysms diagnosed between 1990 and 2016 who had available computed tomography angiography (CTA) were included in this study. CTAs were evaluated using the Vitrea Advanced Visualization software for 3-dimensional (3D) reconstruction. Morphological parameters examined in each model included aneurysm projection, wall irregularity, presence of a daughter dome, presence of hypoplastic or aplastic A1 arteries and hypoplastic or fetal posterior communicating arteries (PCoA), aneurysm height and width, neck diameter, bottleneck factor, aspect and size ratio, height/width ratio, and diameters and angles of surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine the association of morphological characteristics with rupture of MCA aneurysms. Logistic regression was used to build a predictive MCA score. Greater bottleneck and size ratio, and irregular, multilobed, temporally projecting MCA aneurysms are associated with higher rupture risk, whereas higher M1/M2 ratio, larger width, and the presence of an ipsilateral or bilateral hypoplastic PCoA were inversely associated with rupture. The MCA score had good predictive capacity with area under the receiver operating curve = 0.88. These practical morphological parameters specific to MCA aneurysms are easy to assess when examining 3D reconstructions of unruptured aneurysms and could aid in risk evaluation in these patients.

External lumbar cerebrospinal fluid drainage in patients with aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis of controlled trials.

PubMed

Alcalá-Cerra, G; Paternina-Caicedo, Á; Díaz-Becerra, C; Moscote-Salazar, L R; Gutiérrez-Paternina, J J; Niño-Hernández, L M

2016-09-01

External lumbar drainage is a promising measure for the prevention of delayed aneurysmal subarachnoid hemorrhage-related ischemic complications. Controlled studies evaluating the effects of external lumbar drainage in patients with aneurysmal subarachnoid hemorrhage were included. Primary outcomes were: new cerebral infarctions and severe disability. Secondary outcomes were: clinical deterioration due to delayed cerebral ischemia, mortality, and the need of definitive ventricular shunting. Results were presented as pooled relative risks, with their 95% confidence intervals (95% CI). A total of 6 controlled studies were included. Pooled relative risks were: new cerebral infarctions, 0.48 (95% CI: 0.32-0.72); severe disability, 0.5 (95% CI: 0.29-0.85); delayed cerebral ischemia-related clinical deterioration, 0.46 (95% CI: 0.34-0.63); mortality, 0.71 (95% CI: 0.24-2.06), and need of definitive ventricular shunting, 0.80 (95% CI: 0.51-1.24). Assessment of heterogeneity only revealed statistically significant indexes for the analysis of severe disability (I(2)=70% and P=.01). External lumbar drainage was associated with a statistically significant decrease in the risk of delayed cerebral ischemia-related complications (cerebral infarctions and clinical deterioration), as well as the risk of severe disability; however, it was not translated in a lower mortality. Nevertheless, it is not prudent to provide definitive recommendations at this time because of the qualitative and quantitative heterogeneity among included studies. More randomized controlled trials with more homogeneous outcomes and definitions are needed to clarify its impact in patients with aneurysmal subarachnoid hemorrhage. Copyright © 2013 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.

Angiographic evaluation of the effect of intra-arterial milrinone therapy in patients with vasospasm from aneurysmal subarachnoid hemorrhage.

PubMed

Shankar, Jai Jai Shiva; dos Santos, Marlise P; Deus-Silva, Leonardo; Lum, Cheemun

2011-02-01

Several methods have been used to treat cerebral vasospasm, which is a major cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). Here, we examined the effectiveness and safety of intra-arterial injection of milrinone for the treatment of vasospasm. Consecutive patients with angiographically confirmed vasospasm received intra-arterial milrinone between January 2006 and December 2007. The improvement in diameter of vessel (in millimeters) following treatment was assessed by paired t test for statistical significance. The angiographic improvement of supraclinoid internal carotid artery, M1 segment of middle cerebral artery, and A1 and A2 segment of anterior cerebral artery was compared with the modified Rankin score of the patients at discharge. A total of 15 milrinone treatments were performed in 14 patients (11 females and 3 males) with mean age of 52.7 years (31-68 years). There was significant angiographic improvement after milrinone therapy (p < 0.0001). Intra-arterial milrinone was a safe and effective treatment of cerebral vasospasm following aneurysmal SAH.

Ambulatory Care Data Base (ACDB) Data Dictionary Sequential Files of Phase 2.

DTIC Science & Technology

1992-04-01

CEREBRAL ARTERIES 4340 CEREBRAL THROMBOSIS 43491 STROKE , ISCHEMIC 435 TRANSIENT CEREBRAL ISCHEMIA 4359 TRANSIENT ISCHEMIC ATTACK (TIA) 43591 TRANS...HYPERTENSIVE CRISIS 4373 ANEURYSM, CEREBRAL , NONRUPTURED 4374 ARTERITIS, CEREBRAL 4378 CEREBROVASCULAR DISEASE, OTHER ILL-DEFINED 43781 STROKE , LACUNAR...95950 MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOC 95999 OTHER NEUROLOGICAL DIAGNOSTIC PROCEDURES 96500 CHEMO INJ, SINGLE, PRE-MIX, PUSH 96501

Endovascular Treatment of Cerebral Aneurysm with Coils and Onyx

PubMed Central

Ueno, J.; Tohma, N.

2004-01-01

Summary We investigated endovascular treatment of cerebral aneurysm by coil and Onyx in vivo experiment in order to promote the advantages of coil embolization,. The aim of this study was to clarify the advantages and problems of coil and Onyx embolization and to evaluate its potentials for application in clinical medicine. We set experimental aneurysms made of external jugular vein to bilateral carotid arteries of 10 Beagle dogs and embolized aneurysm with coils and Onyx. Two months later, the dogs were sacrificed and took out the experimental aneurysms and examined them histologically. We have experienced Onyx migration into the vessel at the beginning of our experiment. Technical problems were as follows; Onyx was not easily visible on DSA monitor particularly in tight coil packing. Catheter tip was often stuck to the Onyx in the aneurysm. Protect balloon could not completely protect the Onyx leakage into the vessel. Microscopic examinations were as follows; The aneurysm was filled with Onyx, coils, and inflammatory reactants. The orifice of the aneurysm was packed with augmented fibrous tissue. 1. This method increased contact between the aneurysm wall and coils. 2. Onyx filled the intra-aneurismal space more tightly. 3. Coils prevented Onyx from flowing out into the vessel. 4. In Onyx, intimal layer was more rapidly formed at the neck of the aneurysm than coils only. 5. The most important problems during Onyx embolization is how to prevent Onyx migration into the vessel. We should like to propose the guideline for Onyx embolization. PMID:20587272

High-resolution CFD detects high-frequency velocity fluctuations in bifurcation, but not sidewall, aneurysms.

PubMed

Valen-Sendstad, Kristian; Mardal, Kent-André; Steinman, David A

2013-01-18

High-frequency flow fluctuations in intracranial aneurysms have previously been reported in vitro and in vivo. On the other hand, the vast majority of image-based computational fluid dynamics (CFD) studies of cerebral aneurysms report periodic, laminar flow. We have previously demonstrated that transitional flow, consistent with in vivo reports, can occur in a middle cerebral artery (MCA) bifurcation aneurysm when ultra-high-resolution direct numerical simulation methods are applied. The object of the present study was to investigate if such high-frequency flow fluctuations might be more widespread in adequately-resolved CFD models. A sample of N=12 anatomically realistic MCA aneurysms (five unruptured, seven ruptured), was digitally segmented from CT angiograms. Four were classified as sidewall aneurysms, the other eight as bifurcation aneurysms. Transient CFD simulations were carried out assuming a steady inflow velocity of 0.5m/s, corresponding to typical peak systolic conditions at the MCA. To allow for detection of clinically-reported high-frequency flow fluctuations and resulting flow structures, temporal and spatial resolutions of the CFD simulations were in the order of 0.1 ms and 0.1 mm, respectively. A transient flow response to the stationary inflow conditions was found in five of the 12 aneurysms, with energetic fluctuations up to 100 Hz, and in one case up to 900 Hz. Incidentally, all five were ruptured bifurcation aneurysms, whereas all four sidewall aneurysms, including one ruptured case, quickly reached a stable, steady state solution. Energetic, rapid fluctuations may be overlooked in CFD models of bifurcation aneurysms unless adequate temporal and spatial resolutions are used. Such fluctuations may be relevant to the mechanobiology of aneurysm rupture, and to a recently reported dichotomy between predictors of rupture likelihood for bifurcation vs. sidewall aneurysms. Copyright © 2012 Elsevier Ltd. All rights reserved.

Intraventricular Hemorrhage in Adults.

PubMed

Naff

1999-07-01

Intraventricular hemorrhage (IVH) in adults usually occurs in the setting of aneurysmal subarachnoid hemorrhage or hypertension-related intracerebral hemorrhage. Thus, the underlying cause of IVH is apparent from history and radiographic findings. If the underlying cause of IVH is not apparent, additional studies, including cerebral angiography, magnetic resonance imaging, and toxicology screening, should be performed to identify etiologic agents that may alter management of IVH. Management of IVH is thus done amidst (and must be tempered by) the multiple pharmacologic, surgical, and critical care interventions directed toward the diagnosis and treatment of the underlying cause of IVH. The most immediate threat to life posed by IVH is the development of acute obstructive hydrocephalus. If the hydrocephalus is contributing to a neurologic decline, it must be treated emergently with external ventricular drainage (EVD) through an intraventricular catheter (IVC). The patient with IVH should be evaluated and treated for deficient clotting function before an IVC is inserted. For this purpose, clotting function can be adequately assessed by prothrombin and partial thromboplastin times. Insertion of an IVC may significantly lower intracranial pressure, increasing the transmural pressure difference across the wall of a ruptured cerebral aneurysm and precipitating rerupture of the aneurysm. Therefore, with IVH secondary to a ruptured cerebral aneurysm, it is advisable to delay treatment of hydrocephalus that is not contributing to a neurologic decline until the aneurysm is repaired. Hydrocephalus contributing to significant neurologic decline in the setting of a ruptured aneurysm must be treated immediately despite the unprotected status of the aneurysm. Extreme diligence must be used to allow for the slow, controlled release of cerebrospinal fluid after IVC insertion. This will mitigate the effects of increasing the transmural pressure gradient across the wall of the ruptured aneurysm. In the patient with a neurologic deficit who has IVH-related hydrocephalus and an associated intracerebral hemorrhage, it is best to assume that the hydrocephalus is a significant contributor to the deficit and that it should be treated with EVD. An IVH that is not causing hydrocephalus but is apparently occluding one or both foramina of Monro or the third ventricle should be treated with EVD because obstructive hydrocephalus may develop precipitously and, if unrecognized, may cause irreversible brain damage or death. An IVH that is not likely to cause hydrocephalus because of small volume relative to its location can be followed expectantly. Intraventricular injections of thrombolytic agents through an IVC is a treatment option that may be considered in all patients with IVH that is causing or threatening to cause obstructive hydrocephalus. Unrepaired cerebral aneurysms, untreated cerebral arteriovenous malformations, and clotting disorders are contraindications for this intervention. The surgical evacuation of IVH has a role only in very rare cases in which the IVH is causing a significant mass effect independent of hydrocephalus and associated intraparenchymal brain hemorrhage.

Mathematic analysis of incremental packing density with detachable coils: does that last coil matter much?

PubMed

Taussky, P; Kallmes, D F; Cloft, H

2012-05-01

Higher packing attenuation of coils in cerebral aneurysms is associated with a decreased recurrence rate. However, geometric relationships suggest that an additional coil may have very little effect on packing attenuation as aneurysm size increases. We mathematically evaluated the relationship between aneurysm size and incremental packing attenuation for coils currently available.

Stent-Assisted Endovascular Treatment of Anterior Communicating Artery Aneurysms – Literature Review

PubMed Central

Kocur, Damian; Ślusarczyk, Wojciech; Przybyłko, Nikodem; Bażowski, Piotr; Właszczuk, Adam; Kwiek, Stanisław

2016-01-01

Summary The anterior cerebral artery is a common location of intracranial aneurysms. The standard coil embolization technique is limited by its inability to occlude wide-neck aneurysms. Stent deployment across the aneurysm neck supports the coil mass inside the aneurysmal sac, and furthermore, has an effect on local hemodynamic and biologic changes. In this article, various management strategies and techniques as well as angiographic outcomes and complications related to stent-assisted endovascular treatment of anterior communicating artery aneurysms are presented. This treatment method is safe and associated with low morbidity and mortality rates. PMID:27559426

Risk of rupture of unruptured cerebral aneurysms in elderly patients

PubMed Central

Date, Isao; Tokunaga, Koji; Tominari, Shinjiro; Nozaki, Kazuhiko; Shiokawa, Yoshiaki; Houkin, Kiyohiro; Murayama, Yuichi; Ishibashi, Toshihiro; Takao, Hiroyuki; Kimura, Toshikazu; Nakayama, Takeo; Morita, Akio

2015-01-01

Objectives: The aim of this study was to identify risk factors for rupture of unruptured cerebral aneurysms (UCAs) in elderly Japanese patients aged 70 years or older. Methods: The participants included all patients 70 years of age or older in 3 prospective studies in Japan (the Unruptured Cerebral Aneurysm Study of Japan [UCAS Japan], UCAS II, and the prospective study at the Jikei University School of Medicine). A total of 1,896 patients aged 70 years or older with 2,227 UCAs were investigated. The median and mean follow-up periods were 990 and 802.7 days, respectively. Results: The mean aneurysm size was 6.2 ± 3.9 mm. Sixty-eight patients (3.6%) experienced subarachnoid hemorrhage during the follow-up period. Multivariable analysis per patient revealed that in patients aged 80 years or older (hazard ratio [HR], 2.02; 95% confidence interval [CI], 1.16–3.49, p = 0.012), aneurysms 7 mm or larger (HR, 3.08; 95% CI, 1.35–7.03, p = 0.007 for 7–9 mm; HR, 7.82; 95% CI, 3.60–16.98, p < 0.001 for 10–24 mm; and HR, 43.31; 95% CI, 12.55–149.42, p < 0.001 for ≥25 mm) and internal carotid–posterior communicating artery aneurysms (HR, 2.45; 95% CI, 1.23–4.88, p = 0.011) were independent predictors for UCA rupture in elderly patients. Conclusions: In our pooled analysis of prospective cohorts in Japan, patient age and aneurysm size and location were significant risk factors for UCA rupture in elderly patients. PMID:26511450

The Impact of Deep Versus Moderate Hypothermia on Postoperative Kidney Function After Elective Aortic Hemiarch Repair.

PubMed

Arnaoutakis, George J; Vallabhajosyula, Prashanth; Bavaria, Joseph E; Sultan, Ibrahim; Siki, Mary; Naidu, Suveeksha; Milewski, Rita K; Williams, Matthew L; Hargrove, W Clark; Desai, Nimesh D; Szeto, Wilson Y

2016-10-01

There remains concern that moderate hypothermic circulatory arrest (MHCA) with antegrade cerebral perfusion (ACP) may provide suboptimal distal organ protection compared with deep hypothermic circulatory arrest (DHCA) with retrograde cerebral perfusion (RCP). We compared postoperative acute kidney injury (AKI) in in patients who underwent elective hemiarch repair with either DHCA/RCP or MHCA/ACP. This was a retrospective review of all patients undergoing elective aortic hemiarch reconstruction for aneurysmal disease between 2009 and 2014. Patients were stratified according to the use of DHCA/RCP versus MHCA/ACP. The primary outcome was the occurrence of AKI at 48 hours, as defined by the Risk, Injury, Failure, Loss, End-Stage (RIFLE ) criteria. A multivariable logistic regression identified risk factors for AKI. One hundred eighteen patients who underwent ACP and 471 patients who underwent RCP were included. The mean lowest temperature was 26.4°C in patients who underwent MHCA/ACP and 17.5°C in patients who underwent DHCA/RCP. Baseline demographics were similar except that patients who underwent DHCA/RCP were more likely to have peripheral arterial disease or bicuspid aortic valves. Cardiopulmonary bypass and aortic cross-clamp times were shorter in the MHCA/ACP group. AKI occurred in 19 (16.2%) patients who underwent MHCA/ACP and 67 (14.3%) patients who underwent DHCA/RCP. Four (0.8%) patients who underwent DHCA/RCP required postoperative dialysis. In-hospital mortality tended to increase with increasing RIFLE classification (RIFLE class-0 (No AKI) = 0.41%; Risk = 1.35%, and Injury = 10.0%; p = 0.09). On multivariable analysis, the lowest temperature and cerebral perfusion strategy were not significant predictors of AKI. Lower baseline glomerular filtration rate (GFR), lower preoperative ejection fraction, and longer cardiopulmonary bypass (CPB) time were independently associated with higher AKI. We applied the sensitive RIFLE criteria to examine AKI in patients undergoing elective aortic hemiarch replacement for aneurysmal disease. Baseline renal dysfunction, lower ejection fraction, and longer CPB time are independent predictors of AKI. Compared with DHCA/RCP, our data suggest that an MHCA/ACP cerebral protection strategy does not appear to be associated with worse postoperative renal outcomes. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Is fetal-type posterior cerebral artery a risk factor for intracranial aneurysm as analyzed by multislice CT angiography?

PubMed

He, Zhen; Wan, Yeda

2018-01-01

Fetal-type posterior cerebral artery (FTP) is a common anatomic variation that is closely associated with intracranial aneurysm. In the present study, multislice computed tomography angiography (CTA) was performed to assess whether FTP is a risk factor for intracranial aneurysm. CTA data of 364 consecutive cases of patients who were suspected with cerebrovascular disease or intracranial aneurysm of intracranial artery from 2013 to 2016 were reviewed and the incidence rates of FTP, other variations of the circle of Willis, intracranial aneurysm and FTP with intracranial aneurysm were evaluated. The χ 2 test was used to assess the influence of FTP and gender on the incidence rates of other variations of the circle of Willis, intracranial aneurysm and internal carotid artery-posterior communicating artery (ICA-PComA) aneurysm. Binary logistic regression analysis was performed to assess the associations of FTP and gender with intracranial aneurysm and ICA-PComA aneurysm. Compared with non-FTP patients, FTP cases exhibited significantly higher rates of other variations of the circle of Willis (χ 2 =80.173, P<0.001) and ICA-PComA aneurysm (χ 2 =4.437, P=0.035). Among patients with FTP and bilateral FTP, more female than male patients with intracranial aneurysm were identified. However, among all patients with intracranial aneurysm, no statistically significant differences in the prevalence of FTP (χ 2 =2.577, P=0.108) and bilateral FTP (χ 2 =2.199, P=0.159) between males and females were identified. Binary logistic regression analysis revealed that FTP and gender were risk factors for intracranial aneurysm and ICA-PComA aneurysm. A moderate association between FTP and ICA-PComA aneurysm (OR=2.762) were identified, although there was a weak association between FTP and intracranial aneurysm [odds ratio (OR)=1.365]. Furthermore, a strong association was identified between gender and intracranial aneurysm (OR=0.328), and a moderate association existed between gender and ICA-PComA aneurysm (OR=0.357). In conclusion, female gender is an independent risk factor for intracranial aneurysm, and FTP and female gender are independent risk factors for ICA-PComA aneurysm.

Is fetal-type posterior cerebral artery a risk factor for intracranial aneurysm as analyzed by multislice CT angiography?

PubMed Central

He, Zhen; Wan, Yeda

2018-01-01

Fetal-type posterior cerebral artery (FTP) is a common anatomic variation that is closely associated with intracranial aneurysm. In the present study, multislice computed tomography angiography (CTA) was performed to assess whether FTP is a risk factor for intracranial aneurysm. CTA data of 364 consecutive cases of patients who were suspected with cerebrovascular disease or intracranial aneurysm of intracranial artery from 2013 to 2016 were reviewed and the incidence rates of FTP, other variations of the circle of Willis, intracranial aneurysm and FTP with intracranial aneurysm were evaluated. The χ2 test was used to assess the influence of FTP and gender on the incidence rates of other variations of the circle of Willis, intracranial aneurysm and internal carotid artery-posterior communicating artery (ICA-PComA) aneurysm. Binary logistic regression analysis was performed to assess the associations of FTP and gender with intracranial aneurysm and ICA-PComA aneurysm. Compared with non-FTP patients, FTP cases exhibited significantly higher rates of other variations of the circle of Willis (χ2=80.173, P<0.001) and ICA-PComA aneurysm (χ2=4.437, P=0.035). Among patients with FTP and bilateral FTP, more female than male patients with intracranial aneurysm were identified. However, among all patients with intracranial aneurysm, no statistically significant differences in the prevalence of FTP (χ2=2.577, P=0.108) and bilateral FTP (χ2=2.199, P=0.159) between males and females were identified. Binary logistic regression analysis revealed that FTP and gender were risk factors for intracranial aneurysm and ICA-PComA aneurysm. A moderate association between FTP and ICA-PComA aneurysm (OR=2.762) were identified, although there was a weak association between FTP and intracranial aneurysm [odds ratio (OR)=1.365]. Furthermore, a strong association was identified between gender and intracranial aneurysm (OR=0.328), and a moderate association existed between gender and ICA-PComA aneurysm (OR=0.357). In conclusion, female gender is an independent risk factor for intracranial aneurysm, and FTP and female gender are independent risk factors for ICA-PComA aneurysm. PMID:29434687

Verification of a research prototype for hemodynamic analysis of cerebral aneurysms.

PubMed

Suzuki, Takashi; Ioan Nita, Cosmin; Rapaka, Saikiran; Takao, Hiroyuki; Mihalef, Viorel; Fujimura, Soichiro; Dahmani, Chihebeddine; Sharma, Puneet; Mamori, Hiroya; Ishibashi, Toshihiro; Redel, Thomas; Yamamoto, Makoto; Murayama, Yuichi

2016-08-01

Owing to its clinical importance, there has been a growing body of research on understanding the hemodynamics of cerebral aneurysms. Traditionally, this work has been performed using general-purpose, state-of-the-art commercial solvers. This has meant requiring engineering expertise for making appropriate choices on the geometric discretization, time-step selection, choice of boundary conditions etc. Recently, a CFD research prototype has been developed (Siemens Healthcare GmbH, Prototype - not for diagnostic use) for end-to-end analysis of aneurysm hemodynamics. This prototype enables anatomical model preparation, hemodynamic computations, advanced visualizations and quantitative analysis capabilities. In this study, we investigate the accuracy of the hemodynamic solver in the prototype against a commercially available CFD solver ANSYS CFX 16.0 (ANSYS Inc., Canonsburg, PA, www.ansys.com) retrospectively on a sample of twenty patient-derived aneurysm models, and show good agreement of hemodynamic parameters of interest.

[Neuroimaging follow-up of cerebral aneurysms treated with endovascular techniques].

PubMed

Delgado, F; Saiz, A; Hilario, A; Murias, E; San Román Manzanera, L; Lagares Gomez-Abascal, A; Gabarrós, A; González García, A

2014-01-01

There are no specific recommendations in clinical guidelines about the best time, imaging tests, or intervals for following up patients with intracranial aneurysms treated with endovascular techniques. We reviewed the literature, using the following keywords to search in the main medical databases: cerebral aneurysm, coils, endovascular procedure, and follow-up. Within the Cerebrovascular Disease Group of the Spanish Society of Neuroradiology, we aimed to propose recommendations and an orientative protocol based on the scientific evidence for using neuroimaging to monitor intracranial aneurysms that have been treated with endovascular techniques. We aimed to specify the most appropriate neuroimaging techniques, the interval, the time of follow-up, and the best approach to defining the imaging findings, with the ultimate goal of improving clinical outcomes while optimizing and rationalizing the use of available resources. Copyright © 2013 SERAM. Published by Elsevier Espana. All rights reserved.

The impact of hybrid neurosurgeons on the outcomes of endovascular coiling for unruptured cerebral aneurysms

PubMed Central

Bekelis, Kimon; Gottlieb, Dan; Labropoulos, Nicos; Su, Yin; Tzoumakaris, Stavropoula; Jabbour, Pasqual; MacKenzie, Todd A.

2017-01-01

Background The impact of combined practices on the outcomes of unruptured cerebral aneurysm coiling remains an issue of debate. We investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm coiling. Methods We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent endovascular coiling for unruptured cerebral aneurysms from 2007 to 2012. In order to control for confounding we used propensity score conditioning, with mixed effects to account for clustering at the HRR level. Results During the study period, there were 11,716 patients, who underwent endovascular coiling for unruptured cerebral aneurysms, and met the inclusion criteria. Of these, 1,186 (10.1%) underwent treatment by hybrid neurosurgeons, and 10,530 (89.9%) by proceduralists who performed only endovascular coiling. Multivariable regression analysis with propensity score adjustment demonstrated lack of association of combined practice with 1-year postoperative mortality (OR, 0.84; 95% CI, 0.58–1.23), discharge to rehabilitation (OR, 1.0; 95% CI, 0.66–1.51), 30-day readmission rate (OR, 1.07; 95% CI, 0.83–1.38) and length of stay (LOS) (adjusted difference, 0.41; 95% CI, −0.26 to 1.09). Higher procedural volume was independently associated with improved outcomes. Conclusions In a cohort of Medicare patients, we did not demonstrate a difference in mortality, discharge to rehabilitation, readmission rate, and LOS between hybrid neurosurgeons, and proceduralists only performing endovascular coiling. Funding Supported by grants from the National Institute on Aging (PO1- AG19783), the National Institutes of Health Common Fund (U01-AG046830), and the National Center for Advancing Translational Sciences (NCATS) of the NIH (Dartmouth Clinical and Translational Science Institute-UL1TR001086). The funders had no role in the design or execution of the study. PMID:26918479

EARLYDRAIN- outcome after early lumbar CSF-drainage in aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

PubMed Central

2011-01-01

Background Aneurysmal subarachnoid hemorrhage (SAH) may be complicated by delayed cerebral ischemia, which is a major cause of unfavorable clinical outcome and death in SAH-patients. Delayed cerebral ischemia is presumably related to the development of vasospasm triggered by the presence of blood in the basal cisterns. To date, oral application of the calcium antagonist nimodipine is the only prophylactic treatment for vasospasm recognized under international guidelines. In retrospective trials lumbar drainage of cerebrospinal fluid has been shown to be a safe and feasible measure to remove the blood from the basal cisterns and decrease the incidence of delayed cerebral ischemia and vasospasm in the respective study populations. However, the efficacy of lumbar drainage has not been evaluated prospectively in a randomized controlled trial yet. Methods/Design This is a protocol for a 2-arm randomized controlled trial to compare an intervention group receiving early continuous lumbar CSF-drainage and standard neurointensive care to a control group receiving standard neurointensive care only. Adults suffering from a first aneurysmal subarachnoid hemorrhage whose aneurysm has been secured by means of coiling or clipping are eligible for trial participation. The effect of early CSF drainage (starting < 72 h after securing the aneurysm) will be measured in the following ways: the primary endpoint will be disability after 6 months, assessed by a blinded investigator during a personal visit or standardized telephone interview using the modified Rankin Scale. Secondary endpoints include mortality after 6 months, angiographic vasospasm, transcranial Doppler sonography (TCD) mean flow velocity in both middle cerebral arteries and rate of shunt insertion at 6 months after hospital discharge. Discussion Here, we present the study design of a multicenter prospective randomized controlled trial to investigate whether early application of a lumbar drainage improves clinical outcome after aneurysmal subarachnoid hemorrhage. Trial registration www.clinicaltrials.gov Identifier: NCT01258257 PMID:21917146

Successful Coil Embolization of a Ruptured Basilar Artery Aneurysm in a Child with Leukemia: A Case Report

PubMed Central

HAYASHI, Shihori; MAEHARA, Taketoshi; MUKAWA, Maki; AOYAGI, Masaru; YOSHINO, Yoshikazu; NEMOTO, Shigeru; ONO, Toshiaki; OHNO, Kikuo

2014-01-01

Ruptured intracranial aneurysms are rare in the pediatric population compared to adults. This has incited considerable discussion on how to treat children with this condition. Here, we report a child with a ruptured saccular basilar artery aneurysm that was successfully treated with coil embolization. A 12-year-old boy with acute lymphoblastic leukemia and accompanying abdominal candidiasis after chemotherapy suddenly complained of a severe headache and suffered consciousness disturbance moments later. Computed tomography scans and cerebral angiography demonstrated acute hydrocephalus and subarachnoid hemorrhage caused by saccular basilar artery aneurysm rupture. External ventricular drainage was performed immediately. Because the patient was in severe condition and did not show remarkable signs of central nervous system infection in cerebrospinal fluid studies, we applied endovascular treatment for the ruptured saccular basilar artery aneurysm, which was successfully occluded with coils. The patient recovered without new neurological deficits after ventriculoperitoneal shunting. Recent reports indicate that both endovascular and microsurgical techniques can be used to effectively treat ruptured cerebral aneurysms in pediatric patients. A minimally invasive endovascular treatment was effective in the present case, but long-term follow-up will be necessary to confirm the efficiency of endovascular treatment for children with ruptured saccular basilar artery aneurysms. PMID:24257487

Successful coil embolization of a ruptured basilar artery aneurysm in a child with leukemia: a case report.

PubMed

Hayashi, Shihori; Maehara, Taketoshi; Mukawa, Maki; Aoyagi, Masaru; Yoshino, Yoshikazu; Nemoto, Shigeru; Ono, Toshiaki; Ohno, Kikuo

2014-01-01

Ruptured intracranial aneurysms are rare in the pediatric population compared to adults. This has incited considerable discussion on how to treat children with this condition. Here, we report a child with a ruptured saccular basilar artery aneurysm that was successfully treated with coil embolization. A 12-year-old boy with acute lymphoblastic leukemia and accompanying abdominal candidiasis after chemotherapy suddenly complained of a severe headache and suffered consciousness disturbance moments later. Computed tomography scans and cerebral angiography demonstrated acute hydrocephalus and subarachnoid hemorrhage caused by saccular basilar artery aneurysm rupture. External ventricular drainage was performed immediately. Because the patient was in severe condition and did not show remarkable signs of central nervous system infection in cerebrospinal fluid studies, we applied endovascular treatment for the ruptured saccular basilar artery aneurysm, which was successfully occluded with coils. The patient recovered without new neurological deficits after ventriculoperitoneal shunting. Recent reports indicate that both endovascular and microsurgical techniques can be used to effectively treat ruptured cerebral aneurysms in pediatric patients. A minimally invasive endovascular treatment was effective in the present case, but long-term follow-up will be necessary to confirm the efficiency of endovascular treatment for children with ruptured saccular basilar artery aneurysms.

Neuropeptide Y - an early biomarker for cerebral vasospasm after aneurysmal subarachnoid hemorrhage.

PubMed

Schebesch, Karl-Michael; Brawanski, Alexander; Bele, Sylvia; Schödel, Petra; Herbst, Andreas; Bründl, Elisabeth; Kagerbauer, Simone Maria; Martin, Jan; Lohmeier, Anette; Stoerr, Eva-Maria; Proescholdt, Martin

2013-12-01

In the human brain, the potent vasoconstrictive neuropeptide Y (NPY) is abundantly expressed. Neuropeptide Y, which is stored in perivascular nerve fibers of the cerebral arteries, regulates the cerebral vascular diameter as well as cerebral blood flow. However, the role of NPY in the pathogenesis of cerebral vasospasm (CV) related to subarachnoid hemorrhage (SAH) is unclear. We prospectively analyzed and compared the release of endogenous NPY in the cerebrospinal fluid (CSF) of 66 patients with SAH to NPY release in a control group. Additionally, we correlated the levels of NPY with CV and consecutive ischemic stroke. Sixty-six consecutive patients (40 women, 26 men; mean age 53·1 years) with aneurysmal SAH were included. In the SAH group, CSF was drawn daily from day 1 to day 10 after the onset of SAH. The CSF of 29 patients undergoing spinal anesthesia for orthopedic surgery served as control samples. The NPY levels were determined in duplicate CSF samples by means of a competitive enzyme immunoassay (EIA). The levels of NPY in CSF were correlated with the development of CV over the 10-day period after the onset of SAH and to the occurrence of consecutive ischemic stroke. To evaluate CSF NPY levels as a predictive biomarker for vasospasm, we calculated the sensitivity and specificity as well as the positive and negative predictive values. The NPY levels were significantly higher in the SAH group than in the control group (p < 0·001). The treatment modality (clip versus coil) did not influence the level of NPY in CSF (p > 0·05). Patients with CV showed significantly higher NPY levels than patients without CV during the entire observation period. The NPY levels of the non-CV group dissipated over time, whereas the CV group showed continuously increasing values. The NPY levels from day 4 to 10 were significantly higher in patients with CV-related stroke than in non-stroke patients. Using 0·3 ng/ml as a cut-off value, NPY levels on day 3 predicted the occurrence of CV with a sensitivity and specificity of 82% and 72%, respectively. High NPY levels, starting on day 4, significantly correlated with poor Glasgow Outcome Score grading at the follow-up (p < 0·05). Our data indicate that NPY is involved in the pathogenesis of SAH-related CV and ischemia. Neuropeptide Y represents an early and reliable biomarker for the prediction of CV and consecutive stroke due to aneurysmal SAH.

Relevance of Occlusion Test in Endovascular Coiling of Posterior Cerebral Artery (P2 Segment) Aneurysms

PubMed Central

Jayakumar, P. N.; Desai, S.; Srikanth, S. G.; Ravishankar, S.; Kovoor, J. M. E.

2004-01-01

Summary P2 segment aneurysms are located on the posterior cerebral artery (PCA) between the junction of the posterior communicating artery with the PCA and the quadrigeminal cisternal part of the PCA. We reviewed our experience with endovascular coiling in such aneurysms. Clinical and pre-procedural data from four patients, referred for endovascular treatment of P2 segment aneurysms, were retrospectively studied for factors influencing post-interventional neurological deficits caused by ischemia of the PCA distal territory. Balloon occlusion was done in three patients and patient tolerance was assessed using clinical and anatomic criteria. Embryologic and anatomic features of the PCA were reviewed. Balloon occlusion test and endovascular coiling of aneurysms was possible in three patients. Control angiogram after embolization showed elimination of aneurysms from the circulation and the distal PCA filled through leptomeningeal anastomoses. One patient deteriorated due to aneurysmal rupture soon after the balloon occlusion test and coiling could not be done. In the other three patients post-intervention CT and MRI images showed PCA territory infarcts in spite of demonstration of good collateral circulation distal to the occluded PCA. In conclusion, P2 aneurysms can be effectively treated by endovascular coiling without a balloon occlusion test. While the balloon occlusion test does not contribute to clinical decision-making it may be associated with potential morbidity and mortality. PMID:20587236

Play dough as an educational tool for visualization of complicated cerebral aneurysm anatomy

PubMed Central

Eftekhar, Behzad; Ghodsi, Mohammad; Ketabchi, Ebrahim; Ghazvini, Arman Rakan

2005-01-01

Background Imagination of the three-dimensional (3D) structure of cerebral vascular lesions using two-dimensional (2D) angiograms is one of the skills that neurosurgical residents should achieve during their training. Although ongoing progress in computer software and digital imaging systems has facilitated viewing and interpretation of cerebral angiograms enormously, these facilities are not always available. Methods We have presented the use of play dough as an adjunct to the teaching armamentarium for training in visualization of cerebral aneurysms in some cases. Results The advantages of play dough are low cost, availability and simplicity of use, being more efficient and realistic in training the less experienced resident in comparison with the simple drawings and even angiographic views from different angles without the need for computers and similar equipment. The disadvantages include the psychological resistance of residents to the use of something in surgical training that usually is considered to be a toy, and not being as clean as drawings or computerized images. Conclusion Although technology and computerized software using the patients' own imaging data seems likely to become more advanced in the future, use of play dough in some complicated cerebral aneurysm cases may be helpful in 3D reconstruction of the real situation. PMID:15885141

Superselective Wada test for ruptured spontaneous fusiform middle cerebral artery aneurysm: a technical case report.

PubMed

Rajpal, Sharad; Moftakhar, Roham; Bauer, Andrew M; Turk, Aquilla S; Niemann, David B

2011-09-01

Spontaneous fusiform aneurysms of the middle cerebral artery (sfaMCA) are quite uncommon and tend to occur in young adults. The use of superselective angiography for ruptured and unruptured aneurysms can help delineate vital angioarchitecture and assist with perioperative planning and treatment modality. The use of superselective Wada testing (SWT) for treatment of a ruptured sfaMCA involving the dominant hemisphere, however, has never been described in the English literature. We report a case of a ruptured sfaMCA involving the dominant hemisphere where superselective angiography and SWT were utilized to predict the ability to occlude a major vessel without adverse neurological sequelae. A healthy young patient presented with subarachnoid hemorrhage. Initial CT-angiogram of the head identified a left-sided fusiform MCA aneurysm measuring 1.3 cm by 0.5 cm in maximum dimensions. Diagnostic angiography evaluation demonstrated an irregular, fusiform aneurysm involving the central (Rolandic) trunk of the left MCA. An SWT was then performed through an SL 10 microcatheter with injection of sodium amytal. Verbal, motor and cognitive testing were performed twice and revealed no neurological defects. The patient underwent subsequent coil embolization of the aneurysm. Formal post-procedure evaluation revealed no speech, language or cognitive deficits. She was eventually discharged home and remained without neurological deficits at her follow-up appointment 12 months after her initial presentation. Intraoperative SWT can be performed as part of the initial evaluation for patients with sfaMCA of the dominant cerebral hemisphere to help choose the appropriate treatment algorithm and predict post-treatment neurological deficits.

Training in Cerebral Aneurysm Clipping Using Self-Made 3-Dimensional Models.

PubMed

Mashiko, Toshihiro; Kaneko, Naoki; Konno, Takehiko; Otani, Keisuke; Nagayama, Rie; Watanabe, Eiju

Recently, there have been increasingly fewer opportunities for junior surgeons to receive on-the-job training. Therefore, we created custom-built three-dimensional (3D) surgical simulators for training in connection with cerebral aneurysm clipping. Three patient-specific models were composed of a trimmed skull, retractable brain, and a hollow elastic aneurysm with its parent artery. The brain models were created using 3D printers via a casting technique. The artery models were made by 3D printing and a lost-wax technique. Four residents and 2 junior neurosurgeons attended the training courses. The trainees retracted the brain, observed the parent arteries and aneurysmal neck, selected the clip(s), and clipped the neck of an aneurysm. The duration of simulation was recorded. A senior neurosurgeon then assessed the trainee's technical skill and explained how to improve his/her performance for the procedure using a video of the actual surgery. Subsequently, the trainee attempted the clipping simulation again, using the same model. After the course, the senior neurosurgeon assessed each trainee's technical skill. The trainee critiqued the usefulness of the model and the effectiveness of the training course. Trainees succeeded in performing the simulation in line with an actual surgery. Their skills tended to improve upon completion of the training. These simulation models are easy to create, and we believe that they are very useful for training junior neurosurgeons in the surgical techniques needed for cerebral aneurysm clipping. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

CFD and PIV Analysis of Hemodynamics in a Growing Intracranial Aneurysm

PubMed Central

Raschi, Marcelo; Mut, Fernando; Byrne, Greg; Putman, Christopher M.; Tateshima, Satoshi; Viñuela, Fernando; Tanoue, Tetsuya; Tanishita, Kazuo; Cebral, Juan R.

2011-01-01

Hemodynamics is thought to be a fundamental factor in the formation, progression and rupture of cerebral aneurysms. Understanding these mechanisms is important to improve their rupture risk assessment and treatment. In this study we analyze the blood flow field in a growing cerebral aneurysm using experimental particle image velocimetry (PIV) and computational fluid dynamics (CFD) techniques. Patient-specific models were constructed from longitudinal 3D computed tomography angiography (CTA) images acquired at one-year intervals. Physical silicone models were constructed from the CTA images using rapid prototyping techniques and pulsatile flow fields were measured with PIV. Corresponding CFD models were created and run under matching flow conditions. Both flow fields were aligned, interpolated, and compared qualitatively by inspection and quantitatively by defining similarity measures between the PIV and CFD vector fields. Results showed that both flow fields were in good agreement. Specifically, both techniques provided consistent representations of the main intra-aneurysmal flow structures, and their change during the geometric evolution of the aneurysm. Despite differences observed mainly in the near wall region and the inherent limitations of each technique, the information derived is consistent and can be used to study the role of hemodynamics in the natural history of intracranial aneurysms. PMID:22548127

Microsurgical Repair of Ruptured Aneurysms Associated with Moyamoya-Pattern Collateral Vessels of the Middle Cerebral Artery: A Report of Two Cases.

PubMed

Lang, Min; Moore, Nina Z; Witek, Alex M; Kshettry, Varun R; Bain, Mark D

2017-09-01

Patients with Moyamoya or other intracranial steno-occlusive disease are at risk for developing aneurysms associated with flow through collateral vessels. Because these lesions are rare, the optimal management remains unclear. Here, we describe 2 cases of microsurgical repair of ruptured collateral vessel aneurysms associated with middle cerebral artery (MCA) occlusion. The first patient was a 61-year-old man who presented with right frontal and intraventricular hemorrhage. Angiography revealed chronic right M1 occlusion and a 3-mm spherical lenticulostriate aneurysm. The frontal lobe hematoma was evacuated to reveal the aneurysm, which was safely cauterized and resected by coagulating and dividing the lenticulostriate parent vessel. The procedure was carried out with neuronavigation guidance and intraoperative neuromonitoring. The patient was discharged with no neurologic deficits. The second patient was a 53-year-old woman who presented with subarachnoid and intracerebral hemorrhage. Computed tomography angiogram showed a 2-mm saccular MCA aneurysm. Emergency left decompressive hemicraniectomy and hematoma evacuation were performed. The aneurysm, arising from a small collateral type vessel, was safely clipped without complications. Postoperative angiography revealed absence of the superior MCA trunk with a dense network of collateral vessels at the site of the clipped aneurysm. The patient recovered well and was ambulating independently 6 months postoperatively. No rebleeding occurred in the 2 patients. Our experience suggests that patients with MCA occlusion can harbor associated aneurysms related to flow through collateral vessels and can present with hemorrhage. Microsurgical repair of these aneurysms can be performed safely to prevent rebleeding. Copyright © 2017 Elsevier Inc. All rights reserved.

Revascularization of the anterior cerebral artery by Y-shaped superficial temporal artery interposition graft for the treatment of a de novo aneurysm arising at the site of A3-A3 bypass: technical case report.

PubMed

Endo, Hidenori; Sugiyama, Shin-Ichiro; Endo, Toshiki; Fujimura, Miki; Shimizu, Hiroaki; Tominaga, Teiji

2017-12-22

The most frequently used option to reconstruct the anterior cerebral artery (ACA) is an ACA-ACA side-to-side anastomosis. The long-term outcome and complications of this technique are unclear. The authors report a case of a de novo aneurysm arising at the site of A 3 -A 3 anastomosis. A 53-year-old woman underwent A 3 -A 3 side-to-side anastomosis for the treatment of a ruptured right A 2 dissecting aneurysm. At 44 months after surgery, a de novo aneurysm developed at the site of anastomosis. The aneurysm developed in the front wall of the anastomosis site, and projected to the anterosuperior direction. A computational fluid dynamics (CFD) study showed the localized region with high wall shear stress coincident with the pulsation in the front wall of the anastomosis site, where the aneurysm developed. A Y-shaped superficial temporal artery (STA) interposition graft was used successfully to reconstruct both ACAs, and then the aneurysm was trapped. To the authors' knowledge, this is the first case of a de novo aneurysm that developed at the site of an ACA-ACA side-to-side anastomosis. A CFD study showed that hemodynamic stress might be an underlying cause of the aneurysm formation. A Y-shaped STA interposition graft is a useful option to treat this aneurysm. Long-term follow-up is necessary to detect this rare complication after ACA-ACA anastomosis.

Treatment of Recurrent Intracranial Aneurysms After Clipping: A Report of 23 Cases and a Review of the Literature.

PubMed

Hokari, Masaaki; Kazumara, Ken; Nakayama, Naoki; Ushikoshi, Satoshi; Sugiyama, Taku; Asaoka, Katsunori; Uchida, Kazuki; Shimbo, Daisuke; Itamoto, Koji; Yokoyama, Yuka; Isobe, Masanori; Imai, Tetsuaki; Osanai, Toshiya; Houkin, Kiyohiro

2016-08-01

There are no established treatment strategies for aneurysms that recur after clipping. In this study, we present cases of patients who experienced recurrent aneurysms after clipping and subsequently underwent surgical intervention. Between 2004 and 2015, we surgically treated 23 aneurysms that recurred at a previously clipped site. Patient characteristics and clinical history were retrospectively reviewed. Patients included 19 women and 4 men 45-81 years old. Aneurysms recurred 3-31 years (mean, 15.4 years) after the initial operation. For 18 cases, the first clinical presentation was a subarachnoid hemorrhage; aneurysms were incidentally diagnosed in 5 patients. Aneurysm locations were as follows: 9 on the internal carotid artery; 4 on the middle cerebral artery; 7 on the anterior communicating artery; 2 on the distal anterior cerebral artery; and 1 on the basilar artery. The reasons for retreatment included subarachnoid hemorrhage (n = 9) and aneurysm regrowth detected on follow-up examinations (n = 14). Endovascular treatment was performed in 10 cases, and direct surgery was performed in 13 cases (clipping in 8, clipping or trapping with bypass in 5). Various complex vascular reconstructions, including high-flow bypass and intracranial-intracranial in situ bypass, were performed for recurrent aneurysms. In our experience, coil embolization is a safe and effective procedure for treating recurrent aneurysms. When cases are unsuitable for coil embolization, surgical treatment often requires neurosurgeons not only to overcome the general technical difficulty of reoperative clipping but also to perform challenging vascular reconstruction. Copyright © 2016. Published by Elsevier Inc.

Verapamil-induced breakdown of the blood-brain barrier presenting as a transient right middle cerebral artery syndrome.

PubMed

Pace, Jonathan; Nelson, Jeffrey; Ray, Abhishek; Hu, Yin

2017-12-01

A middle-aged patient presented for elective embolization of an incidentally found right internal carotid aneurysm. An angiogram was performed, during which the left internal carotid artery was visualized to evaluate a second, small aneurysm. During the embolization of the right internal carotid artery aneurysm, a catheter-induced vasospasm was identified that prompted treatment with intra-arterial verapamil. The procedure was uncomplicated; a postoperative rotational flat-panel computed tomography scan was performed on the angiography table that demonstrated right hemisphere contrast staining. The patient developed a right middle cerebral artery (MCA) syndrome after extubation with repeat cerebral angiography negative for occlusion and magnetic resonance imaging negative for stroke. The patient was observed for 48 hours, during which time the patient had slowly improved. At a six-week follow up visit, the patient had fully recovered. We present an interesting case of a verapamil-induced breakdown of the blood-brain barrier and self-limited right MCA syndrome.

3D real-time visualization of blood flow in cerebral aneurysms by light field particle image velocimetry

NASA Astrophysics Data System (ADS)

Carlsohn, Matthias F.; Kemmling, André; Petersen, Arne; Wietzke, Lennart

2016-04-01

Cerebral aneurysms require endovascular treatment to eliminate potentially lethal hemorrhagic rupture by hemostasis of blood flow within the aneurysm. Devices (e.g. coils and flow diverters) promote homeostasis, however, measurement of blood flow within an aneurysm or cerebral vessel before and after device placement on a microscopic level has not been possible so far. This would allow better individualized treatment planning and improve manufacture design of devices. For experimental analysis, direct measurement of real-time microscopic cerebrovascular flow in micro-structures may be an alternative to computed flow simulations. An application of microscopic aneurysm flow measurement on a regular basis to empirically assess a high number of different anatomic shapes and the corresponding effect of different devices would require a fast and reliable method at low cost with high throughout assessment. Transparent three dimensional 3D models of brain vessels and aneurysms may be used for microscopic flow measurements by particle image velocimetry (PIV), however, up to now the size of structures has set the limits for conventional 3D-imaging camera set-ups. On line flow assessment requires additional computational power to cope with the processing large amounts of data generated by sequences of multi-view stereo images, e.g. generated by a light field camera capturing the 3D information by plenoptic imaging of complex flow processes. Recently, a fast and low cost workflow for producing patient specific three dimensional models of cerebral arteries has been established by stereo-lithographic (SLA) 3D printing. These 3D arterial models are transparent an exhibit a replication precision within a submillimeter range required for accurate flow measurements under physiological conditions. We therefore test the feasibility of microscopic flow measurements by PIV analysis using a plenoptic camera system capturing light field image sequences. Averaging across a sequence of single double or triple shots of flashed images enables reconstruction of the real-time corpuscular flow through the vessel system before and after device placement. This approach could enable 3D-insight of microscopic flow within blood vessels and aneurysms at submillimeter resolution. We present an approach that allows real-time assessment of 3D particle flow by high-speed light field image analysis including a solution that addresses high computational load by image processing. The imaging set-up accomplishes fast and reliable PIV analysis in transparent 3D models of brain aneurysms at low cost. High throughput microscopic flow assessment of different shapes of brain aneurysms may therefore be possibly required for patient specific device designs.

Role of 0D peripheral vasculature model in fluid-structure interaction modeling of aneurysms

NASA Astrophysics Data System (ADS)

Torii, Ryo; Oshima, Marie; Kobayashi, Toshio; Takagi, Kiyoshi; Tezduyar, Tayfun E.

2010-06-01

Patient-specific simulations based on medical images such as CT and MRI offer information on the hemodynamic and wall tissue stress in patient-specific aneurysm configurations. These are considered important in predicting the rupture risk for individual aneurysms but are not possible to measure directly. In this paper, fluid-structure interaction (FSI) analyses of a cerebral aneurysm at the middle cerebral artery (MCA) bifurcation are presented. A 0D structural recursive tree model of the peripheral vasculature is incorporated and its impedance is coupled with the 3D FSI model to compute the outflow through the two branches accurately. The results are compared with FSI simulation with prescribed pressure variation at the outlets. The comparison shows that the pressure at the two outlets are nearly identical even with the peripheral vasculature model and the flow division to the two branches is nearly the same as what we see in the simulation without the peripheral vasculature model. This suggests that the role of the peripheral vasculature in FSI modeling of the MCA aneurysm is not significant.

Intraoperative Matas test using microscope-integrated intraoperative indocyanine green videoangiography with temporary unilateral occlusion of the A1 segment of the anterior cerebral artery.

PubMed

Murai, Yasuo; Adachi, Koji; Takagi, Ryo; Koketsu, Kenta; Matano, Fumihiro; Teramoto, Akira

2011-11-01

The aim of the present study was to assess a new technique of surgical microscope-based indocyanine green (ICG) videoangiography (VAG) to confirm the patency of the anterior communicating artery (AcomA) after clipping AcomA aneurysms. Aneurysmal clipping of five cases of unruptured, broad-neck AcomA aneurysm was performed using the Carl Zeiss Surgical Microscope OPMI Pentero INFRARED 800. In all five patients, after clipping AcomA aneurysms, the patency of AcomA was confirmed using ICGVAG findings and temporary unilateral occlusion of the A1 segment of the anterior cerebral artery using temporary clips. Images were excellent and enabled a real-time surgical assessment because the structures of interest, including vessels, perforating arteries, or residual aneurysm neck, were visible to the surgeon's eye under the microscope in all five patients. ICGVAG and temporary unilateral occlusion with clips provides a simple, reliable, real-time, and rapid intraoperative assessment of the patency of AcomA. This technique may help to improve the quality of neurosurgical procedures. Copyright © 2011 Elsevier Inc. All rights reserved.

Surgical management of an ACM aneurysm eight years after coiling.

PubMed

Pogády, P; Fellner, F; Trenkler, J; Wurm, G

2007-04-01

The authors present a case report on rebleeding of a medial cerebral aneurysm (MCA) eight years after complete endovascular coiling. The primarily successfully coiled MCA aneurysm showed a local regrowth which, however, was not the source of the rebleeding. The angiogram demonstrated no evidence of contrast filling of the coiled segment, but according to intraoperative findings (haematoma location, displacement of coils, evident place of rupture) there is no doubt that the coiled segment of the aneurysm was responsible for the haemorrhage.

Impact of metal artifact reduction software on image quality of gemstone spectral imaging dual-energy cerebral CT angiography after intracranial aneurysm clipping.

PubMed

Dunet, Vincent; Bernasconi, Martine; Hajdu, Steven David; Meuli, Reto Antoine; Daniel, Roy Thomas; Zerlauth, Jean-Baptiste

2017-09-01

We aimed to assess the impact of metal artifact reduction software (MARs) on image quality of gemstone spectral imaging (GSI) dual-energy (DE) cerebral CT angiography (CTA) after intracranial aneurysm clipping. This retrospective study was approved by the institutional review board, which waived patient written consent. From January 2013 to September 2016, single source DE cerebral CTA were performed in 45 patients (mean age: 60 ± 9 years, male 9) after intracranial aneurysm clipping and reconstructed with and without MARs. Signal-to-noise (SNR), contrast-to-noise (CNR), and relative CNR (rCNR) ratios were calculated from attenuation values measured in the internal carotid artery (ICA) and middle cerebral artery (MCA). Volume of clip and artifacts and relative clip blurring reduction (rCBR) ratios were also measured at each energy level with/without MARs. Variables were compared between GSI and GSI-MARs using the paired Wilcoxon signed-rank test. MARs significantly reduced metal artifacts at all energy levels but 130 and 140 keV, regardless of clips' location and number. The optimal rCBR was obtained at 110 and 80 keV, respectively, on GSI and GSI-MARs images, with up to 96% rCNR increase on GSI-MARs images. The best compromise between metal artifact reduction and rCNR was obtained at 70-75 and 65-70 keV for GSI and GSI-MARs images, respectively, with up to 15% rCBR and rCNR increase on GSI-MARs images. MARs significantly reduces metal artifacts on DE cerebral CTA after intracranial aneurysm clipping regardless of clips' location and number. It may be used to reduce radiation dose while increasing CNR.

Ambulatory Care Data Base (ACDB) Data Dictionary Sequential Files of Phase 2.

DTIC Science & Technology

1992-04-01

ARTERIES 4340 CEREBRAL THROMBOSIS 43491 STROKE , ISCHEMIC 435 TRANSIENT CEREBRAL ISCHEMIA 4359 TRANSIENT ISCHEMIC ATTACK (TIA) 43591 TRANS ISCHEMIC ATTACK W...CRISIS 4373 ANEURYSM, CEREBRAL , NONRUPTURED 4374 ARTERITIS, CEREBRAL 4378 CEREBROVASCULAR DISEASE, OTHER ILL-DEFINED 43781 STROKE , LACUNAR 438 LATE...FOR LOCALIZATION OF CEREBRAL SEIZURE FOC 95999 OTHER NEUROLOGICAL DIAGNOSTIC PROCEDURES 96500 CHEMO INJ, SINGLE, PRE-MIX, PUSH 96501 CHEMO INJ, SINGLE

HIMALAIA (Hypertension Induction in the Management of AneurysmaL subArachnoid haemorrhage with secondary IschaemiA): a randomized single-blind controlled trial of induced hypertension vs. no induced hypertension in the treatment of delayed cerebral ischemia after subarachnoid hemorrhage.

PubMed

Gathier, C S; van den Bergh, W M; Slooter, A J C

2014-04-01

Delayed cerebral ischemia (DCI) is a major complication after aneurysmal subarachnoid hemorrhage (SAH). One option to treat delayed cerebral ischemia is to use induced hypertension, but its efficacy on the eventual outcome has not been proven in a randomized clinical trial. This article describes the design of the HIMALAIA trial (Hypertension Induction in the Management of AneurysmaL subArachnoid haemorrhage with secondary IschaemiA), designed to assess the effectiveness of induced hypertension on neurological outcome in patients with DCI after SAH. To investigate whether induced hypertension improves the functional outcome in patients with delayed cerebral ischemia after SAH. The HIMALAIA trial is a multicenter, singe-blinded, randomized controlled trial in patients with DCI after a recent SAH. Eligible patients will be randomized to either induced hypertension (n = 120) or to no induced hypertension (n = 120). In selected centers, the efficacy of induced hypertension in augmenting cerebral blood flow will be measured by means of cerebral perfusion computerized tomography scanning. Follow-up assessments will be performed at 3 and 12 months after randomization by trial nurses who are blinded to the treatment allocation and management. We will include patients during five years. The primary outcome is the proportion of subarachnoid hemorrhage patients with delayed cerebral ischemia with poor outcome three-months after randomization, defined as a modified Rankin scale of more than 3. Secondary outcome measures are related to treatment failure, functional outcome, adverse events, and cerebral hemodynamics. The HIMALAIA trial is registered at clinicaltrials.gov under identifier NCT01613235. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.

Intraoperative Computed Tomography (CT) for Treating Giant Carotid Intracavernous Aneurysms

PubMed Central

Xue, Zhe; Wang, Fuyu; Sun, Zhenghui; Zhang, Hui; Wu, Chen; Kong, Dongsheng; Xu, Bainan

2017-01-01

Background Giant carotid intracavernous aneurysm refers to those lesions larger than 2.5 cm and derived from a cavernous segment, accounting for about 30% of all intracranial tumors. Dynamic CT perfusion imaging (PCT) is a common method recently employed to evaluate cerebral perfusion. This study investigated the efficacy and clinical application of intraoperative CT in the surgery for giant symptomatic carotid intracavernous aneurysm. Material/Methods A retrospective analysis was performed on 23 cases with giant symptomatic carotid intracavernous aneurysm. BTO testing was performed before surgery. Differential treatments were performed based on the condition of aneurysm, and some patients received intraoperative PCT. Postoperative anti-coagulation was given with DSA or CTA follow-up examinations at 3–6 months, 1 year, and 2 years after surgery. Results A total of 17 patients received aneurysm isolation coupled with high-flow bypass surgery. Among those, 9 developed early-onset neurological function after surgery, with gradual recover within 6 months. One coma patient died 25 months after discharge. One patient had aneurysm isolation with clapping of anterior communicating artery, and the other 5 cases received artery clapping only. In those patients, 4 had improvement at early phase, while 1 patient had numbness of the oculomotor nerve. Six patients received surgery in the CT room, including 5 cases with single proximal ligation of the internal carotid artery plus 1 aneurysm isolation combined with high-flow bypass surgery. Conclusions Intraoperative PCT can provide objective evidence and effective evaluation of cerebral perfusion. PMID:28640793

Flow diverter device for the treatment of small middle cerebral artery aneurysms.

PubMed

Briganti, Francesco; Delehaye, Luigi; Leone, Giuseppe; Sicignano, Carmine; Buono, Giuseppe; Marseglia, Mariano; Caranci, Ferdinando; Tortora, Fabio; Maiuri, Francesco

2016-03-01

Experience with the endovascular treatment of middle cerebral artery (MCA) aneurysms by flow diverter devices (FDD) is still limited. This study examines the results and complications of FDD for small aneurysms at this location. From February 2010 to December 2013, 14 patients (10 women; mean age 59 years) with 15 small MCA aneurysms were treated with FDD. All procedures were performed with the Pipeline embolization device (PED). Complete occlusion was obtained in 12/15 aneurysms (80%) and partial occlusion in 3 (20%). Among 13 aneurysms with a side branch, this was patent at the angiographic control in 4 cases, showed decreased filling in 6, and was occluded in 3 (with neurological deficits in 2). All PEDs were patent at follow-up. Post-procedural ischemic complications occurred in 4 (27%) procedures with permanent neurological deficit (modified Rankin score 2) in 3 (21%). No early or delayed aneurysm rupture, no subarachnoid or intraparenchymal hemorrhage and no deaths occurred. Endovascular treatment with FDD is a relatively safe treatment for small MCA aneurysms resulting in a high occlusion rate. The findings of this study suggest that complete occlusion after endovascular treatment with FDD can be delayed (>6 months). Ischemic complications may occur as early or delayed, particularly at clopidogrel interruption. 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/

Outcomes of CSF spectrophotometry in cases of suspected subarachnoid haemorrhage with negative CT: two years retrospective review in a Birmingham hospital.

PubMed

Bakr, A; Silva, D; Cramb, R; Flint, G; Foroughi, M

2017-04-01

The aim of this study was to evaluate the adherence to current guidelines for the investigation of suspected subarachnoid haemorrhage and the prevalence and outcome of computed tomography (CT)-negative aneurysmal subarachnoid haemorrhage. A retrospective review in a single large tertiary referral centre. A total of 796 patients, aged 16-90 years, who underwent lumbar puncture (LP) for suspected subarachnoid haemorrhage (SAH) following a negative or equivocal CT scan between January 2012 and November 2013 (23 months). Xanthochromia reports were obtained using the hospital's department of biochemistry database and clinical data for these patients were reviewed using patient notes. Of 796 CSF reports reviewed, 728 (91%) were negative for xanthochromia, 31 (4%) were positive and 37 (5%) were equivocal. Only 2 out of the 31 patients with positive spectrophotometry results were subsequently found to have an underlying aneurysm on CT angiography. A further 9 out of these 31 patients underwent digital subtraction angiography, with no cerebral aneurysms being detected. Amongst the 37 patients with equivocal xanthochromia reports, 13 underwent CT angiography and only 1 cerebral aneurysm was detected. In patients with clinically suspected SAH but who have negative or questionable CT findings, CSF analysis is likely to be negative in the vast majority of cases, which was 91% in our series. In patients yielding positive or equivocal CSF results the likelihood of an aneurysm being detected is low, amounting to three out of 68 or approximately one in 23 (approximately 4%). Overall in suspected SAH cases where CT scan has been negative, the rate for the detection of cerebral aneurysm is three out of 796 cases (0.4%).

Median Supraorbital Keyhole Approach for Clipping Ruptured Distal Anterior Cerebral Artery Aneurysm: Technical Report with Review of Literature.

PubMed

Dhandapani, Sivashanmugam; Sahoo, Sushant Kumar

2018-04-01

The minimally invasive approach to distal anterior cerebral artery (DACA) aneurysms has not gained much acceptance due to difficulties associated with the conventional frontal paramedian approach. The more proximal basal interhemispheric approach, however, necessitates extensive dissection of soft tissues. We describe a novel minimally invasive median supraorbital keyhole craniotomy with a basal interhemispheric approach for clipping a ruptured DACA aneurysm. A 62-year-old patient presented with subarachnoid hemorrhage. Computed tomography angiography revealed a DACA aneurysm. The surgical technique involved a keyhole craniotomy made via an eyebrow incision extending between the supraorbital notches, and flush with the anterior cranial fossa. The dura was opened at the anterior part, the falx was cut, an interhemispheric dissection was carried out, adequate proximal control was obtained, and the aneurysm neck was dissected and clipped. A relevant review of the literature was carried out. The patient recovered well, with no residual aneurysm or forehead numbness, with good cosmesis. Compared with the previously described "keyhole unilateral interhemispheric" approaches, our technique has less likelihood of encountering bridging veins; easier cisternal cerebrospinal fluid release, making it feasible even in swollen brain; better proximal vascular control; and trajectory toward the neck rather than dome. The median supraorbital keyhole approach is a minimally invasive technique sufficient for clipping most DACA aneurysms, with easier access, better proximal control, and good cosmesis. Copyright © 2018 Elsevier Inc. All rights reserved.

Dual-Channel Endoscopic Indocyanine Green Fluorescence Angiography for Clipping of Cerebral Aneurysms.

PubMed

Cho, Won-Sang; Kim, Jeong Eun; Kang, Hyun-Seung; Ha, Eun Jin; Jung, Minwoong; Lee, Choonghee; Shin, Il Hyung; Kang, Uk

2017-04-01

Neuroendoscopy is useful for assessing status of perforators, parent arteries, and aneurysms beyond the straight line of microscopic view during aneurysm clipping. We aimed to evaluate the clinical usefulness of our endoscopic indocyanine green angiography (ICGA) system, which can simultaneously display visible light and indocyanine green fluorescent images. Surgical clipping of 16 unruptured aneurysms in 10 patients was performed via the keyhole approach. Using our endoscopic ICGA and commercial microscopic ICGA systems, we prospectively compared 10 targeted cerebral aneurysms at the posterior communicating (n = 4) and anterior choroidal (n = 6) arteries. Microscopic ICGA and endoscopic ICGA were feasible during surgery. Microscopic ICGA displayed 50% of branch orifices, 100% of branch trunks, and 20% of exact clip positions, whereas endoscopic ICGA showed 100% of these. Based on endoscopic ICGA findings such as incomplete clipping and compromise of parent arteries or branches, clips were repositioned in 2 cases, and additional clips were applied in 2 cases. Complete occlusion and residual neck states were achieved in 6 and 4 aneurysms after surgery. There were no neurologic deficits within 3 months after surgery except for frontalis palsy and anosmia in each patient. The endoscopic ICGA system with dual imaging of visible light and indocyanine green fluorescence was very useful for assessing geometry of aneurysms and surrounding vessels before clipping and for evaluating completeness of clip position after clipping. Copyright © 2017 Elsevier Inc. All rights reserved.

Clinical Outcome Prediction in Aneurysmal Subarachnoid Hemorrhage Using Bayesian Neural Networks with Fuzzy Logic Inferences

PubMed Central

Lo, Benjamin W. Y.; Macdonald, R. Loch; Baker, Andrew; Levine, Mitchell A. H.

2013-01-01

Objective. The novel clinical prediction approach of Bayesian neural networks with fuzzy logic inferences is created and applied to derive prognostic decision rules in cerebral aneurysmal subarachnoid hemorrhage (aSAH). Methods. The approach of Bayesian neural networks with fuzzy logic inferences was applied to data from five trials of Tirilazad for aneurysmal subarachnoid hemorrhage (3551 patients). Results. Bayesian meta-analyses of observational studies on aSAH prognostic factors gave generalizable posterior distributions of population mean log odd ratios (ORs). Similar trends were noted in Bayesian and linear regression ORs. Significant outcome predictors include normal motor response, cerebral infarction, history of myocardial infarction, cerebral edema, history of diabetes mellitus, fever on day 8, prior subarachnoid hemorrhage, admission angiographic vasospasm, neurological grade, intraventricular hemorrhage, ruptured aneurysm size, history of hypertension, vasospasm day, age and mean arterial pressure. Heteroscedasticity was present in the nontransformed dataset. Artificial neural networks found nonlinear relationships with 11 hidden variables in 1 layer, using the multilayer perceptron model. Fuzzy logic decision rules (centroid defuzzification technique) denoted cut-off points for poor prognosis at greater than 2.5 clusters. Discussion. This aSAH prognostic system makes use of existing knowledge, recognizes unknown areas, incorporates one's clinical reasoning, and compensates for uncertainty in prognostication. PMID:23690884

Flow in cerebral aneurysms: 4D Flow MRI measurements and CFD models

NASA Astrophysics Data System (ADS)

Rayz, Vitaliy; Schnell, Susanne

2017-11-01

4D Flow MRI is capable of measuring blood flow in vivo, providing time-resolved velocity fields in 3D. The dynamic range of the 4D Flow MRI is determined by a velocity sensitivity parameter (venc), set above the expected maximum velocity, which can result in noisy data for slow flow regions. A dual-venc 4D flow MRI technique, where both low- and high-venc data are acquired, can improve velocity-to-noise ratio and, therefore, quantification of clinically-relevant hemodynamic metrics. In this study, patient-specific CFD simulations were used to evaluate the advantages of the dual-venc approach for assessment of the flow in cerebral aneurysms. The flow in 2 cerebral aneurysms was measured in vivo with dual-venc 4D Flow MRI and simulated with CFD, using the MRI data to prescribe flow boundary conditions. The flow fields obtained with computations were compared to those measured with a single- and dual-venc 4D Flow MRI. The numerical models resolved small flow structures near the aneurysmal wall, that were not detected with a single-venc acquisition. Comparison of the numerical and imaging results shows that the dual-venc approach can improve the accuracy of the 4D Flow MRI measurements in regions characterized by high-velocity jets and slow recirculating flows.

Tuberothalamic artery infarction following coil embolization of a ruptured posterior communicating artery aneurysm belonging to a transitional type posterior cerebral artery. A case report.

PubMed

Lee, Kyeong Duk; Kwon, Soon Chan; Muniandy, Sarawana; Park, Eun Suk; Sim, Hong Bo; Lyo, In Uk

2013-09-01

There are many potential anatomical variations in the connection between the internal carotid artery and the posterior circulation through the posterior communicating artery (PCoA). We describe the endovascular treatment of an aneurysm arising near the origin of the PCoA belonging to a transitional type posterior cerebral artery. Coil embolization subsequently resulted in thrombo-occlusion of the adjacent PCoA causing thalamic infarction even though sufficient retrograde flow had been confirmed pre-operatively by Allcock's test.

Tuberothalamic Artery Infarction Following Coil Embolization of a Ruptured Posterior Communicating Artery Aneurysm Belonging to a Transitional Type Posterior Cerebral Artery

PubMed Central

Lee, Kyeong Duk; Kwon, Soon Chan; Muniandy, Sarawana; Park, Eun Suk; Sim, Hong Bo; Lyo, In Uk

2013-01-01

Summary There are many potential anatomical variations in the connection between the internal carotid artery and the posterior circulation through the posterior communicating artery (PCoA). We describe the endovascular treatment of an aneurysm arising near the origin of the PCoA belonging to a transitional type posterior cerebral artery. Coil embolization subsequently resulted in thrombo-occlusion of the adjacent PCoA causing thalamic infarction even though sufficient retrograde flow had been confirmed pre-operatively by Allcock’s test. PMID:24070079

Microsurgical Treatment of Distal Anterior Cerebral Artery Aneurysms: 3-Dimensional Operative Video.

PubMed

Agarwal, Vijay; Barrow, Daniel L

2018-05-18

Selecting appropriate patient position for surgery must take into consideration a variety of factors. For an interhemispheric approach to distal anterior cerebral artery (DACA) aneurysms, the patient may be positioned with the head either horizontal or vertical with respect to the floor. We preferentially place the patient in the supine position with the shoulder elevated and the head turned parallel to the floor with the side of the approach down and the vertex tilted 45° up. In this way, gravity is utilized to allow the right frontal lobe to fall away from the falx, eliminating the need for retraction. To demonstrate the importance of individualizing the choice of position to each patient, we present here 2 illustrative cases of DACA aneurysms in which different positioning was selected. One patient presented with a 7-mm bilobed pericallosal artery aneurysm; the aneurysm was approached with the head horizontal with respect to the floor. The second patient had a 3-mm DACA aneurysm and a right frontal proliferative angiopathy and developmental venous anomaly with evidence of prior hemorrhage. Due to the vascular anomaly, we positioned the head in a vertical position for surgery to clip the aneurysm, which was thought to be the source of hemorrhage. The videos illustrate the approach to DACA aneurysms, which typically exposes the aneurysm before complete exposure of the proximal parent artery is obtained. In one case, the use of both frameless guidance and intraoperative angiography was useful in identifying a small previously ruptured aneurysm. All appropriate patient consents were obtained for this submission. Video and Figures (0:57-1:16 and 6:30-6:37), © 2017 Department of Neurosurgery, Emory University. Used with permission.

Endoluminal Reconstruction for Nonsaccular Aneurysms of the Proximal Posterior Cerebral Artery with the Pipeline Embolization Device.

PubMed

Zumofen, D W; Shapiro, M; Becske, T; Raz, E; Potts, M B; Riina, H A; Nelson, P K

2015-07-01

Treatment options for nonsaccular posterior cerebral artery aneurysms include a range of surgical and endovascular reconstructive and deconstructive methods. However, no truly satisfactory treatment option is available to date for lesions arising from the P1 and P2 segments. The purpose of the present case series is to investigate both the efficacy and safety of the Pipeline Embolization Device in treating these challenging aneurysms. We present a series of 6 consecutive patients who underwent endoluminal reconstruction with the Pipeline Embolization Device for nonsaccular P1 or P2 segment aneurysms between January 2009 and June 2013. Aneurysm location included the P1 segment in 2 patients and the P2 segment in 4 patients. Mean aneurysm diameter was 23 mm (range, 5-44 mm). Mean length of the arterial segment involved was 10 mm (range, 6-19 mm). Clinical presentation included mass effect in 4 patients and perforator stroke and subacute aneurysmal subarachnoid hemorrhage in 1 patient each. Endovascular reconstruction was performed by using 1 Pipeline Embolization Device in 5 patients and 2 overlapping Pipeline Embolization Devices in the remaining patient. Angiographic aneurysm occlusion was immediate in 1 patient, within 6 months in 4 patients, and within 1 year in the remaining patient. Index symptoms resolved in 4 patients and stabilized in the remaining 2. No new permanent neurologic sequelae and no aneurysm recurrence were recorded during the mean follow-up period of 613 days (range, 540-725 days). Endovascular reconstruction with the Pipeline Embolization Device for nonsaccular aneurysms arising from the P1 and P2 segments compares favorably with historical treatment options in terms of occlusion rate, margin of safety, and neurologic outcome. © 2015 by American Journal of Neuroradiology.

Understanding the Role of Hemodynamics in the Initiation, Progression, Rupture, and Treatment Outcome of Cerebral Aneurysm from Medical Image-Based Computational Studies

PubMed Central

Castro, Marcelo A.

2013-01-01

About a decade ago, the first image-based computational hemodynamic studies of cerebral aneurysms were presented. Their potential for clinical applications was the result of a right combination of medical image processing, vascular reconstruction, and grid generation techniques used to reconstruct personalized domains for computational fluid and solid dynamics solvers and data analysis and visualization techniques. A considerable number of studies have captivated the attention of clinicians, neurosurgeons, and neuroradiologists, who realized the ability of those tools to help in understanding the role played by hemodynamics in the natural history and management of intracranial aneurysms. This paper intends to summarize the most relevant results in the field reported during the last years. PMID:24967285

Experimental study of physiological flow in a cerebral saccular basilar tip aneurysm

NASA Astrophysics Data System (ADS)

Tsai, William; Savas, Omer; Ortega, Jason; Maitland, Duncan; Saloner, David

2008-11-01

The subject matter of the research is the flow within cerebral saccular basilar tip aneurysms and exploring correlations with their growth and rupture. The flow phantom consists of an inlet pipe branching out 90^o into two outlets, simulating the basilar artery bifurcation and a nearly spherical dome at the flow divider simulating the aneurysm. Input flow is a physiological waveform for the basilar artery. Flow outlet branching ratios are controlled at will. Experiments are done at Reynolds numbers 221-376 and Sexl-Wormersley number 4.46. Flow visualization and particle image velocimetry are used to study velocity, vorticity, and wall shear stress. All flows can be characterized by an off-center inlet jet and a circulation region, whose transient strength and behavior depends on the outflow ratios.

Delayed pan-hypopituitarism as a complication following endovascular treatment of bilateral internal carotid artery aneurysms. A case report and review.

PubMed

Hall, Jonathan; Caputo, Carmela; Chung, Carlos; Holt, Michael; Wang, Yi Yuen

2015-04-01

Pan-hypopituitarism has been reported in patients who are subsequently found to have a cerebral aneurysm and there have been reports of pituitary dysfunction immediately following both surgical and endovascular treatment. The authors report a rare case of delayed pan-hypopituitarism following endovascular treatment of bilateral internal carotid artery aneurysms with coil embolisation and flow-diverting stents.

@neurIST complex information processing toolchain for the integrated management of cerebral aneurysms

PubMed Central

Villa-Uriol, M. C.; Berti, G.; Hose, D. R.; Marzo, A.; Chiarini, A.; Penrose, J.; Pozo, J.; Schmidt, J. G.; Singh, P.; Lycett, R.; Larrabide, I.; Frangi, A. F.

2011-01-01

Cerebral aneurysms are a multi-factorial disease with severe consequences. A core part of the European project @neurIST was the physical characterization of aneurysms to find candidate risk factors associated with aneurysm rupture. The project investigated measures based on morphological, haemodynamic and aneurysm wall structure analyses for more than 300 cases of ruptured and unruptured aneurysms, extracting descriptors suitable for statistical studies. This paper deals with the unique challenges associated with this task, and the implemented solutions. The consistency of results required by the subsequent statistical analyses, given the heterogeneous image data sources and multiple human operators, was met by a highly automated toolchain combined with training. A testimonial of the successful automation is the positive evaluation of the toolchain by over 260 clinicians during various hands-on workshops. The specification of the analyses required thorough investigations of modelling and processing choices, discussed in a detailed analysis protocol. Finally, an abstract data model governing the management of the simulation-related data provides a framework for data provenance and supports future use of data and toolchain. This is achieved by enabling the easy modification of the modelling approaches and solution details through abstract problem descriptions, removing the need of repetition of manual processing work. PMID:22670202

The Influence of Dome Size, Parent Vessel Angle, and Coil Packing Density on Coil Embolization Treatment in Cerebral Aneurysms

NASA Astrophysics Data System (ADS)

Frakes, David H.; Indahlastari, Aprinda; Ryan, Justin; Babiker, M. Haithem; Nair, Priya; Parthas, Varsha

2013-11-01

Intracranial aneurysms (ICAs) are dilated cerebral blood vessels. Treating ICAs effectively prior rupture is crucial since their association with 45% mortality rate. Embolic coiling is the most effective ICA treatment. Series of embolic coils are deployed into the aneurysm with the intent of reaching a sufficient packing density (PD) to help seal off the ICA from circulation. While coiling is effective, treatment failures have been associated with basilar tip aneurysms (BTAs), perhaps because of their geometry. The aim of this study was to examine the effect of dome size, parent vessel (PV) angle, and PD on intraaneurysmal (IA) velocity, crossneck (CN) flow and low wall shear stress (WSS) area using simulations and experiments in idealized BTA models. IA velocity and CN flow decreased after coiling, while low WSS area increased. With increasing PD, IA velocity and CN flow were further reduced, but low WSS area had a minimal change. Coil PD had the greatest impact on post-treatment flow while dome size had a greater impact than PV angle. Overall, the role of aneurysmal geometries may vary depending on treatment goal and timing e.g., high coil PD may reduce IA velocity more effectively during early aneurysmal growth when the dome size is small. Funded by the American Heart Association.

Precision medicine of aneurysmal subarachnoid hemorrhage, vasospasm and delayed cerebral ischemia.

PubMed

Burrell, Christian; Avalon, Nicole E; Siegel, Jason; Pizzi, Michael; Dutta, Tumpa; Charlesworth, M Cristine; Freeman, William D

2016-11-01

Precision medicine provides individualized treatment of diseases through leveraging patient-to-patient variation. Aneurysmal subarachnoid hemorrhage carries tremendous morbidity and mortality with cerebral vasospasm and delayed cerebral ischemia proving devastating and unpredictable. Lack of treatment measures for these conditions could be improved through precision medicine. Areas covered: Discussed are the pathophysiology of CV and DCI, treatment guidelines, and evidence for precision medicine used for prediction and prevention of poor outcomes following aSAH. A PubMed search was performed using keywords cerebral vasospasm or delayed cerebral ischemia and either biomarkers, precision medicine, metabolomics, proteomics, or genomics. Over 200 peer-reviewed articles were evaluated. The studies presented cover biomarkers identified as predictive markers or therapeutic targets following aSAH. Expert commentary: The biomarkers reviewed here correlate with CV, DCI, and neurologic outcomes after aSAH. Though practical use in clinical management of aSAH is not well established, using these biomarkers as predictive tools or therapeutic targets demonstrates the potential of precision medicine.

Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial.

PubMed

Mooney, Michael A; Simon, Elias D; Brigeman, Scott; Nakaji, Peter; Zabramski, Joseph M; Lawton, Michael T; Spetzler, Robert F

2018-04-27

OBJECTIVE A direct comparison of endovascular versus microsurgical treatment of ruptured middle cerebral artery (MCA) aneurysms in randomized trials is lacking. As endovascular treatment strategies continue to evolve, the number of reports of endovascular treatment of these lesions is increasing. Herein, the authors report a detailed post hoc analysis of ruptured MCA aneurysms treated by microsurgical clipping from the Barrow Ruptured Aneurysm Trial (BRAT). METHODS The cases of patients enrolled in the BRAT who underwent microsurgical clipping for a ruptured MCA aneurysm were reviewed. Characteristics of patients and their clinical outcomes and long-term angiographic results were analyzed. RESULTS Fifty patients underwent microsurgical clipping of a ruptured MCA aneurysm in the BRAT, including 21 who crossed over from the endovascular treatment arm. Four patients with nonsaccular (e.g., dissecting, fusiform, or blister) aneurysms were excluded, leaving 46 patients for analysis. Most (n = 32; 70%) patients presented with a Hunt and Hess grade II or III subarachnoid hemorrhage, with a high prevalence of intraparenchymal blood (n = 23; 50%), intraventricular blood (n = 21; 46%), or both. At the last follow-up (up to 6 years after treatment), clinical outcomes were good (modified Rankin Scale score 0-2) in 70% (n = 19) of 27 Hunt and Hess grades I-III patients and in 36% (n = 4) of 11 Hunt and Hess grade IV or V patients. There were no instances of rebleeding after the surgical clipping of aneurysms in this series at the time of last clinical follow-up. CONCLUSIONS Microsurgical clipping of ruptured MCA aneurysms has several advantages over endovascular treatment, including durability over time. The authors report detailed outcome data of patients with ruptured MCA aneurysms who underwent microsurgical clipping as part of a prospective, randomized trial. These results should be used for comparison with future endovascular and surgical series to ensure that the best results are being achieved for patients with ruptured MCA aneurysms.

Aneurysmal subarachnoid hemorrhage with concomitant posterior communicating artery fenestration.

PubMed

Weiner, Gregory M; Grandhi, Ramesh; Zwagerman, Nathan T; Agarwal, Nitin; Friedlander, Robert M

2015-02-01

Fenestrations of the posterior communicating artery (PCoA) are extremely rare. Associated aneurysms have only been documented three times in the literature, and none associated with a subarachnoid hemorrhage. We describe a 52-year-old female who presented with a subarachnoid hemorrhage secondary to a ruptured saccular aneurysm at the proximal limb of a fenestrated right PCoA. The patient was also found to have bilateral middle cerebral artery (MCA) aneurysms. Surgical management included surmising the etiology of the subarachnoid hemorrhage with subsequent clipping of both the right PCoA and MCA aneurysm. The potential embryological mechanisms leading to a PCoA fenestration are discussed.

Intracranial aneurysm and arachnoid cyst: just a coincidence? A case report.

PubMed

Aguiar, Guilherme Brasileiro de; Santos, Rafael Gomes Dos; Paiva, Aline Lariessy Campos; Silva, João Miguel de Almeida; Silva, Rafael Carlos da; Veiga, José Carlos Esteves

2017-12-18

Presence of an arachnoid cyst and a non-ruptured intracystic brain aneurysm is extremely rare. The aim of this paper was to describe a case of a patient with an arachnoid cyst and a non-ruptured aneurysm inside it. Clinical, surgical and radiological data were analyzed and the literature was reviewed. A patient complained of chronic headache. She was diagnosed as having a temporal arachnoid cyst and a non-ruptured middle cerebral artery aneurysm inside it. Surgery was performed to clip the aneurysm and fenestrate the cyst. This report raises awareness about the importance of intracranial vascular investigation in patients with arachnoid cysts and brain hemorrhage.

Crohns disease with central nervous system vasculitis causing subarachnoid hemorrhage due to aneurysm and cerebral ischemic stroke

PubMed Central

Garge, Shaileshkumar S.; Vyas, Pooja D.; Modi, Pranav D.; Ghatge, Sharad

2014-01-01

Cerebral vasculitis secondary to Crohn's disease (CD) seems to be a very rare phenomenon. We report a 39-year-old male who presented with headache, vomiting, and left-sided weakness in the known case of CD. Cross-sectional imaging (computed tomography and magnetic resonance imaging,) showed right gangliocapsular acute infarct with supraclinoid cistern subarachnoid hemorrhage (SAH). Cerebral digital substraction angiography (DSA) showed dilatation and narrowing of right distal internal carotid artery (ICA). Left ICA was chronically occluded. His inflammatory markers were significantly raised. Imaging features are suggestive of cerebral vasculitis. Arterial and venous infarcts due to thrombosis are known in CD. Our case presented with acute subarachnoid hemorrhage in supraclinoid cistern due to rupture of tiny aneurysm of perforator arteries causing SAH and infarction in right basal ganglia. Patient was treated conservatively with immunosuppression along with medical management of SAH. PMID:25506170

Crohns disease with central nervous system vasculitis causing subarachnoid hemorrhage due to aneurysm and cerebral ischemic stroke.

PubMed

Garge, Shaileshkumar S; Vyas, Pooja D; Modi, Pranav D; Ghatge, Sharad

2014-10-01

Cerebral vasculitis secondary to Crohn's disease (CD) seems to be a very rare phenomenon. We report a 39-year-old male who presented with headache, vomiting, and left-sided weakness in the known case of CD. Cross-sectional imaging (computed tomography and magnetic resonance imaging,) showed right gangliocapsular acute infarct with supraclinoid cistern subarachnoid hemorrhage (SAH). Cerebral digital substraction angiography (DSA) showed dilatation and narrowing of right distal internal carotid artery (ICA). Left ICA was chronically occluded. His inflammatory markers were significantly raised. Imaging features are suggestive of cerebral vasculitis. Arterial and venous infarcts due to thrombosis are known in CD. Our case presented with acute subarachnoid hemorrhage in supraclinoid cistern due to rupture of tiny aneurysm of perforator arteries causing SAH and infarction in right basal ganglia. Patient was treated conservatively with immunosuppression along with medical management of SAH.

Return of visual function after bilateral visual loss following flow diversion embolization of a giant ophthalmic aneurysm due to both reduction in mass effect and reduction in aneurysm pulsation.

PubMed

Patel, Saharsh; Fargen, Kyle M; Peters, Keith; Krall, Peter; Samy, Hazem; Hoh, Brian L

2014-01-10

Large and giant paraclinoid aneurysms are challenging to treat by either surgical or endovascular means. Visual dysfunction secondary to optic nerve compression and its relationship with aneurysm size, pulsation and thrombosis is poorly understood. We present a patient with a giant paraclinoid aneurysm resulting in bilateral visual loss that worsened following placement of a Pipeline Embolization Device and adjunctive coiling. Visual worsening occurred in conjunction with aneurysm thrombosis, increase in maximal aneurysm diameter and new adjacent edema. Her visual function spontaneously improved in a delayed fashion to better than pre-procedure, in conjunction with reduced aneurysmal mass effect, size and pulsation artifact on MRI. This report documents detailed ophthalmologic and MRI evidence for the role of thrombosis, aneurysm mass effect and aneurysm pulsation as causative etiologies for both cranial nerve dysfunction and delayed resolution following flow diversion treatment of large cerebral aneurysms.

Subdural and intracerebral hemorrhage caused by spontaneous bleeding in the middle meningeal artery after coil embolization of a cerebral aneurysm.

PubMed

Kohyama, Shinya; Kakehi, Yoshiaki; Yamane, Fumitaka; Ooigawa, Hidetoshi; Kurita, Hiroki; Ishihara, Shoichiro

2014-10-01

Nontraumatic acute subdural hemorrhage (SDH) with intracerebral hemorrhage (ICH) is rare and is usually caused by severe bleeding from aneurysms or arteriovenous fistulas. We encountered a very rare case of spontaneous bleeding from the middle meningeal artery (MMA), which caused hemorrhage in the temporal lobe and subdural space 2 weeks after coil embolization of an ipsilateral, unruptured internal cerebral artery aneurysm in the cavernous portion. At onset, the distribution of hematoma on a computed tomography scan led us to believe that the treated intracavernous aneurysm could bleed into the intradural space. Emergency craniotomy revealed that the dura of the middle fossa was intact except for the point at the foramen spinosum where the exposed MMA was bleeding. Retrospectively, angiography just before and after embolization of the aneurysm did not show any aberrations in the MMA. Although the MMA usually courses on the outer surface of the dura and is unlikely to rupture without an external force, physicians should be aware that the MMA may bleed spontaneously and cause SDH and ICH. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Embolic Signals during Routine Transcranial Doppler Ultrasonography in Aneurysmal Subarachnoid Hemorrhage

PubMed Central

Paschoal, Fernando Mendes; de Almeida Lins Ronconi, Karla; de Lima Oliveira, Marcelo; Nogueira, Ricardo de Carvalho; Paschoal, Eric Homero Albuquerque; Teixeira, Manoel Jacobsen; Figueiredo, Eberval Gadelha; Bor-Seng-Shu, Edson

2015-01-01

Introduction. Cerebral emboli may occur in subarachnoid hemorrhage (SAH) and intracranial aneurysm surgery. Although embolic signs (ES) have been reported in SAH, their origin remains unclear. The aim of this study was to report the detection of ES during routine TCD monitoring in patients with aneurysmal SAH. Methods. A total of 105 patients with aneurysmal SAH were submitted to TCD evaluation. Patients were monitored almost daily (5 times per week). In each monitoring session, one experienced operator performed TCD to detect or assess vasospasm and ES in arteries of the Willis polygon. Results. Four patients out of a total of 105 patients with aneurysmal SAH were found to present spontaneous cerebral embolization during routine TCD monitoring. The average age of the 4 patients (mean ± standard deviation) was 59.5 ± 8.34 years (range 49–68 ys); female patients predominated representing 75% (3/4) of subjects. Conclusion. Although detection of ES was relatively rare in this study, rates of emboli occurrence may be higher under systematic monitoring. The detection of ES after SAH surgery reinforces the need to study the role of embolus in this condition and may be an indicator for prophylactic antithrombotic treatment. PMID:25893190

Delayed recovery of adipsic diabetes insipidus (ADI) caused by elective clipping of anterior communicating artery and left middle cerebral artery aneurysms.

PubMed

Tan, Jeffrey; Ndoro, Samuel; Okafo, Uchenna; Garrahy, Aoife; Agha, Amar; Rawluk, Danny

2016-12-16

Adipsic diabetes insipidus (ADI) is an extremely rare complication following microsurgical clipping of anterior communicating artery aneurysm (ACoA) and left middle cerebral artery (MCA) aneurysm. It poses a significant challenge to manage due to an absent thirst response and the co-existence of cognitive impairment in our patient. Recovery from adipsic DI has hitherto been reported only once. A 52-year-old man with previous history of clipping of left posterior communicating artery aneurysm 20 years prior underwent microsurgical clipping of ACoA and left MCA aneurysms without any intraoperative complications. Shortly after surgery, he developed clear features of ADI with adipsic severe hypernatraemia and hypotonic polyuria, which was associated with cognitive impairment that was confirmed with biochemical investigations and cognitive assessments. He was treated with DDAVP along with a strict intake of oral fluids at scheduled times to maintain eunatremia. Repeat assessment at six months showed recovery of thirst and a normal water deprivation test. Management of ADI with cognitive impairment is complex and requires a multidisciplinary approach. Recovery from ADI is very rare, and this is only the second report of recovery in this particular clinical setting.

Crossed Wernicke's aphasia after aneurysmal subarachnoid hemorrhage: a case report.

PubMed

Seçkin, Hakan; Yiğitkanli, Kazim; Kapucu, Ozlem; Bavbek, Murad

2009-01-01

Crossed aphasia (CA) refers to aphasia occurring after right brain damage in right handers. In the literature, numerous CA cases following cerebral ischemia have been reported, but few met the criteria for a prompt diagnosis. The authors present the case of a 52-year-old woman with SAH caused by a right middle cerebral artery (MCA) saccular aneurysm who developed non-fluent aphasia characterized by reduced verbal output, word-finding disturbances and phonemic paraphasias in both oral and written language. 99mTc-HMPAO SPECT was also consistent with right parieto-temporal and frontoparietal ischemia with crossed cerebellar diaschisis on the right cerebellum. A diagnosis of CA was made. One year follow-up showed improvement in communication skills but persistent right fronto-temporo-parietal ischemia. Cerebral vasospasm after aneurysmal SAH symptomatology may vary from motor and sensory disturbances to cognitive disabilities. Aphasia developing after cerebral ischemia of the right hemisphere in a right-hand dominant patient following vasospasm may be a misleading symptom for the localization of the insult. Keeping a high index of suspicion may help in making the correct diagnosis. The changes in the perfusion patterns of cerebellum as assessed by SPECT study during the acute and recovery phases suggests the involvement of cerebellum in language functions.

Biochemical changes related to hypoxia during cerebral aneurysm surgery: combined microdialysis and tissue oxygen monitoring: case report.

PubMed

Hutchinson, P J; Al-Rawi, P G; O'Connell, M T; Gupta, A K; Pickard, J D; Kirkpatrick, P J

2000-01-01

The objective of this study was to monitor brain metabolism on-line during aneurysm surgery, by combining the use of a multiparameter (brain tissue oxygen, brain carbon dioxide, pH, and temperature) sensor with microdialysis (extracellular glucose, lactate, pyruvate, and glutamate). The case illustrates the potential value of these techniques by demonstrating the effects of adverse physiological events on brain metabolism and the ability to assist in both intraoperative and postoperative decision-making. A 41-year-old woman presented with a World Federation of Neurological Surgeons Grade I subarachnoid hemorrhage. Angiography revealed a basilar artery aneurysm that was not amenable to coiling, so the aneurysm was clipped. Before the craniotomy was performed, a multiparameter sensor and a microdialysis catheter were inserted to monitor brain metabolism. During the operation, the brain oxygen level decreased, in relation to biochemical changes, including the reduction of extracellular glucose and pyruvate and the elevation of lactate and glutamate. These changes were reversible. However, when the craniotomy was closed, a second decrease in brain oxygen occurred in association with brain swelling, which immediately prompted a postoperative computed tomographic scan. The scan demonstrated acute hydrocephalus, requiring external ventricular drainage. The patient made a full recovery. The monitoring techniques influenced clinical decision-making in the treatment of this patient. On-line measurement of brain tissue gases and extracellular chemistry has the potential to assist in the perioperative and postoperative management of patients undergoing complex cerebrovascular surgery and to establish the effects of intervention on brain homeostasis.

Unruptured cerebral aneurysm clipping: the association of combined open and endovascular expertise with outcomes

PubMed Central

Bekelis, Kimon; Gottlieb, Dan; Bovis, George; Su, Yin; Tjoumakaris, Stavropoula; Jabbour, Pascal; MacKenzie, Todd A.

2017-01-01

Background It is often questioned if one physician can conduct both open and endovascular techniques successfully and safely. We investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm clipping. Methods We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent surgical clipping for unruptured cerebral aneurysms from 2007 to 2012. In order to control for confounding we used propensity score conditioning, and controlled for clustering at the physician level. Results During the study period, there were 3,247 patients, who underwent clipping for unruptured cerebral aneurysms, and met the inclusion criteria. Of these, 766 (23.6%) underwent treatment by hybrid neurosurgeons, and 2,481 (76.4%) by proceduralists who performed only clipping. Multivariable regression analysis with propensity score adjustment demonstrated lack of association of combined practice with 1-year postoperative mortality (OR, 0.81; 95% CI, 0.51–1.28), discharge to rehabilitation (OR, 0.95; 95% CI, 0.72–1.25), LOS (adjusted difference 0.85 days; 95% CI, −0.31 to 2.00), or 30-day readmission rate (OR, 1.05; 95% CI, 0.80–1.39). Higher procedural volume was independently associated with improved outcomes. Conclusions In a cohort of Medicare patients with unruptured aneurysms, we did not demonstrate a difference in mortality, discharge to rehabilitation, or readmission rate between hybrid neurosurgeons and surgeons only performing clipping. Funding Supported by grants from the National Institute on Aging (PO1- AG19783), and the National Institutes of Health (NIH) Common Fund (U01-AG046830) and the National Center for Advancing Translational Sciences (NCATS) of the NIH (Dartmouth Clinical and Translational Science Institute-UL1TR001086). The funders had no role in the design or execution of the study. PMID:26385788

Improved Visualization of Intracranial Vessels with Intraoperative Coregistration of Rotational Digital Subtraction Angiography and Intraoperative 3D Ultrasound

PubMed Central

Podlesek, Dino; Meyer, Tobias; Morgenstern, Ute; Schackert, Gabriele; Kirsch, Matthias

2015-01-01

Introduction Ultrasound can visualize and update the vessel status in real time during cerebral vascular surgery. We studied the depiction of parent vessels and aneurysms with a high-resolution 3D intraoperative ultrasound imaging system during aneurysm clipping using rotational digital subtraction angiography as a reference. Methods We analyzed 3D intraoperative ultrasound in 39 patients with cerebral aneurysms to visualize the aneurysm intraoperatively and the nearby vascular tree before and after clipping. Simultaneous coregistration of preoperative subtraction angiography data with 3D intraoperative ultrasound was performed to verify the anatomical assignment. Results Intraoperative ultrasound detected 35 of 43 aneurysms (81%) in 39 patients. Thirty-nine intraoperative ultrasound measurements were matched with rotational digital subtraction angiography and were successfully reconstructed during the procedure. In 7 patients, the aneurysm was partially visualized by 3D-ioUS or was not in field of view. Post-clipping intraoperative ultrasound was obtained in 26 and successfully reconstructed in 18 patients (69%) despite clip related artefacts. The overlap between 3D-ioUS aneurysm volume and preoperative rDSA aneurysm volume resulted in a mean accuracy of 0.71 (Dice coefficient). Conclusions Intraoperative coregistration of 3D intraoperative ultrasound data with preoperative rotational digital subtraction angiography is possible with high accuracy. It allows the immediate visualization of vessels beyond the microscopic field, as well as parallel assessment of blood velocity, aneurysm and vascular tree configuration. Although spatial resolution is lower than for standard angiography, the method provides an excellent vascular overview, advantageous interpretation of 3D-ioUS and immediate intraoperative feedback of the vascular status. A prerequisite for understanding vascular intraoperative ultrasound is image quality and a successful match with preoperative rotational digital subtraction angiography. PMID:25803318

Improved visualization of intracranial vessels with intraoperative coregistration of rotational digital subtraction angiography and intraoperative 3D ultrasound.

PubMed

Podlesek, Dino; Meyer, Tobias; Morgenstern, Ute; Schackert, Gabriele; Kirsch, Matthias

2015-01-01

Ultrasound can visualize and update the vessel status in real time during cerebral vascular surgery. We studied the depiction of parent vessels and aneurysms with a high-resolution 3D intraoperative ultrasound imaging system during aneurysm clipping using rotational digital subtraction angiography as a reference. We analyzed 3D intraoperative ultrasound in 39 patients with cerebral aneurysms to visualize the aneurysm intraoperatively and the nearby vascular tree before and after clipping. Simultaneous coregistration of preoperative subtraction angiography data with 3D intraoperative ultrasound was performed to verify the anatomical assignment. Intraoperative ultrasound detected 35 of 43 aneurysms (81%) in 39 patients. Thirty-nine intraoperative ultrasound measurements were matched with rotational digital subtraction angiography and were successfully reconstructed during the procedure. In 7 patients, the aneurysm was partially visualized by 3D-ioUS or was not in field of view. Post-clipping intraoperative ultrasound was obtained in 26 and successfully reconstructed in 18 patients (69%) despite clip related artefacts. The overlap between 3D-ioUS aneurysm volume and preoperative rDSA aneurysm volume resulted in a mean accuracy of 0.71 (Dice coefficient). Intraoperative coregistration of 3D intraoperative ultrasound data with preoperative rotational digital subtraction angiography is possible with high accuracy. It allows the immediate visualization of vessels beyond the microscopic field, as well as parallel assessment of blood velocity, aneurysm and vascular tree configuration. Although spatial resolution is lower than for standard angiography, the method provides an excellent vascular overview, advantageous interpretation of 3D-ioUS and immediate intraoperative feedback of the vascular status. A prerequisite for understanding vascular intraoperative ultrasound is image quality and a successful match with preoperative rotational digital subtraction angiography.

Prototyping of cerebral vasculature physical models.

PubMed

Khan, Imad S; Kelly, Patrick D; Singer, Robert J

2014-01-01

Prototyping of cerebral vasculature models through stereolithographic methods have the ability to accurately depict the 3D structures of complicated aneurysms with high accuracy. We describe the method to manufacture such a model and review some of its uses in the context of treatment planning, research, and surgical training. We prospectively used the data from the rotational angiography of a 40-year-old female who presented with an unruptured right paraclinoid aneurysm. The 3D virtual model was then converted to a physical life-sized model. The model constructed was shown to be a very accurate depiction of the aneurysm and its associated vasculature. It was found to be useful, among other things, for surgical training and as a patient education tool. With improving and more widespread printing options, these models have the potential to become an important part of research and training modalities.

Comparison of 3D computer-aided with manual cerebral aneurysm measurements in different imaging modalities.

PubMed

Groth, M; Forkert, N D; Buhk, J H; Schoenfeld, M; Goebell, E; Fiehler, J

2013-02-01

To compare intra- and inter-observer reliability of aneurysm measurements obtained by a 3D computer-aided technique with standard manual aneurysm measurements in different imaging modalities. A total of 21 patients with 29 cerebral aneurysms were studied. All patients underwent digital subtraction angiography (DSA), contrast-enhanced (CE-MRA) and time-of-flight magnetic resonance angiography (TOF-MRA). Aneurysm neck and depth diameters were manually measured by two observers in each modality. Additionally, semi-automatic computer-aided diameter measurements were performed using 3D vessel surface models derived from CE- (CE-com) and TOF-MRA (TOF-com) datasets. Bland-Altman analysis (BA) and intra-class correlation coefficient (ICC) were used to evaluate intra- and inter-observer agreement. BA revealed the narrowest relative limits of intra- and inter-observer agreement for aneurysm neck and depth diameters obtained by TOF-com (ranging between ±5.3 % and ±28.3 %) and CE-com (ranging between ±23.3 % and ±38.1 %). Direct measurements in DSA, TOF-MRA and CE-MRA showed considerably wider limits of agreement. The highest ICCs were observed for TOF-com and CE-com (ICC values, 0.92 or higher for intra- as well as inter-observer reliability). Computer-aided aneurysm measurement in 3D offers improved intra- and inter-observer reliability and a reproducible parameter extraction, which may be used in clinical routine and as objective surrogate end-points in clinical trials.

In vitro study of near-wall flow in a cerebral aneurysm model with and without coils.

PubMed

Goubergrits, L; Thamsen, B; Berthe, A; Poethke, J; Kertzscher, U; Affeld, K; Petz, C; Hege, H-C; Hoch, H; Spuler, A

2010-09-01

Coil embolization procedures change the flow conditions in the cerebral aneurysm and, therefore, in the near-wall region. Knowledge of these flow changes may be helpful to optimize therapy. The goal of this study was to investigate the effect of the coil-packing attenuation on the near-wall flow and its variability due to differences in the coil structure. An enlarged transparent model of an ACA aneurysm was fabricated on the basis of CT angiography. The near-wall flow was visualized by using a recently proposed technique called Wall-PIV. Coil-packing attenuation of 10%, 15%, and 20% were investigated and compared with an aneurysmal flow without coils. Then the flow variability due to the coil introduction was analyzed in 10 experiments by using a packing attenuation of 15%. A small packing attenuation of 10% already alters the near-wall flow significantly in a large part of the aneurysmal sac. These flow changes are characterized by a slow flow with short (interrupted) path lines. An increased packing attenuation expands the wall area exposed to the altered flow conditions. This area, however, depends on the coil position and/or on the 3D coil structure in the aneurysm. To our knowledge, this is the first time the near-wall flow changes caused by coils in an aneurysm model have been visualized. It can be concluded that future hydrodynamic studies of coil therapy should include an investigation of the coil structure in addition to the coil-packing attenuation.

Endovascular minimally invasive treatment of the intracranial aneurysms--first 124 cases.

PubMed

Dima, S; Scheau, C; Stefanescu, F; Danaila, L

2012-09-15

Since May 2005, we have started to treat the intracranial aneurysms endovascular way as an alternative minimally invasive technique to the classic neurosurgery treatment. Studying the patients' demographics, clinical presentation, aneurysm size and configuration, type of coils used for embolization, the percentage of compaction and recanalization (especially in patients who presented with subarachnoid hemorrhage), and immediate complications. An all-inclusive retrospective review of every patient who underwent coils embolization (stent or balloon assisted included) of saccular aneurysms from May 2005 to September 2011 was performed. A total of 116 patients (46 men and 60 women) and 124 aneurysms were treated. A total of 96 patients (41 men and 55 women) underwent follow-up femoral cerebral angiograms (mean follow-up was 25 months and the longest was at 37 months). Five patients required intra-arterial abciximab due to thrombus formation. Four patients had aneurysm rupture while the coil was being advanced. Eleven patients were treated during vasospasm peak. Seven patients had recanalization at 12 months follow-up. The average hospitalization period was of 4 days. There is a close relation between Hunt and Hess scale score before treatment and post interventional neurological status. Due to subarachnoid hemorrhage, the vasospasm remains a threat to the patient's neurological status. The treatment of cerebral aneurysms with endosacular embolization by coils is a safe and durable option. The risk of recanalization or re-rupture in our cohort is small compared to series published elsewhere. Larger series of patients are needed to support our evidence.

@neurIST - chronic disease management through integration of heterogeneous data and computer-interpretable guideline services.

PubMed

Dunlop, R; Arbona, A; Rajasekaran, H; Lo Iacono, L; Fingberg, J; Summers, P; Benkner, S; Engelbrecht, G; Chiarini, A; Friedrich, C M; Moore, B; Bijlenga, P; Iavindrasana, J; Hose, R D; Frangi, A F

2008-01-01

This paper presents an overview of computerised decision support for clinical practice. The concept of computer-interpretable guidelines is introduced in the context of the @neurIST project, which aims at supporting the research and treatment of asymptomatic unruptured cerebral aneurysms by bringing together heterogeneous data, computing and complex processing services. The architecture is generic enough to adapt it to the treatment of other diseases beyond cerebral aneurysms. The paper reviews the generic requirements of the @neurIST system and presents the innovative work in distributing executable clinical guidelines.

Unruptured Cerebral Aneurysms: Evaluation and Management

PubMed Central

Chalouhi, Nohra; Starke, Robert M.; Bell, Rodney

2015-01-01

The evolution of imaging techniques and their increased use in clinical practice have led to a higher detection rate of unruptured intracranial aneurysms. The diagnosis of an unruptured intracranial aneurysm is a source of significant stress to the patient because of the concerns for aneurysmal rupture, which is associated with substantial rates of morbidity and mortality. Therefore, it is important that decisions regarding optimum management are made based on the comparison of the risk of aneurysmal rupture with the risk associated with intervention. This review provides a comprehensive overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management options for unruptured intracranial aneurysms based on the current evidence in the literature. Furthermore, the authors discuss the genetic abnormalities associated with intracranial aneurysm and current guidelines for screening in patients with a family history of intracranial aneurysms. Since there is significant controversy in the optimum management of small unruptured intracranial aneurysms, we provided a systematic approach to their management based on patient and aneurysm characteristics as well as the risks and benefits of intervention. PMID:26146657

Conventional versus frozen elephant trunk surgery for extensive disease of the thoracic aorta.

PubMed

Di Eusanio, Marco; Borger, Michael; Petridis, Francesco D; Leontyev, Sergey; Pantaleo, Antonio; Moz, Monica; Mohr, Friedrich; Di Bartolomeo, Roberto

2014-11-01

To compare early and mid-term outcomes after repair of extensive aneurysm of the thoracic aorta using the conventional elephant trunk or frozen elephant trunk (FET) procedures. Fifty-seven patients with extensive thoracic aneurysmal disease were treated using elephant trunk (n = 36) or FET (n = 21) procedures. Patients with aortic dissection, descending thoracic aorta (DTA) diameter less than 40 mm, and thoracoabdominal aneurysms were excluded from the analysis, as were those who did not undergo antegrade selective cerebral perfusion during circulatory arrest. Short-term and mid-term outcomes were compared according to elephant trunk/FET surgical management. Preoperative and intraoperative variables were similar in the two groups, except for a higher incidence of female sex, coronary artery disease and associated procedures in elephant trunk patients. Hospital mortality (elephant trunk: 13.9% versus FET: 4.8%; P = 0.2), permanent neurologic dysfunction (elephant trunk: 5.7% versus FET: 9.5%; P = 0.4) and paraplegia (elephant trunk: 2.9% versus FET: 4.8%; P = 0.6) rates were similar in the two groups. Follow-up was 100% complete. In the elephant trunk group, 68.4% of patients did not undergo a second-stage procedure during follow-up for a variety of reasons. Of these patients, the DTA diameter was greater than 51 mm in 72.2% and two (6.7%) died due to aortic rupture while awaiting stage-two intervention. Endovascular second-stage procedures were successfully performed in all FET patients with residual DTA aneurysmal disease (n = 3), whereas nine of 11 elephant trunk patients who returned for second-stage procedures required conventional surgical replacement through a lateral thoracotomy. Kaplan-Meier estimate of 4-year survival was 75.8 ± 7.6 and 72.8 ± 10.6 in elephant trunk and FET patients, respectively (log-rank P = 0.8). In patients with extensive aneurysmal disease of thoracic aorta, elephant trunk and FET procedures seem to be associated with similar satisfactory early and mid-term outcomes. The FET approach leads to single-stage treatment of all aortic disease in most patients, and facilitates endovascular second-stage treatment in patients with residual DTA disease. The elephant trunk staged-approach appears to leave a considerable percentage of patients at risk for adverse aortic events.

Mechanisms of perianeurysmal edema following endovascular embolization of aneurysms.

PubMed

Tomokiyo, M; Kazekawa, K; Onizuka, M; Aikawa, H; Tsutsumi, M; Ikoh, M; Kodama, T; Nii, K; Matsubara, S; Tanaka, A

2007-03-15

After coil embolization for an aneurysm, edema surrounding the aneurysm revealed by magnetic resonance imaging (MRI) is rarely seen and is usually associated with neurological symptoms. Perianeurysmal edema was found by postoperative MRI in three out of 182 patients with cerebral aneurysm, which was treated with Guglielmi Detachable Coil (GDC), and neurological symptoms developed simultaneously. In cases where neurological symptoms improved with conservative medical treatment, a temporary increase in the volume of an aneurysm, due to coil and thrombus formation, may result in edema. In cases where symptoms were not alleviated with conservative medical treatment, persistent water-hammer effect against the residual lumen of the aneurysm as well as an increase in the volume of aneurysm by hemorrhage in the aneurysmal wall may contribute to the development of perianeurysmal edema. Consideration of the mechanism of edema development by neurological symptoms, MRI findings, and angiographic findings is needed in order to select appropriate treatment.

Mechanisms of Perianeurysmal Edema Following Endovascular Embolization of Aneurysms

PubMed Central

Tomokiyo, M.; K., Kazekawa; Onizuka, M.; Aikawa, H.; Tsutsumi, M.; Ikoh, M.; Kodama, T.; Nii, K.; Matsubara, S.; Tanaka, A.

2007-01-01

Summary After coil embolization for an aneurysm, edema surrounding the aneurysm revealed by magnetic resonance imaging (MRI) is rarely seen and is usually associated with neurological symptoms. Perianeurysmal edema was found by postoperative MRI in three out of 182 patients with cerebral aneurysm, which was treated with Guglielmi Detachable Coil (GDC), and neurological symptoms developed simultaneously. In cases where neurological symptoms improved with conservative medical treatment, a temporary increase in the volume of an aneurysm, due to coil and thrombus formation, may result in edema. In cases where symptoms were not alleviated with conservative medical treatment, persistent water-hammer effect against the residual lumen of the aneurysm as well as an increase in the volume of aneurysm by hemorrhage in the aneurysmal wall may contribute to the development of perianeurysmal edema. Consideration of the mechanism of edema development by neurological symptoms, MRI findings, and angiographic findings is needed in order to select appropriate treatment. PMID:20566093

Is Conventional Open Repair for Abdominal Aortic Aneurysm Feasible in Nonagenarians?

PubMed

Uehara, Kyokun; Matsuda, Hitoshi; Inoue, Yosuke; Omura, Atsushi; Seike, Yoshimasa; Sasaki, Hiroaki; Kobayashi, Junjiro

2017-09-25

Background : Although endovascular repair for abdominal aortic aneurysm has been found to be beneficial in very elderly patients, some patients have contraindications to this procedure. For nonagenarians, the results of open repair remain unclear. The purpose of this study was to compare the outcomes of open vs. endovascular repair for abdominal aortic aneurysm in nonagenarian patients. Methods and Results : Fourteen patients undergoing open surgical repair and 24 undergoing endovascular repair for abdominal aortic aneurysm were evaluated. There was no significant difference in early mortality between the open and endovascular groups (0% vs. 4.1%, p=0.16). The open repair group required much longer hospital stays (26.4 vs. 10.6 days, respectively, p=0.003). Finally, 12 patients (86%) undergoing open repair vs. 21 (88%) undergoing endovascular repair returned home (p=0.49). During a mean follow-up period of 23.4±23.5 months, cumulative estimated 1- and 3-year survival rates were 90.0% and 48.0%, respectively in the open repair group and 90.6% and 54.9%, respectively in the endovascular repair group (p=0.51). Conclusion : Although endovascular repair for abdominal aortic aneurysm was superior in terms of recovery, the results of conventional open repair were acceptable even in nonagenarian patients. Open repair remains an alternative for patients with contraindications to endovascular repair.

Flow Changes after Endovascular Treatment of a Wide-Neck Anterior Communicating Artery Aneurysm by using X-configured Kissing Stents (Cross-Kissing Stents) Technique

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zelenak, Kamil, E-mail: zelenak@unm.sk; Zelenakova, Jana; DeRiggo, Julius

2011-12-15

Endovascular treatment for a wide-neck anterior communicating artery (AcomA) aneurysm remains technically challenging. Stent-assisted embolization has been proposed as an alternative of treatment of complex aneurysms. The X-configuration double-stent-assisted technique was used to achieve successful coiling of wide-neck AcomA aneurysm. Implanted stent can alter intra-arterial flow. Follow-up angiograms 4 months later showed flow changes due to used X-technique of stents implantation and filling of the anterior cerebral artery from the opposite internal carotid artery.

Non-invasive assessment of vasospasm following aneurysmal SAH using C-arm FDCT parenchymal blood volume measurement in the neuro-interventional suite: Technical feasibility

PubMed Central

Downer, Jonathan; Corkill, Rufus; Byrne, James V

2015-01-01

Introduction Cerebral vasospasm is the leading cause of morbidity and mortality in patients with aneurysmal subarachnoid haemorrhage (SAH) surviving the initial ictus. Commonly used techniques for vasospasm assessment are digital subtraction angiography and transcranial Doppler sonography. These techniques can reliably identify only the major vessel spasm and fail to estimate its haemodynamic significance. To overcome these issues and to enable comprehensive non-invasive assessment of vasospasm inside the interventional suite, a novel protocol involving measurement of parenchymal blood volume (PBV) using C-arm flat detector computed tomography (FDCT) was implemented. Materials and methods Patients from the neuro-intensive treatment unit (ITU) with suspected vasospasm following aneurysmal SAH were scanned with a biplane C-arm angiography system using an intravenous contrast injection protocol. The PBV maps were generated using prototype software. Contemporaneous clinically indicated MR scan including the diffusion- and perfusion-weighted sequences was performed. C-arm PBV maps were compared against the MR perfusion maps. Results Distribution of haemodynamic impairment on C-arm PBV maps closely matched the pattern of abnormality on MR perfusion maps. On visual comparison between the two techniques, the extent of abnormality indicated PBV to be both cerebral blood flow and cerebral blood volume weighted. Conclusion C-arm FDCT PBV measurements allow an objective assessment of the severity and localisation of cerebral hypoperfusion resulting from vasospasm. The technique has proved feasible and useful in very sick patients after aneurysmal SAH. The promise shown in this early study indicates that it deserves further evaluation both for post-SAH vasospasm and in other relevant clinical settings. PMID:26017197

Non-invasive assessment of vasospasm following aneurysmal SAH using C-arm FDCT parenchymal blood volume measurement in the neuro-interventional suite: Technical feasibility.

PubMed

Kamran, Mudassar; Downer, Jonathan; Corkill, Rufus; Byrne, James V

2015-08-01

Cerebral vasospasm is the leading cause of morbidity and mortality in patients with aneurysmal subarachnoid haemorrhage (SAH) surviving the initial ictus. Commonly used techniques for vasospasm assessment are digital subtraction angiography and transcranial Doppler sonography. These techniques can reliably identify only the major vessel spasm and fail to estimate its haemodynamic significance. To overcome these issues and to enable comprehensive non-invasive assessment of vasospasm inside the interventional suite, a novel protocol involving measurement of parenchymal blood volume (PBV) using C-arm flat detector computed tomography (FDCT) was implemented. Patients from the neuro-intensive treatment unit (ITU) with suspected vasospasm following aneurysmal SAH were scanned with a biplane C-arm angiography system using an intravenous contrast injection protocol. The PBV maps were generated using prototype software. Contemporaneous clinically indicated MR scan including the diffusion- and perfusion-weighted sequences was performed. C-arm PBV maps were compared against the MR perfusion maps. Distribution of haemodynamic impairment on C-arm PBV maps closely matched the pattern of abnormality on MR perfusion maps. On visual comparison between the two techniques, the extent of abnormality indicated PBV to be both cerebral blood flow and cerebral blood volume weighted. C-arm FDCT PBV measurements allow an objective assessment of the severity and localisation of cerebral hypoperfusion resulting from vasospasm. The technique has proved feasible and useful in very sick patients after aneurysmal SAH. The promise shown in this early study indicates that it deserves further evaluation both for post-SAH vasospasm and in other relevant clinical settings. © The Author(s) 2015.

Comparison of false-negative/positive results of intraoperative evoked potential monitoring between no and partial neuromuscular blockade in patients receiving propofol/remifentanil-based anesthesia during cerebral aneurysm clipping surgery: A retrospective analysis of 685 patients.

PubMed

Kim, Sung-Hoon; Jin, Seok-Joon; Karm, Myong-Hwan; Moon, Young-Jin; Jeong, Hye-Won; Kim, Jae-Won; Ha, Seung-Il; Kim, Joung-Uk

2016-08-01

Although the elicited responses of motor evoked potential (MEP) monitoring are very sensitive to suppression by anesthetic agents and muscle relaxants, the use of neuromuscular blockade (NMB) during MEP monitoring is still controversial because of serious safety concerns and diagnostic accuracy. Here, we evaluated the incidence of unacceptable movement and compared false-negative MEP results between no and partial NMB during cerebral aneurysm clipping surgery. We reviewed patient medical records for demographic data, anesthesia regimen, neurophysiology event logs, MEP results, and clinical outcomes. Patients were divided into 2 groups according to the intraoperative use of NMB: no NMB group (n = 276) and partial NMB group (n = 409). We compared the diagnostic accuracy of MEP results to predict postoperative outcomes between both groups. Additionally, we evaluated unwanted patient movement during MEP monitoring in both groups. Of the 685 patients, 622 (90.8%) manifested no intraoperative changes in MEP and no postoperative motor deficits. Twenty patients showed postoperative neurologic deficits despite preserved intraoperative MEP. False-positive MEP results were 3.6% in the no NMB group and 3.9% in the partial NMB group (P = 1.00). False-negative MEP results were 1.1% in the no NMB group and 4.2% in the partial NMB group (P = 0.02). No spontaneous movement or spontaneous respiration was observed in either group. Propofol/remifentanil-based anesthesia without NMB decreases the stimulation intensity of MEPs, which may reduce the false-negative ratio of MEP monitoring during cerebral aneurysm surgery. Our anesthetic protocol enabled reliable intraoperative MEP recording and patient immobilization during cerebral aneurysm clipping surgery.

Occlusion of M1 segment after superficial temporal artery-middle cerebral artery bypass in a giant M1 aneurysm with Onyx-34 injected via a double-lumen balloon under balloon inflation.

PubMed

Clarençon, Frédéric; Nouet, Aurelien; Redondo, Aimée; Di Maria, Federico; Iosif, Christina; Le Jean, Lise; Chiras, Jacques; Sourour, Nader

2013-05-31

A 29-year-old patient attended our institution for recurrent strokes related to a giant partially thrombosed M1 aneurysm. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass and subsequent occlusion of both the aneurysm and the dysplastic M1 segment were planned. However, owing to the shortness of the non-dysplastic segment of M1 and the risk of occlusion of the lenticulostriate arteries, the use of a double-lumen balloon was considered for coiling and subsequent injection of Onyx. STA-MCA bypass was performed using a regular technique. Endovascular occlusion of both the aneurysm and the parent artery was subsequently performed by means of coils and Onyx-34 that was injected via the Ascent balloon under balloon inflation. No complications were recorded and no stroke was observed on control MRI. The injection of Onyx-34 through a double-lumen balloon under balloon inflation is a quick and safe technique for precise occlusion of a parent artery.

Occlusion of M1 segment after superficial temporal artery-middle cerebral artery bypass in a giant M1 aneurysm with Onyx-34 injected via a double-lumen balloon under balloon inflation.

PubMed

Clarençon, Frédéric; Nouet, Aurelien; Redondo, Aimée; Di Maria, Federico; Iosif, Christina; Le Jean, Lise; Chiras, Jacques; Sourour, Nader

2014-05-01

A 29-year-old patient attended our institution for recurrent strokes related to a giant partially thrombosed M1 aneurysm. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass and subsequent occlusion of both the aneurysm and the dysplastic M1 segment were planned. However, owing to the shortness of the non-dysplastic segment of M1 and the risk of occlusion of the lenticulostriate arteries, the use of a double-lumen balloon was considered for coiling and subsequent injection of Onyx. STA-MCA bypass was performed using a regular technique. Endovascular occlusion of both the aneurysm and the parent artery was subsequently performed by means of coils and Onyx-34 that was injected via the Ascent balloon under balloon inflation. No complications were recorded and no stroke was observed on control MRI. The injection of Onyx-34 through a double-lumen balloon under balloon inflation is a quick and safe technique for precise occlusion of a parent artery.

Occlusion of M1 segment after superficial temporal artery-middle cerebral artery bypass in a giant M1 aneurysm with Onyx-34 injected via a double-lumen balloon under balloon inflation

PubMed Central

Clarençon, Frédéric; Nouet, Aurelien; Redondo, Aimée; Di Maria, Federico; Iosif, Christina; Le Jean, Lise; Chiras, Jacques; Sourour, Nader

2013-01-01

A 29-year-old patient attended our institution for recurrent strokes related to a giant partially thrombosed M1 aneurysm. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass and subsequent occlusion of both the aneurysm and the dysplastic M1 segment were planned. However, owing to the shortness of the non-dysplastic segment of M1 and the risk of occlusion of the lenticulostriate arteries, the use of a double-lumen balloon was considered for coiling and subsequent injection of Onyx. STA-MCA bypass was performed using a regular technique. Endovascular occlusion of both the aneurysm and the parent artery was subsequently performed by means of coils and Onyx-34 that was injected via the Ascent balloon under balloon inflation. No complications were recorded and no stroke was observed on control MRI. The injection of Onyx-34 through a double-lumen balloon under balloon inflation is a quick and safe technique for precise occlusion of a parent artery. PMID:23729720

Prototyping of cerebral vasculature physical models

PubMed Central

Khan, Imad S.; Kelly, Patrick D.; Singer, Robert J.

2014-01-01

Background: Prototyping of cerebral vasculature models through stereolithographic methods have the ability to accurately depict the 3D structures of complicated aneurysms with high accuracy. We describe the method to manufacture such a model and review some of its uses in the context of treatment planning, research, and surgical training. Methods: We prospectively used the data from the rotational angiography of a 40-year-old female who presented with an unruptured right paraclinoid aneurysm. The 3D virtual model was then converted to a physical life-sized model. Results: The model constructed was shown to be a very accurate depiction of the aneurysm and its associated vasculature. It was found to be useful, among other things, for surgical training and as a patient education tool. Conclusion: With improving and more widespread printing options, these models have the potential to become an important part of research and training modalities. PMID:24678427

CE-MRA for follow-up of aneurysms post stent-assisted coiling.

PubMed

Agid, R; Schaaf, M; Farb, Ri

2012-09-01

This study compared the accuracy of contrast-enhanced MR angiography (CE-MRA) to intra-arterial cerebral angiography (IA-DSA) for assessment of intracranial aneurysms after stent-assisted coiling and to check if the presence of a stent in the parent artery diminishes the accuracy of CE-MRA. Consecutive patients with cerebral aneurysms treated by stent-assisted coiling were evaluated retrospectively. Matching follow-up CE-MRA and IA-DSA were evaluated separately. Evaluation included the presence of aneurysmal remnant, patency and stenosis of parent artery. Twenty-seven patients with 28 aneurysms and 33 matched CE-MRA and IA-DSA studies were evaluated. Nineteen aneurysmal remnants were seen on CE-MRA and 16 on IA-DSA. CE-MRA diagnosed three aneurysmal remnants not appreciated on IA-DSA. Five other remnants were larger on CE-MRA than IA-DSA. None of the remnants were missed on CE-MRA. Parent arteries were patent on both modalities. CE-MRA showed false stenosis of the stented artery in six cases and exaggerated stenosis in two. In 18 cases, CE-MRA showed a short focal "pseudo-stenosis" where the stent's marker bands were located. This was noted whenever the stent's marker bands were located in an artery with luminal diameter ≤2 mm and was called "marker band effect". CE-MRA is an accurate technique for follow-up of aneurysms post stent-assisted coiling with excellent depiction of remnants in spite of the presence of a stent. Apparent stenosis of the stented parent artery on CE-MRA is often false or exaggerated. "Marker band effect" should be recognized as an artifact that appears when stent's marker bands are in a small artery.

CE-MRA for Follow-up of Aneurysms Post Stent-Assisted Coiling

PubMed Central

Agid, R.; Schaaf, M.; Farb, RI.

2012-01-01

Summary This study compared the accuracy of contrast-enhanced MR angiography (CE-MRA) to intra-arterial cerebral angiography (IA-DSA) for assessment of intracranial aneurysms after stent-assisted coiling and to check if the presence of a stent in the parent artery diminishes the accuracy of CE-MRA. Consecutive patients with cerebral aneurysms treated by stent-assisted coiling were evaluated retrospectively. Matching follow-up CE-MRA and IA-DSA were evaluated separately. Evaluation included the presence of aneurysmal remnant, patency and stenosis of parent artery. Twenty-seven patients with 28 aneurysms and 33 matched CE-MRA and IA-DSA studies were evaluated. Nineteen aneurysmal remnants were seen on CE-MRA and 16 on IA-DSA. CE-MRA diagnosed three aneurysmal remnants not appreciated on IA-DSA. Five other remnants were larger on CE-MRA than IA-DSA. None of the remnants were missed on CE-MRA. Parent arteries were patent on both modalities. CE-MRA showed false stenosis of the stented artery in six cases and exaggerated stenosis in two. In 18 cases, CE-MRA showed a short focal “pseudo-stenosis” where the stent’s marker bands were located. This was noted whenever the stent’s marker bands were located in an artery with luminal diameter ≤2 mm and was called “marker band effect”. CE-MRA is an accurate technique for follow-up of aneurysms post stent-assisted coiling with excellent depiction of remnants in spite of the presence of a stent. Apparent stenosis of the stented parent artery on CE-MRA is often false or exaggerated. “Marker band effect” should be recognized as an artifact that appears when stent’s marker bands are in a small artery. PMID:22958765

Wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques: a multicentre, core lab adjudicated study evaluating safety and durability of occlusion (BRANCH).

PubMed

De Leacy, Reade A; Fargen, Kyle M; Mascitelli, Justin R; Fifi, Johanna; Turkheimer, Lena; Zhang, Xiangnan; Patel, Aman B; Koch, Matthew J; Pandey, Aditya S; Wilkinson, D Andrew; Griauzde, Julius; James, Robert F; Fortuny, Enzo M; Cruz, Aurora; Boulos, Alan; Nourollah-Zadeh, Emad; Paul, Alexandra; Sauvageau, Eric; Hanel, Ricardo; Aguilar-Salinas, Pedro; Novakovic, Roberta L; Welch, Babu G; Almardawi, Ranyah; Jindal, Gaurav; Shownkeen, Harish; Levy, Elad I; Siddiqui, Adnan H; Mocco, J

2018-06-01

BRANCH (wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques) is a multicentre, retrospective study comparing core lab evaluation of angiographic outcomes with self-reported outcomes. Consecutive patients were enrolled from 10 US centres, aged between 18 and 85 with unruptured wide-neck middle cerebral artery (MCA) or basilar apex aneurysms treated endovascularly. Patient demographics, aneurysm morphology, procedural information, mortality and morbidity data and core lab and self-reported modified Raymond Roy (RR) outcomes were obtained. 115 patients met inclusion criteria. Intervention-related mortality and significant morbidity rates were 1.7% (2/115) and 5.8% (6/103) respectively. Core lab adjudicated RR1 and 2 occlusion rates at follow-up were 30.6% and 32.4% respectively. The retreatment rate within the follow-up window was 10/115 (8.7%) and in stent stenosis at follow-up was 5/63 (7.9%). Self-reporting shows a statistically significant direction to angiographic RR one outcomes at follow-up compared with core lab evaluation, with OR 1.75 (95% CI 1.08 to 2.83). Endovascular treatment of wide-neck MCA and basilar apex aneurysms resulted in a core lab adjudicated RR1 occlusion rate of 30.6%. Self-reported results at follow-up favour better angiographic outcomes, with OR 1.75 (95% CI 1.08 to 2.83). These data demonstrate the need for novel endovascular devices specifically designed to treat complex intracranial aneurysms, as well as the importance of core lab adjudication in assessing outcomes in such a trial. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Investigation of Patient-Specific Cerebral Aneurysm using Volumetric PIV, CFD, and In Vitro PC-MRI

NASA Astrophysics Data System (ADS)

Brindise, Melissa; Dickerhoff, Ben; Saloner, David; Rayz, Vitaliy; Vlachos, Pavlos

2017-11-01

4D PC-MRI is a modality capable of providing time-resolved velocity fields in cerebral aneurysms in vivo. The MRI-measured velocities and subsequent hemodynamic parameters such as wall shear stress, and oscillatory shear index, can help neurosurgeons decide a course of treatment for a patient, e.g. whether to treat or monitor the aneurysm. However, low spatiotemporal resolution, limited velocity dynamic range, and inherent noise of PC-MRI velocity fields can have a notable effect on subsequent calculations, and should be investigated. In this work, we compare velocity fields obtained with 4D PC-MRI, computational fluid dynamics (CFD) and volumetric particle image velocimetry (PIV), using a patient-specific model of a basilar tip aneurysm. The same in vitro model is used for all three modalities and flow input parameters are controlled. In vivo, PC-MRI data was also acquired for this patient and used for comparison. Specifically, we investigate differences in the resulting velocity fields and biases in subsequent calculations. Further, we explore the effect these errors may have on assessment of the aneurysm progression and seek to develop corrective algorithms and other methodologies that can be used to improve the accuracy of hemodynamic analysis in clinical setting.

Infundibular dilatation of the posterior communicating artery in a defined population.

PubMed

Vlajković, Slobodan; Vasović, Ljiljana; Trandafilović, Milena; Jovanović, Ivan; Ugrenović, Slađana; Dorđević, Gordana

2015-01-01

Unusual widening of the posterior communicating artery (PCoA) at its beginning from the cerebral portion of the internal carotid artery (ICA) was described as its infundibular dilatation (ID). A possibility of ID rupture or progression to aneurysm was the reason for an investigation of its frequency and morphologic features in specimens of the Serbian population. Cerebral arteries on the brain base of 267 adult cadavers of both genders and varying age and causes of death were dissected. The images of the PCoA in 190 fetuses were also reviewed. ID of the PCoA was defined as a funnel shaped beginning of different width from ICA, wherein PCoA continues from ID apex to the posterior cerebral artery. There were no cases of ID in fetuses. ID and aneurysms of the PCoA were found in 6/267 or 2.2% and 3/267 or 1.12% of adults, respectively. Unilaterally, they existed on the left side and, frequently, in male cases aging 70 years and older, that had died without cerebral cause. Bilaterally, ID was found in 2/6 cases. There was only one case of ID and aneurysm of the PCoA, but from the ID. We are of the opinion that ID of the PCoA only develops postnatally and probably is due to the influence of hemodynamic factors or hypertension. Copyright © 2014 Elsevier GmbH. All rights reserved.

Endovascular minimally invasive treatment of the intracranial aneurysms – first 124 cases

PubMed Central

Dima, S; Scheau, C; Stefanescu, F; Danaila, L

2012-01-01

Introduction: Since May 2005, we have started to treat the intracranial aneurysms endovascular way as an alternative minimally invasive technique to the classic neurosurgery treatment. Objective: Studying the patients’ demographics, clinical presentation, aneurysm size and configuration, type of coils used for embolization, the percentage of compaction and recanalization (especially in patients who presented with subarachnoid hemorrhage), and immediate complications. Methods and Results: An all-inclusive retrospective review of every patient who underwent coils embolization (stent or balloon assisted included) of saccular aneurysms from May 2005 to September 2011 was performed. A total of 116 patients (46 men and 60 women) and 124 aneurysms were treated. A total of 96 patients (41 men and 55 women) underwent follow-up femoral cerebral angiograms (mean follow-up was 25 months and the longest was at 37 months). Five patients required intra-arterial abciximab due to thrombus formation. Four patients had aneurysm rupture while the coil was being advanced. Eleven patients were treated during vasospasm peak. Seven patients had recanalization at 12 months follow-up. Discussion: The average hospitalization period was of 4 days. There is a close relation between Hunt and Hess scale score before treatment and post interventional neurological status. Due to subarachnoid hemorrhage, the vasospasm remains a threat to the patient’s neurological status. The treatment of cerebral aneurysms with endosacular embolization by coils is a safe and durable option. The risk of recanalization or re-rupture in our cohort is small compared to series published elsewhere. Larger series of patients are needed to support our evidence. PMID:23049642

Current Perspectives in Imaging Modalities for the Assessment of Unruptured Intracranial Aneurysms: A Comparative Analysis and Review.

PubMed

Turan, Nefize; Heider, Robert A; Roy, Anil K; Miller, Brandon A; Mullins, Mark E; Barrow, Daniel L; Grossberg, Jonathan; Pradilla, Gustavo

2018-05-01

Intracranial aneurysms (IAs) are pathologic dilatations of cerebral arteries. This systematic review summarizes and compares imaging techniques for assessing unruptured IAs (UIAs). This review also addresses their uses in different scopes of practice. Pathophysiologic mechanisms are reviewed to better understand the clinical usefulness of each imaging modality. A literature review was performed using PubMed with these search terms: "intracranial aneurysm," "cerebral aneurysm," "magnetic resonance angiography (MRA)," computed tomography angiography (CTA)," "catheter angiography," "digital subtraction angiography," "molecular imaging," "ferumoxytol," and "myeloperoxidase". Only studies in English were cited. Since the development and improvement of noninvasive diagnostic imaging (computed tomography angiography and magnetic resonance angiography), many prospective studies and meta-analyses have compared these tests with gold standard digital subtraction angiography (DSA). Although computed tomography angiography and magnetic resonance angiography have lower detection rates for UIAs, they are vital in the treatment and follow-up of UIAs. The reduction in ionizing radiation and lack of endovascular instrumentation with these modalities provide benefits compared with DSA. Novel molecular imaging techniques to detect inflammation within the aneurysmal wall with the goal of stratifying risk based on level of inflammation are under investigation. DSA remains the gold standard for preoperative planning and follow-up for patients with IA. Newer imaging modalities such as ferumoxytol-enhanced magnetic resonance imaging are emerging techniques that provide critical in vivo information about the inflammatory milieu within aneurysm walls. With further study, these techniques may provide aneurysm rupture risk and prediction models for individualized patient care. Copyright © 2018 Elsevier Inc. All rights reserved.

Subarachnoid haemorrhage with "Ecstasy" abuse in a young adult.

PubMed

Auer, J; Berent, R; Weber, T; Lassnig, E; Eber, B

2002-10-01

Abuse of the drugs like amphetamine, cocaine and "Ecstasy" may be complicated by intracerebral, subdural or subarachnoid haemorrhage. Contrary to historical opinion, drug-related intracranial haemorrhage (ICH) is frequently related to an underlying vascular malformation. We report the case of an 18-year-old man with a history of Ecstasy abuse preceding the onset of severe occipital headache. Cerebral computed tomography revealed right-sided subarachnoid haemorrhage and cerebral angiography showed right-sided middle cerebral artery aneurysm of 1 cm diameter. The patient was treated surgically with aneurysm clipping. Three weeks after onset of intracranial haemorrhage, neurological examination demonstrated normal findings. A history of severe headache immediately after using amphetamine, Ecstasy, or cocaine should alert doctors to the possibility of intracerebral haemorrhage. Arteriography should be part of the evaluation of most young patients with stroke or non-traumatic ICH.

Inadequate communication between patients with unruptured cerebral aneurysms and neurosurgeons.

PubMed

Saito, Makoto; Takahashi, Yoshimitsu; Yoshimura, Yayoi; Shima, Ayako; Morita, Akio; Houkin, Kiyohiro; Nakayama, Takeo; Nozaki, Kazuhiko

2012-01-01

Communication between patients with cerebral aneurysms and consulting neurosurgeons remains unstudied in Japan. The present clinical study surveyed patients with unruptured cerebral aneurysms and their neurosurgeons after explanation of the disease and its treatment options and expected outcomes in clinic visits using a one-page written questionnaire about treatment options and decisions given to patients and their neurosurgeons. The numbers of participating patients and neurosurgeons were 42 and 9, respectively, and 42 paired patient-neurosurgeon responses were obtained. Agreement was quite low (κ = 0.17-0.31 for 6-point Likert scale and κ = 0.44-0.67 for 2 category scale) regarding the "best" treatment for each patient as agreed on by the patient and neurosurgeon. Agreement in the understanding of treatment options and general application was unexpectedly low (κ = 0.12 and 0.01 for 6-point Likert scale and κ = not applicable and -0.03, respectively, for 2 category scale). Agreement tended to be higher between experienced neurosurgeons and patients than non-experienced neurosurgeons and patients. Patients estimated much higher risks of stroke or death after surgical intervention (p < 0.001) or no intervention (p = 0.006) compared with the estimates offered by their neurosurgeons.

Current controversies in the prediction, diagnosis, and management of cerebral vasospasm: where do we stand?

PubMed

Lee, Young; Zuckerman, Scott L; Mocco, J

2013-01-01

Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 persons in the United States each year. Around 30 percent of patients with aneurysmal subarachnoid hemorrhage suffer from cerebral ischemia and infarction due to cerebral vasospasm, a leading cause of treatable death and disability following aneurysmal subarachnoid hemorrhage. Methods used to predict, diagnose, and manage vasospasm are the topic of recent active research. This paper utilizes a comprehensive review of the recent literature to address controversies surrounding these topics. Evidence regarding the effect of age, smoking, and cocaine use on the incidence and outcome of vasospasm is reviewed. The abilities of different computed tomography grading schemes to predict vasospasm in the aftermath of subarachnoid hemorrhage are presented. Additionally, the utility of different diagnostic methods for the detection and visualization of vasospasm, including transcranial Doppler ultrasonography, CT angiography, digital subtraction angiography, and CT perfusion imaging is discussed. Finally, the recent literature regarding interventions for the prophylaxis and treatment of vasospasm, including hyperdynamic therapy, albumin, calcium channel agonists, statins, magnesium sulfate, and endothelin antagonists is summarized. Recent studies regarding each topic were reviewed for consensus recommendations from the literature, which were then presented.

Targeting chronic inflammation in cerebral aneurysms: focusing on NF-kappaB as a putative target of medical therapy.

PubMed

Aoki, Tomohiro; Nishimura, M

2010-03-01

Cerebral aneurysms (CAs) are the main cause of life-threatening subarachnoid hemorrhage. Given its prevalence and endpoint, CA treatment is a public health issue. Effective medical treatment of CAs is lacking because the detailed mechanisms of CA formation are incompletely understood. The aim of this contribution is to review recent articles about CA formation, to suggest the underlying mechanisms of CA formation, and to discuss potential therapeutic targets for treatment. Articles were collected by an internet search of PubMed using the keywords 'intracranial' or 'cerebral aneurysm'. A review of articles about the pathogenesis of CA formation focusing on inflammation. Recent articles demonstrate that inflammation-related-molecule induction and inflammatory cell infiltration in CA walls and the close relationship between inflammatory responses and CA formation. From studies in experimental models, chronic inflammation triggered primarily by NF-kappaB activation in endothelial cells and subsequent macrophage infiltration have critical roles in CA formation. Inhibition of inflammation-related molecules in CA walls results in the decreased incidence of CA formation. Agents with anti-inflammatory activity (particularly anti- NF-kappaB effects) have potential as therapeutic drugs for CAs.

Aneurysmal subarachnoid haemorrhage in Parry–Rhomberg syndrome

PubMed Central

Kuechler, Derek; Kaliaperumal, Chandrasekaran; Hassan, Alfrazdaq; Fanning, Noel; Wyse, Gerry; O’Sullivan, Michael

2011-01-01

Parry–Romberg syndrome (PRS) or progressive hemi facial atrophy syndrome is a rare condition of unknown aetiology that is characterised by progressive unilateral facial and cranial atrophic changes of skin, subcutaneous tissues and bone. The authors describe a 37-year-old female with a history of PRS, who presented with a subarachnoid haemorrhage secondary to rupture of a 9 mm fusiform aneurysm of the posterior cerebral artery. There was an associated external carotid arterio-venous fistula noted with this aneurysm. The aneurysm was treated by endovascular route and was successfully coiled. Follow-up angiogram revealed spontaneous resolution of the fistula with good occlusion of the aneurysm. The aetio-pathogenesis of this rare occurrence, literature review and its management is discussed. PMID:22674607

Use of the 2.8 French Progreat microcatheter in diagnostic cerebral angiography.

PubMed

Griauzde, Julius; Gemmete, Joseph J; Shastri, Ravi; Pandey, Aditya S; Chaudhary, Neeraj

2017-01-01

Tortuous vascular anatomy poses a significant challenge to performing diagnostic cerebral angiography. To report a new cerebral angiography technique for overcoming tortuous aortic and supra-aortic anatomy using a 2.8 French (F) Progreat microcatheter (0.028 inch (internal diameter) (Terumo; Somerset, New Jersey, USA) to obtain a diagnostic cerebral angiogram. A retrospective analysis of consecutive cases undergoing diagnostic cerebral angiography at our institution between 1 January 2013 and 30 November 2015 in which a 2.8F Progreat microcatheter was used. Clinical and operative notes were reviewed and correlated with imaging. Radiologic imaging, including CT, MRI, and digital subtraction angiography, was reviewed. Neurologic, systemic, and local complications were recorded on the basis of clinical follow-up results after each angiographic examination. Events that occurred within 24 h of the angiography were considered to be complications of the procedure. Initial attempts at catheterization of the target vessel with various 4F and 5F catheters were unsuccessful owing to tortuosity, atherosclerotic disease, or occlusion of the catheter in the target vessel. Microcatheterization of the target vessel was successful in 59/62 (95%) target vessels. A diagnostic cerebral angiogram with a power injection was obtained in 59 (100%) of the successfully catheterized vessels. In one case, angiography proceeded to aneurysm coiling after over-the-wire exchange. In two cases, angiography proceeded to mechanical thrombectomy after over-the-wire exchange. No procedural complications were seen. The 2.8F Progreat microcatheter can be used to obtain a diagnostic cerebral angiogram in patients with anatomic challenges limiting catheterization by standard techniques. 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/.

Acute postoperative neurological deterioration associated with surgery for ruptured intracranial aneurysm: incidence, predictors, and outcomes.

PubMed

Mahaney, Kelly B; Todd, Michael M; Bayman, Emine O; Torner, James C

2012-06-01

Subarachnoid hemorrhage (SAH) results in significant morbidity and mortality, even among patients who reach medical attention in good neurological condition. Many patients have neurological decline in the perioperative period, which contributes to long-term outcomes. The focus of this study is to characterize the incidence of, characteristics predictive of, and outcomes associated with acute postoperative neurological deterioration in patients undergoing surgery for ruptured intracranial aneurysm. The Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) was a multicenter randomized clinical trial that enrolled 1001 patients and assesssed the efficacy of hypothermia as neuroprotection during surgery to secure a ruptured intracranial aneurysm. All patients had a radiographically confirmed SAH, were classified as World Federation of Neurosurgical Societies (WFNS) Grade I-III immediately prior to surgery, and underwent surgery to secure the ruptured aneurysm within 14 days of SAH. Neurological assessment with the National Institutes of Health Stroke Scale (NIHSS) was performed preoperatively, at 24 and 72 hours postoperatively, and at time of discharge. The primary outcome variable was a dichotomized scoring based on an IHAST version of the Glasgow Outcome Scale (GOS) in which a score of 1 represents a good outcome and a score > 1 a poor outcome, as assessed at 90-days' follow-up. Data from IHAST were analyzed for occurrence of a postoperative neurological deterioration. Preoperative and intraoperative variables were assessed for associations with occurrence of postoperative neurological deterioration. Differences in baseline, intraoperative, and postoperative variables and in outcomes between patients with and without postoperative neurological deterioration were compared with Fisher exact tests. The Wilcoxon rank-sum test was used to compare variables reported as means. Multiple logistic regression was used to adjust for covariates associated with occurrence of postoperative deficit. Acute postoperative neurological deterioration was observed in 42.6% of the patients. New focal motor deficit accounted for 65% of postoperative neurological deterioration, while 60% was accounted for using the NIHSS total score change and 51% by Glasgow Coma Scale score change. Factors significantly associated with occurrence of postoperative neurological deterioration included: age, Fisher grade on admission, occurrence of a procedure prior to aneurysm surgery (ventriculostomy), timing of surgery, systolic blood pressure during surgery, ST segment depression during surgery, history of abnormality in cardiac valve function, use of intentional hypotension during surgery, duration of anterior cerebral artery occlusion, intraoperative blood loss, and difficulty of aneurysm exposure. Of the 426 patients with postoperative neurological deterioration at 24 hours after surgery, only 46.2% had a good outcome (GOS score of 1) at 3 months, while 77.7% of those without postoperative neurological deterioration at 24 hours had a good outcome (p < 0.05). Neurological injury incurred perioperatively or in the acute postoperative period accounts for a large percentage of poor outcomes in patients with good admission WFNS grades undergoing surgery for aneurysmal SAH. Avoiding surgical factors associated with postoperative neurological deterioration and directing investigative efforts at developing improved neuroprotection for use in aneurysm surgery may significantly improve long-term neurological outcomes in patients with SAH.

An Unruptured Aneurysm Coexisting with an Infundibular Dilatation: A Case Report.

PubMed

Kitamura, Takao; Murai, Yasuo; Shirokane, Kazutaka; Matano, Fumihiro; Kitamura, Takayuki; Morita, Akio

2016-01-01

Infundibular dilatation (ID) is a funnel-shaped enlargement of the origin of cerebral arteries. The coexistence of an aneurysm and ID is relatively rare. Patients with IDs are rarely followed up. However, some IDs have been reported to develop into aneurysms with subsequent rupture. Here we report on a case of an aneurysm that coexisted with ID of the posterior communicating artery. A 51-year-old woman underwent magnetic resonance imaging (MRI) to check for aneurysms and other problems. MRI revealed an unruptured aneurysm of the right internal carotid artery, for which the patient was admitted to our hospital. Three-dimensional computed tomographic angiography revealed an aneurysm, which protruded outward, and ID of the posterior communicating artery, which protruded inward. A right pterional craniotomy was performed with aneurysm clipping. The postoperative course was uneventful. In this report, we demonstrate operative views of the aneurysm and ID with the use of neuroendoscopy. ID can develop into a true arterial aneurysm and potentially rupture. Therefore, we need to observe the patients with IDs carefully, particularly in young women.

Fatal Mycotic Aneurysms Due to Scedosporium and Pseudallescheria Infection▿

PubMed Central

Ong, Adrian; Blyth, Christopher C.; Bency, Rosamma; Vicaretti, Mauro; Harun, Azian; Meyer, Wieland; Shingde, Meena; Gilroy, Nicky; Chapman, Jeremy; Chen, Sharon C.-A.

2011-01-01

Angioinvasive complications of Scedosporium infections are rare. We report two cases of mycotic aneurysm, following apparent localized infection, due to Scedosporium apiospermum and Pseudallescheria boydii. The thoracoabdominal aorta was affected in one patient, and cerebral vessels were affected in the other. Despite voriconazole therapy and surgical resection, the patients died. Previously reported cases are reviewed. PMID:21430108

Endovascular Device Testing with Particle Image Velocimetry Enhances Undergraduate Biomedical Engineering Education

ERIC Educational Resources Information Center

Nair, Priya; Ankeny, Casey J.; Ryan, Justin; Okcay, Murat; Frakes, David H.

2016-01-01

We investigated the use of a new system, HemoFlow™, which utilizes state of the art technologies such as particle image velocimetry to test endovascular devices as part of an undergraduate biomedical engineering curriculum. Students deployed an endovascular stent into an anatomical model of a cerebral aneurysm and measured intra-aneurysmal flow…

Development of a diagnostic system for bilirubin detection in cerebral spinal fluid

NASA Astrophysics Data System (ADS)

Bhadri, Prashant R.; Salgaonkar, Vasant A.; Majumdar, Anindya; Morgan, Chad J.; Zuccarello, Mario; Pyne, Gail J.; Dulaney, Elizabeth; Caffery, James, Jr.; Shukla, Rakesh; Beyette, Fred R., Jr.

2004-11-01

A weakened portion of an artery in the brain leads to a medical condition known as a cerebral aneurysm. A subarachnoid hemorrhage (SAH) occurs when an aneurysm ruptures. For those individuals suspected of having a SAH, a computerized tomography (CT) scan of the brain usually demonstrates evidence of the bleeding. However, in a considerable portion of people, the CT scan is unable to detect the blood that has escaped from the blood vessel. Recent studies have indicated nearly 30% of patients with a SAH are initially misdiagnosed. For circumstances when a SAH is suspected despite a normal CT scan, physicians make the diagnosis of SAH by performing a spinal tap. A spinal tap uses a needle to sample the cerebrospinal fluid (CSF) collected from the patient"s lumbar spine. However, it is also possible for blood to be introduced into the CSF as a result of the spinal tap procedure. Therefore, an effective solution is required to help medical personnel differentiate between the blood that results from a tap and that from a ruptured aneurysm. In this paper, the development of a prototype is described which is sensitive and specific for measuring bilirubin in CSF, hemorrhagic-CSF and CSF-like solutions. To develop this instrument a combination of spectrophotometric analysis, custom data analysis software and other hardware interfaces are assembled that lay the foundation for the development of portable and user-friendly equipment suitable for assisting trained medical personnel with the diagnosis of a ruptured cerebral aneurysm.

Surgery of intracranial aneurysms at Yonsei University: 780 cases.

PubMed

Lee, K C

1991-03-01

Seven hundred and eighty patients with intracranial aneurysm, which were surgically treated by the author since 1976, were analyzed. Strategies important for intracranial aneurysm surgery were the timing of surgery, preoperative preparation and intraoperative management. The best management outcome could be achieved by early operation, removal of subarachnoid blood clot, maintenance of circulating blood volume, administration of nimodipine, and meticulous surgical tactics to avoid pitfalls. Indications for aneurysm surgery in the acute phase were determined by intracerebral hematoma, angiographic findings, clinical grade, general physical status and readiness of the surgical team. Important goals to be considered during the operation were obtaining a slack brain, preparation of proximal control, protection of the brain, awareness of microsurgical anatomy, and complete dissection of the sac. The morbidity and mortality were 2.7% and 4.0%, respectively. The mortality was attributed to intracranial causes in 20 cases (poor grade, delayed ischemic deficits, rebleeding, postoperative infarction, and postoperative epidural hematoma), extracranial causes in 7 cases (pulmonary embolism, heparin induced intracerebral hemorrhage, hepatic failure, myocardial infarction, and gastrointestinal bleeding), and unknown problems in 5 cases. The postoperative intracerebral hemorrhage occurred in 16 cases and seemed to be caused by one or more of the following events: cerebral infarction developed during the preoperative period, occlusion of the cerebral veins during the Sylvian dissection, cerebral retraction and/or sudden change of intracranial hemodynamics. Hydrocephalus, almost always a communicating type as confirmed by isotope cisternography, was managed by lumboperitoneal shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

The Effect of Hemodynamics on Cerebral Aneurysm Morphology

NASA Astrophysics Data System (ADS)

Metcalfe, Ralph; Mantha, Aishwarya; Karmonik, Christof; Strother, Charles

2004-11-01

One of the difficulties in applying principles of hemodynamics to the study of blood flow in aneurysms are the drastic variations in possible shape of both the aneurysms and the parent arteries in the region of interest. We have taken data from three para-opthalmic internal carotid artery aneurysms using 3D-digital subtraction angiography (3D-DSA) and performed CFD simulations of steady and unsteady flows through the three different cases using the same pressure gradients and pulsatile flow waveforms (based on the Ku model for flow through the Carotid bifurcation). We have found that the total pressure differential within the aneurysms is consistent with the direction of flow, and that the dynamic pressure gradient within the aneurysm is very small compared with the static pressure variations. Wall shear stresses were highest near regions of sharp arterial curvature, but always remained low inside the aneurysm. These results suggest a more complex role for hemodynamics in aneurysm generation, growth and rupture.

The hemodynamics in intracranial aneurysm ruptured region with active contrast leakage during computed tomography angiography

NASA Astrophysics Data System (ADS)

Li, Ming-Lung; Wang, Yi-Chou; Liou, Tong-Miin; Lin, Chao-An

2014-10-01

Precise locations of rupture region under contrast agent leakage of five ruptured cerebral artery aneurysms during computed tomography angiography, which is to our knowledge for the first time, were successfully identified among 101 patients. These, together with numerical simulations based on the reconstructed aneurysmal models, were used to analyze hemodynamic parameters of aneurysms under different cardiac cyclic flow rates. For side wall type aneurysms, different inlet flow rates have mild influences on the shear stresses distributions. On the other hand, for branch type aneurysms, the predicted wall shear stress (WSS) correlates strongly with the increase of inlet vessel velocity. The mean and time averaged WSSes at rupture regions are found to be lower than those over the surface of the aneurysms. Also, the levels of the oscillatory shear index (OSI) are higher than the reported threshold value, supporting the assertion that high OSI correlates with rupture of the aneurysm. However, the present results also indicate that OSI level at the rupture region is relatively lower.

Multiple intracranial aneurysms and moyamoya disease associated with microcephalic osteodysplastic primordial dwarfism type II: surgical considerations.

PubMed

Waldron, James S; Hetts, Steven W; Armstrong-Wells, Jennifer; Dowd, Christopher F; Fullerton, Heather J; Gupta, Nalin; Lawton, Michael T

2009-11-01

Microcephalic osteodysplastic primordial dwarfism type II (MOPD II) is a rare genetic syndrome characterized by extremely small stature and microcephaly, and is associated in 25% of patients with intracranial aneurysms and moyamoya disease. Although aneurysmal subarachnoid hemorrhage and stroke are leading causes of morbidity and death in these patients, MOPD II is rarely examined in the neurosurgical literature. The authors report their experience with 3 patients who presented with MOPD II, which includes a patient with 8 aneurysms (the most aneurysms reported in the literature), and the first report of a patient with both moyamoya disease and multiple aneurysms. The poor natural history of these lesions indicates aggressive microsurgical and/or endovascular therapy. Microsurgery, whether for aneurysm clip placement or extracranial-intracranial bypass, is challenging due to tight surgical corridors and diminutive arteries in these patients, but is technically feasible and strongly indicated when multiple aneurysms must be treated or cerebral revascularization is needed.

Polyuria and cerebral vasospasm after aneurysmal subarachnoid hemorrhage.

PubMed

Brown, Robert J; Epling, Brian P; Staff, Ilene; Fortunato, Gilbert; Grady, James J; McCullough, Louise D

2015-10-13

Natriuresis with polyuria is common after aneurysmal subarachnoid hemorrhage (aSAH). Previous studies have shown an increased risk of symptomatic cerebral vasospasm or delayed cerebral ischemia (DCI) in patients with hyponatremia and/or the cerebral salt wasting syndrome (CSW). However, natriuresis may occur in the absence of hyponatremia or hypovolemia and it is not known whether the increase in DCI in patients with CSW is secondary to a concomitant hypovolemia or because the physiology that predisposes to natriuretic peptide release also predisposes to cerebral vasospasm. Therefore, we investigated whether polyuria per se was associated with vasospasm and whether a temporal relationship existed. A retrospective review of patients with aSAH was performed. Exclusion criteria were admission more than 48 h after aneurysmal rupture, death within 5 days, and the development of diabetes insipidus or acute renal failure. Polyuria was defined as > 6 liters of urine in a 24 h period. Vasospasm was defined as a mean velocity > 120 m/s on Transcranial Doppler Ultrasonography (TCDs) or by evidence of vasospasm on computerized tomography (CT) or catheter angiography. Multivariable logistic regression was performed to assess the relationship between polyuria and vasospasm. 95 patients were included in the study. 51 had cerebral vasospasm and 63 met the definition of polyuria. Patients with polyuria were significantly more likely to have vasospasm (OR 4.301, 95% CI 1.378-13.419) in multivariate analysis. Polyuria was more common in younger patients (52 vs 68, p <.001) but did not impact mortality after controlling for age and disease severity. The timing of the development of polyuria was clustered around the diagnosis of vasospasm and patients with polyuria developed vasospasm faster than those without polyuria. Polyuria is common after aSAH and is significantly associated with cerebral vasospasm. The development of polyuria may be temporally related to the development of vasospasm. An increase in urine volume may be a useful clinical predictor of patients at risk for vasospasm.

Spectrophotometry or visual inspection to most reliably detect xanthochromia in subarachnoid hemorrhage: systematic review.

PubMed

Chu, Kevin; Hann, Angus; Greenslade, Jaimi; Williams, Julian; Brown, Anthony

2014-09-01

We assess the sensitivity and specificity of xanthochromia as adjudicated by visual inspection and spectrophotometry at predicting the presence of cerebral aneurysm in patients with suspected subarachnoid hemorrhage who have a normal computed tomography (CT) head scan result. A systematic review was performed. MEDLINE and EMBASE databases were searched. Relevant studies with clinical data on the diagnostic accuracy of visual inspection or spectrophotometry were considered. Patients who had a normal CT head scan result followed by a lumbar puncture were included in this review. Sensitivities, specificities, and heterogeneity (I(2)) were calculated. Subgroup analyses were performed to explore reasons for the heterogeneity. There were major methodological limitations in the studies found. Twenty-two relevant articles were heterogeneous in regard to time to lumbar puncture, spectrophotometry methods, and follow-up of patients not undergoing cerebral angiography. Twelve of the 22 studies selected patients on the basis of a cerebral aneurysm or subarachnoid hemorrhage on imaging, or a positive lumbar puncture result. These studies were excluded from our initial analysis, which included only patients with clinically suspected subarachnoid hemorrhage. In this initial analysis, pooled estimates of sensitivity and specificity for spectrophotometry were 87% (95% confidence interval [CI] 71% to 96%; I(2)=26%) and 86% (95% CI 84% to 88%; I(2)=96%), respectively. For visual inspection, pooled sensitivity and specificity were 83% (95% CI 59% to 96%; I(2)=52%) and 96% (95% CI 93% to 97%; I(2)=76%), respectively. Sensitivity estimates are difficult to interpret without knowing time to lumbar puncture. The heterogeneity in the underlying studies, combined with significant overlap in pooled confidence limits, makes it impossible to provide a definite conclusion about the diagnostic accuracy of spectrophotometry versus visual inspection. Copyright © 2014 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Monorail snare technique for the recovery of stretched platinum coils: technical case report.

PubMed

Fiorella, David; Albuquerque, Felipe C; Deshmukh, Vivek R; McDougall, Cameron G

2005-07-01

Coil stretching represents a potentially hazardous technical complication not infrequently encountered during the embolization of cerebral aneurysms. Often, the stretched coil cannot be advanced into the aneurysm or withdrawn intact. The operator is then forced to attempt to retract the damaged coil, which may result in coil breakage, leaving behind a significant length of potentially thrombogenic stretched coil material within the parent vessel. To overcome this problem, we devised a technique to snare the distal, unstretched, intact portion of the platinum coil by use of the indwelling microcatheter and stretched portion of the coil as a monorail guide. We have used this technique successfully in four patients to snare coils stretched during cerebral aneurysm embolization. Three of these patients were undergoing Neuroform (Boston Scientific/Target, Fremont, CA) stent-supported coil embolization of unruptured aneurysms. In all cases, the snare was advanced easily to the targeted site for coil engagement by use of the microcatheter as a monorail guide. Once the intact distal segment of the coil was ensnared, coil removal was uneventful, with no disturbance of the remainder of the indwelling coil pack or Neuroform stent. A 2-mm Amplatz Goose Neck microsnare (Microvena Corp., White Bear Lake, MN) was placed through a Prowler-14 microcatheter (Cordis Corp., Miami, FL). The hub of the indwelling SL-10 microcatheter (Boston Scientific, Natick, MA) was then cut away with a scalpel, leaving the coil pusher wire intact, and removed. The open 2-mm snare was then advanced over the outside of the coil pusher wire and microcatheter. The snare and Prowler-14 microcatheter were then advanced into the guiding catheter (6- or 7-French) as a unit over the indwelling SL-10 microcatheter. By use of the SL-10 microcatheter and coil as a "monorail" guide, the snare was advanced over and beyond the microcatheter and the stretched portion of the coil until the snare was in position to engage the distal unstretched coil. At this point, the snare was then closed around the intact portion of the coil, and the microcatheters, snare, and coil were removed as a unit. The monorail snare technique represents a fast, safe, and easy method by which a stretched coil can be removed.

Return of visual function after bilateral visual loss following flow diversion embolization of a giant ophthalmic aneurysm due to both reduction in mass effect and reduction in aneurysm pulsation.

PubMed

Patel, Saharsh; Fargen, Kyle M; Peters, Keith; Krall, Peter; Samy, Hazem; Hoh, Brian L

2015-01-01

Large and giant paraclinoid aneurysms are challenging to treat by either surgical or endovascular means. Visual dysfunction secondary to optic nerve compression and its relationship with aneurysm size, pulsation and thrombosis is poorly understood. We present a patient with a giant paraclinoid aneurysm resulting in bilateral visual loss that worsened following placement of a Pipeline Embolization Device and adjunctive coiling. Visual worsening occurred in conjunction with aneurysm thrombosis, increase in maximal aneurysm diameter and new adjacent edema. Her visual function spontaneously improved in a delayed fashion to better than pre-procedure, in conjunction with reduced aneurysmal mass effect, size and pulsation artifact on MRI. This report documents detailed ophthalmologic and MRI evidence for the role of thrombosis, aneurysm mass effect and aneurysm pulsation as causative etiologies for both cranial nerve dysfunction and delayed resolution following flow diversion treatment of large cerebral aneurysms. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Various origins of the duplicated middle cerebral artery.

PubMed

Tutar, Nihal Uslu; Töre, Hüseyin Gürkan; Kirbaş, Ismail; Tarhan, Nefise Cağla; Coşkun, Mehmet

2008-10-01

We describe the features of a duplicated middle cerebral artery identified by computed tomographic angiography that originates from a previously undefined origin, ie, from the petrous portion of the internal carotid artery. Recognition of this anomaly is important in patients with a possible aneurysm, which was not present in our patient.

[Neuroanesthetic management for surgical clipping of a ruptured cerebral aneurysm: clinical practice guidelines].

PubMed

Ingelmo Ingelmo, I; Carmona Aurioles, J; Rama-Maceiras, P; Fàbregas Julià, N; Hernández-Palazón, J

2010-12-01

Subarachnoid hemorrhage due to spontaneous rupture of a cerebral aneurysm is associated with high rates of morbidity and mortality and requires multidisciplinary treatment. The debate on surgical vs endovascular treatment continues, although short-term clinical outcomes and survival rates are better after endovascular treatment. In Spain, a strong trend toward reduced use of clipping has been noted, and neuroanesthetists are less often called on to provide anesthesia in this setting. Our intervention, however, can be decisive. The neuroscience working group of the Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor has developed guidelines for managing anesthesia in these procedures. Based on a national survey and a systematic review of the literature, the recommendations emphasize the importance of ensuring appropriate intracranial conditions, treating complications, and taking steps to protect against cerebral hemorrhage.

On the mechanics of cerebral aneurysms: experimental research and numerical simulation

NASA Astrophysics Data System (ADS)

Parshin, D. V.; Kuianova, I. O.; Yunoshev, A. S.; Ovsyannikov, K. S.; Dubovoy, A. V.

2017-10-01

This research extends existing experimental data for CA tissues [1, 2] and presents the preliminary results of numerical calculations. Experiments were performed to measure aneurysm wall stiffness and the data obtained was analyzed. To reconstruct the geometry of the CAs, DICOM images of real patients with aneurysms and ITK Snap [3] were used. In addition, numerical calculations were performed in ANSYS (commercial software, License of Lavrentyev Institute of Hydrodynamics). The results of these numerical calculations show a high level of agreement with experimental data from previous literature.

In vivo and in vitro measurements of cerebral aneurysm hemodynamics

NASA Astrophysics Data System (ADS)

Amili, Omid; Toloui, Mostafa; van de Moortele, Pierre-Francois; Jagadeesan, Bharathi; Coletti, Filippo

2017-11-01

The hemodynamics of cerebral aneurysms is thought to play a critical role in their formation, growth, and potential rupture. Our understanding in this area, however, comes mostly from in vitro experiments and numerical simulations, which have limited realism. In vivo measurements of the intracranial blood flow can be obtained by Magnetic Resonance Imaging (MRI), but they typically suffer from limited accuracy and inadequate resolution. Here we present a direct comparison between in vivo and in vitro measurements of the flow inside an internal carotid artery aneurysm. For both, we use 4D (i.e. volumetric and time-resolved) MRI velocimetry performed in a 7 Tesla magnet at sub-millimeter resolution. The in vitro measurements are carried out in a 3D printed aneurysm replica scaled up by a factor three, effectively increasing the spatial resolution. The patient-specific inflow waveform and the corresponding Reynolds and Womersley numbers are matched in a flow loop that mimics the impedance of the vascular bed. Direct comparison of the velocity fields allows assessing the robustness of the in vivo measurements, while highlighting the insight achievable in vitro. The data also represents a comprehensive test case for numerical simulations.

[A Case of Aphasia after Neck Clipping of a Ruptured Aneurysm at the Origin of the Duplicated Middle Cerebral Artery].

PubMed

Miyoshi, Hiroyuki; Migita, Keisuke; Kumano, Kiyoshi; Hashimoto, Naomi; Toyota, Akihiro

2016-11-01

We report a case of aphasia after neck clipping of a ruptured aneurysm at the origin of the duplicated middle cerebral artery(DMCA). A 60-year-old woman had a sudden onset of headache and nausea. A computed tomography(CT)scan revealed diffuse subarachnoid hemorrhage. Head three-dimensional CT angiography(3D-CTA)showed a left DMCA with a saccular aneurysm at the origin. She became aphasic on the third day after aneurysmal neck clipping. A CT scan revealed a low-density area in the anterior portion of the left temporal lobe, which is perfused by the DMCA. The DMCA was patent on 3D-CTA, but the angle between the ICA and the DMCA changed steep. It is suspected that the clip changed the branching angle at the DMCA origin, which may have led to decreased blood flow in the DMCA. She received linguistic rehabilitation for dysnomia and was discharged with slight difficulty in naming objects. Six months later, she recovered from the aphasia. One year later, the DMCA was patent on 3D-CTA. We should pay attention to ischemic complications in clipping because DMCAs are easily deformed.

Pre-hemorrhage statin use and the risk of vasospasm following aneurysmal subarachnoid hemorrhage

PubMed Central

Moskowitz, Shaye I.; Ahrens, Christine; Provencio, J Javier; Chow, Michael; Rasmussen, Peter A

2010-01-01

Background and Purpose Aneurysmal subarachnoid hemorrhage (SAH) is often followed by delayed ischemic deficits attributable to cerebral vasospasm. Recent studies suggest a positive impact of statin therapy on the incidence of vasospasm. This study was designed to assess whether a history of prior use of statin therapy was associated with a lower risk of vasospasm in patients with SAH. Methods We performed a comprehensive retrospective review of patients with aneurysmal SAH between 1997 and 2004. Clinical demographics and imaging data for all patients were reviewed and a logistic regression analysis was performed to identify the predictors of cerebral vasospasm, defined as a combination of clinical signs with radiographic confirmation. Results 308 patients were included. Mean age was higher in the group receiving statins (64 +/- 12 versus 54+/- 12 years). Hunt and Hess scores and treatment modality were not significantly different between the groups. Vasospasm was observed in 31% of patients not taking a statin (n=282) versus 23% taking a statin (n=26), without achieving statistical significance. Discontinuation of the statin did not affect risk of vasospasm. Conclusions Use of a statin prior to an aneurysmal SAH trended to reduce the incidence of subsequent vasospasm, without achieving statistical significance. PMID:18423529

Osteogenesis imperfecta presenting as aneurysmal subarachnoid haemorrhage in a 53-year-old man

PubMed Central

Kaliaperumal, Chandrasekaran; Walsh, Tom; Balasubramanian, Chandramouli; Wyse, Gerry; Fanning, Noel; Kaar, George

2011-01-01

The authors describe a case of aneurysmal subarachnoid haemorrhage in a 53-year-old man with background of osteogenesis imperfecta (OI). CT brain revealed diffuse subarachnoid haemorrhage (SAH) and cerebral angiogram subsequently confirmed vertebral artery aneurysm rupture leading to SAH. To the authors knowledge this is the first case of vertebral artery aneurysmal SAH described in OI. A previously undiagnosed OI was confirmed by genetic analysis (COL1A1 gene mutation). This aneurysm was successfully treated by endovascular route. Post interventional treatment patient developed stroke secondary to vasospasm. Communicating hydrocephalus, which developed in the process of management, was successfully treated with ventriculo-peritoneal shunt. The aetio-pathogenesis and management of this condition is described. The authors have reviewed the literature and genetic basis of this disease. PMID:22674700

Clinical and angiographic outcomes after stent-assisted coiling of cerebral aneurysms with Enterprise and Neuroform stents: a comparative analysis of the literature.

PubMed

King, Brent; Vaziri, Sasha; Singla, Amit; Fargen, Kyle M; Mocco, J

2015-12-01

The most widely used intracranial stents for stent-assisted coiling are Neuroform (NEU) and Enterprise stents (ENT). This study compares published outcomes between the ENT and NEU coil-assist systems and comments on the published safety and efficacy of stent-assisted coiling in general. A literature search was performed through PubMed for all published series of ENT or NEU stent-assisted coiling of cerebral aneurysms from 2004 to 2014. All studies including 10 or more published cases of stent-assisted coiling with ENT or NEU were included. 47 studies met the inclusion criteria, containing 4238 aneurysms in 4039 patients. 2111 aneurysms were treated with NEU and 2127 were treated with ENT. Mean follow-up was 14.1 months. Overall, thromboembolic events occurred in 6.4% of aneurysms, intracranial hemorrhage (ICH) in 2.6%, permanent morbidity in 3.9%, and mortality in 2.3%. Initial and final 100% angiographic occlusion was seen in 53% and 69% of patients, respectively. Deployment failures (p<0.001), ICH (p=0.001), mortality among all patients (p=0.03), and recanalization (p=0.02) were more commonly reported in NEU treated aneurysms. The ENT system was also associated with higher reported complete occlusion at follow-up (p<0.001). This literature review represents the largest and most robust comparison of stent-assisted coiling devices to date, containing over 4200 aneurysms in more than 4000 patients. Comparative analyses demonstrate that both devices are reported to be safe and effective with comparable permanent morbidity. 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/

Nonaneurysmal "Pseudo-Subarachnoid Hemorrhage" Computed Tomography Patterns: Challenges in an Acute Decision-Making Heuristics.

PubMed

Hasan, Tasneem F; Duarte, Walter; Akinduro, Oluwaseun O; Goldstein, Eric D; Hurst, Rebecca; Haranhalli, Neil; Miller, David A; Wharen, Robert E; Tawk, Rabih G; Freeman, William D

2018-06-05

Acute aneurysmal subarachnoid hemorrhage (SAH) is a medical and neurosurgical emergency from ruptured brain aneurysm. Aneurysmal SAH is identified on brain computed tomography (CT) as increased density of basal cisterns and subarachnoid spaces from acute blood products. Aneurysmal SAH-like pattern on CT appears as an optical illusion effect of hypodense brain parenchyma and/or hyperdense surrounding cerebral cisterns and blood vessels termed as "pseudo-subarachnoid hemorrhage" (pseudo-SAH). We reviewed clinical, laboratory, and radiographic data of all SAH diagnoses between January 2013 and January 2018, and found subsets of nonaneurysmal SAH, originally suspected to be aneurysmal in origin. We performed a National Library of Medicine search methodology using terms "subarachnoid hemorrhage," "pseudo," and "non-aneurysmal subarachnoid hemorrhage" singly and in combination to understand the sensitivity, specificity, and precision of pseudo-SAH. Over 5 years, 230 SAH cases were referred to our tertiary academic center and only 7 (3%) met the definition of pseudo-SAH. Searching the National Library of Medicine using subarachnoid hemorrhage yielded 27,402 results. When subarachnoid hemorrhage and pseudo were combined, this yielded 70 results and sensitivity was 50% (n = 35). Similarly, search precision was relatively low (26%) as only 18 results fit the clinical description similar to the 7 cases discussed in our series. Aneurysmal SAH pattern on CT is distinct from nonaneurysmal and pseudo-SAH patterns. The origin of pseudo-SAH terminology appears mostly tied to comatose cardiac arrest patients with diffuse dark brain Hounsfield units and cerebral edema, and is a potential imaging pitfall in acute medical decision-making. Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Novel application of a balloon-anchoring technique for the realignment of a prolapsed pipeline embolization device: a technical report.

PubMed

Crowley, R Webster; Abla, Adib A; Ducruet, Andrew F; McDougall, Cameron G; Albuquerque, Felipe C

2014-07-01

Flow-diverting stents represent a substantial advancement in the treatment of cerebral aneurysms. They can, however, be associated with unique complications that may require management through adjunctive techniques. To present a technical report of a salvage technique used to realign a prolapsed Pipeline Embolization Device (PED) during the treatment of a giant internal carotid artery (ICA) aneurysm. A patient in his late 70s with an incidental giant supraclinoid ICA aneurysm presented for endovascular consideration. Treatment was planned using the PED. Following placement of the device there were two focal areas of incomplete expansion and balloon angioplasty was performed. This manipulation resulted in foreshortening of the distal aspect of the PED which caused the device to prolapse into the aneurysm. After multiple unsuccessful attempts to regain distal access, a salvage technique was attempted in which a balloon was inflated in the middle cerebral artery and, by applying traction, the PED was realigned with the parent artery. After the PED was realigned, direct distal catheter access was achieved and a second Pipeline device was deployed, successfully covering the aneurysm neck with resultant flow stasis. The patient had no postoperative issues and was discharged 2 days later without deficit. The balloon-anchoring technique was successfully used to realign a PED that had prolapsed into a giant ICA aneurysm. This maneuver prevented potentially disastrous complications and allowed the satisfactory completion of the aneurysm embolization. This represents a useful salvage technique that should be considered when encountering a prolapsed stent. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Are Fetal-Type Posterior Cerebral Arteries Associated With an Increased Risk of Posterior Communicating Artery Aneurysms?

PubMed

Thiarawat, Peeraphong; Jahromi, Behnam Rezai; Kozyrev, Danil A; Intarakhao, Patcharin; Teo, Mario K; Choque-Velasquez, Joham; Niemelä, Mika; Hernesniemi, Juha

2018-05-21

Fetal-type posterior cerebral arteries (F-PCAs) might result in alterations in hemodynamic flow patterns and may predispose an individual to an increased risk of posterior communicating artery aneurysms (PCoAAs). To determine the association between PCoAAs and the presence of ipsilateral F-PCAs. We retrospectively reviewed the radiographic findings from 185 patients harboring 199 PCoAAs that were treated at our institution between 2005 and 2015. Our study population consisted of 4 cohorts: (A) patients with 171 internal carotid arteries (ICAs) harboring unilateral PCoAAs; (B) 171 unaffected ICAs in the same patients from the first group; (C) 28 ICAs of 14 patients with bilateral PCoAAs; and (D) 180 ICAs of 90 patients with aneurysms in other locations. We then determined the presence of ipsilateral F-PCAs and recorded all aneurysm characteristics. Group A had the highest prevalence of F-PCAs (42%) compared to 19% in group B, 3% in group C, and 14% in group D (odds ratio A : B = 3.041; A : C = 19.626; and A : D = 4.308; P < .001). PCoAAs were associated with larger diameters of the posterior communicating arteries (median value 1.05 vs 0.86 mm; P = .001). The presence of F-PCAs was associated with larger sizes of the aneurysm necks (median value 3.3 vs 3.0 mm; P = .02). PCoAAs were associated with a higher prevalence of ipsilateral F-PCAs. This variant was associated with larger sizes of the aneurysm necks but was not associated with the sizes of the aneurysm domes or with their rupture statuses.

Lethal Ultra-Early Subarachnoid Hemorrhage Due to Rupture of De Novo Aneurysm 5 Months After Primary Aneurysmatic Subarachnoid Hemorrhage.

PubMed

Walter, Johannes; Unterberg, Andreas W; Zweckberger, Klaus

2018-05-01

Approximately 1% of all patients surviving rupture of a cerebral aneurysm suffer from a second aneurysmatic subarachnoid hemorrhage later in their lives, 61% of which are caused by rupture of a de novo aneurysm. Latency between bleedings is usually many years, and younger patients tend to achieve better outcomes from a second subarachnoid hemorrhage. We report an unusual case of lethal ultra-early rupture of a de novo aneurysm of the anterior communicating artery only 5 months after the initial subarachnoid hemorrhage and complete coiling in a young, healthy male patient. Despite complete aneurysm obliteration, young age, and good recovery, patients may be subjected to secondary subarachnoid hemorrhages from de novo aneurysms after only a few months of the initial bleeding. Early-control magnetic resonance angiography might hence be advisable. Copyright © 2018 Elsevier Inc. All rights reserved.

In vivo tissue response following implantation of shape memory polyurethane foam in a porcine aneurysm model

PubMed Central

Rodriguez, Jennifer N.; Clubb, Fred J.; Wilson, Thomas S.; Miller, Matthew W.; Fossum, Theresa W.; Hartman, Jonathan; Tuzun, Egemen; Singhal, Pooja; Maitland, Duncan J.

2014-01-01

Cerebral aneurysms treated by traditional endovascular methods using platinum coils have a tendency to be unstable, either due to chronic inflammation, compaction of coils, or growth of the aneurysm. We propose to use alternate filling methods for the treatment of intracranial aneurysms using polyurethane based shape memory polymer (SMP) foams. SMP polyurethane foams were surgically implanted in a porcine aneurysm model to determine biocompatibility, localized thrombogenicity, and their ability to serve as a stable filler material within an aneurysm. The degree of healing was evaluated via gross observation, histopathology and low vacuum scanning electron microscopy (LV-SEM) imaging after zero, thirty and ninety days. Clotting was initiated within the SMP foam at time zero (less than one hour exposure to blood prior to euthanization), partial healing was observed at thirty days, and almost complete healing had occurred at ninety days in vivo, with minimal inflammatory response. PMID:23650278

In vivo response to an implanted shape memory polyurethane foam in a porcine aneurysm model.

PubMed

Rodriguez, Jennifer N; Clubb, Fred J; Wilson, Thomas S; Miller, Matthew W; Fossum, Theresa W; Hartman, Jonathan; Tuzun, Egemen; Singhal, Pooja; Maitland, Duncan J

2014-05-01

Cerebral aneurysms treated by traditional endovascular methods using platinum coils have a tendency to be unstable, either due to chronic inflammation, compaction of coils, or growth of the aneurysm. We propose to use alternate filling methods for the treatment of intracranial aneurysms using polyurethane-based shape memory polymer (SMP) foams. SMP polyurethane foams were surgically implanted in a porcine aneurysm model to determine biocompatibility, localized thrombogenicity, and their ability to serve as a stable filler material within an aneurysm. The degree of healing was evaluated via gross observation, histopathology, and low vacuum scanning electron microscopy imaging after 0, 30, and 90 days. Clotting was initiated within the SMP foam at time 0 (<1 h exposure to blood before euthanization), partial healing was observed at 30 days, and almost complete healing had occurred at 90 days in vivo, with minimal inflammatory response. Copyright © 2013 Wiley Periodicals, Inc.

Global miRNA expression profile reveals novel molecular players in aneurysmal subarachnoid haemorrhage.

PubMed

Lopes, Katia de Paiva; Vinasco-Sandoval, Tatiana; Vialle, Ricardo Assunção; Paschoal, Fernando Mendes; Bastos, Vanessa Albuquerque P Aviz; Bor-Seng-Shu, Edson; Teixeira, Manoel Jacobsen; Yamada, Elizabeth Sumi; Pinto, Pablo; Vidal, Amanda Ferreira; Ribeiro-Dos-Santos, Arthur; Moreira, Fabiano; Santos, Sidney; Paschoal, Eric Homero Albuquerque; Ribeiro-Dos-Santos, Ândrea

2018-06-08

The molecular mechanisms behind aneurysmal subarachnoid haemorrhage (aSAH) are still poorly understood. Expression patterns of miRNAs may help elucidate the post-transcriptional gene expression in aSAH. Here, we evaluate the global miRNAs expression profile (miRnome) of patients with aSAH to identify potential biomarkers. We collected 33 peripheral blood samples (27 patients with cerebral aneurysm, collected 7 to 10 days after the haemorrhage, when usually is the cerebral vasospasm risk peak, and six controls). Then, were performed small RNA sequencing using an Illumina Next Generation Sequencing (NGS) platform. Differential expression analysis identified eight differentially expressed miRNAs. Among them, three were identified being up-regulated, and five down-regulated. miR-486-5p was the most abundant expressed and is associated with poor neurological admission status. In silico miRNA gene target prediction showed 148 genes associated with at least two differentially expressed miRNAs. Among these, THBS1 and VEGFA, known to be related to thrombospondin and vascular endothelial growth factor. Moreover, MYC gene was found to be regulated by four miRNAs, suggesting an important role in aneurysmal subarachnoid haemorrhage. Additionally, 15 novel miRNAs were predicted being expressed only in aSAH, suggesting possible involvement in aneurysm pathogenesis. These findings may help the identification of novel biomarkers of clinical interest.

Super-selective Balloon Test Occlusion of the Posterior Communicating Artery in the Treatment of a Posterior Cerebral Artery Fusiform Aneurysm: a Case Report.

PubMed

Isozaki, Makoto; Arai, Hiroshi; Neishi, Hiroyuki; Kitai, Ryuhei; Kikuta, Ken-Ichiro

2016-10-01

We report the case of a 49-year-old man with underlying hypertension who developed diplopia lasting 2 months. Magnetic resonance imaging and digital subtraction angiography showed multi-lobular unruptured aneurysms in the P2 portion of the posterior cerebral artery (PCA) migrating into the interpeduncular cistern of the midbrain. Because the shapes of the aneurysms were serpentine fusiform and the posterior communicating artery (PCoA) was the fetal type, we planned anastomosis of the occipital artery to the P4 portion of the PCA followed by endovascular obliteration of the parent artery including the aneurysms. Endovascular treatment was performed via a femoral approach one week after the anastomosis. Super-selective balloon test occlusion (BTO) of the PCoA was performed by using an occlusion balloon microcatheter before endovascular treatment. Occlusion of the proximal segment of the PCoA induced disturbance of consciousness of the patient. Occlusion of the distal segment other than the first point of the PCoA did not induce any neurological symptoms. The information from this super-selective BTO helped us to perform precise endovascular obliteration. The aneurysm was successfully obliterated, and the diplopia almost disappeared in a few months. Super-selective BTO of the PCoA might be a useful method for preventing ischemic complications due to occlusion of invisible perforators.

Super-selective Balloon Test Occlusion of the Posterior Communicating Artery in the Treatment of a Posterior Cerebral Artery Fusiform Aneurysm: a Case Report

PubMed Central

Isozaki, Makoto; Arai, Hiroshi; Neishi, Hiroyuki; Kitai, Ryuhei; Kikuta, Ken-ichiro

2016-01-01

We report the case of a 49-year-old man with underlying hypertension who developed diplopia lasting 2 months. Magnetic resonance imaging and digital subtraction angiography showed multi-lobular unruptured aneurysms in the P2 portion of the posterior cerebral artery (PCA) migrating into the interpeduncular cistern of the midbrain. Because the shapes of the aneurysms were serpentine fusiform and the posterior communicating artery (PCoA) was the fetal type, we planned anastomosis of the occipital artery to the P4 portion of the PCA followed by endovascular obliteration of the parent artery including the aneurysms. Endovascular treatment was performed via a femoral approach one week after the anastomosis. Super-selective balloon test occlusion (BTO) of the PCoA was performed by using an occlusion balloon microcatheter before endovascular treatment. Occlusion of the proximal segment of the PCoA induced disturbance of consciousness of the patient. Occlusion of the distal segment other than the first point of the PCoA did not induce any neurological symptoms. The information from this super-selective BTO helped us to perform precise endovascular obliteration. The aneurysm was successfully obliterated, and the diplopia almost disappeared in a few months. Super-selective BTO of the PCoA might be a useful method for preventing ischemic complications due to occlusion of invisible perforators. PMID:28664014

Reversible cerebral vasospasm, multilobular intracerebral hemorrhages, and nonaneurysmal subarachnoid hemorrhage: review of possible interrelationships.

PubMed

Hantson, Philippe; Forget, Patrice

2010-06-01

"Reversible cerebral vasoconstriction syndrome" (RCVS) is a recently described entity that is mainly characterized by the association of severe ("thunderclap") headaches with or without additional neurological symptoms and diffuse, multifocal, segmental narrowings involving large and medium-sized cerebral arteries. By definition, angiographic abnormalities disappear within 3 months. The clinical course is usually benign, with a higher prevalence in young women. RCVS is idiopathic in the majority of the cases. However, recent papers have outlined the role of precipitating factors, including the use of vasoactive substances. Some patients, nevertheless, have a more severe clinical course with transient or permanent ischemic events. Hemorrhagic complications appear to have been underestimated. They are usually restricted to circumscribed cortical subarachnoid hemorrhage, in the absence of any ruptured cerebral aneurysm. This limited bleeding is unlikely at the origin of the diffuse vasoconstriction. The finding of an unruptured cerebral aneurysm in RCVS patients is probably incidental. An overlap is possible between RCVS and other syndromes such as posterior reversible encephalopathy syndrome. There is no standardized treatment regimen for RCVS patients. It appears rational to further investigate the efficacy and safety of the calcium-channel antagonist nimodipine.

Acute Aneurismal Bilateral Subdural Haematoma without Subarachnoid Haemorrhage: A Case Report and Review of the Literature

PubMed Central

Mansour, Ossama; Hassen, Tamer; Fathy, Sameh

2014-01-01

Spontaneous pure acute bilateral subdural haematoma (ASDH) without intraparenchymal or subarachnoid haemorrhage caused by a ruptured cerebral aneurysm is extremely rare. It can follow rupture of different aneurysms specially located in anterior incisural space; the most frequently encountered location is the PcoA aneurysms as demonstrated in the present case. We present a case report of a PcoA aneurysm presenting as pure bilateral ASDH. A high level of suspicion for bleeding of arterial origin should be maintained in all cases of acute subdural haematoma without history of trauma. The neurological status on admission dictates the appropriate timing and methodology of the neuroradiological investigations. PMID:25045554

Characteristics of time-varying intracranial pressure on blood flow through cerebral artery: A fluid-structure interaction approach.

PubMed

Syed, Hasson; Unnikrishnan, Vinu U; Olcmen, Semih

2016-02-01

Elevated intracranial pressure is a major contributor to morbidity and mortality in severe head injuries. Wall shear stresses in the artery can be affected by increased intracranial pressures and may lead to the formation of cerebral aneurysms. Earlier research on cerebral arteries and aneurysms involves using constant mean intracranial pressure values. Recent advancements in intracranial pressure monitoring techniques have led to measurement of the intracranial pressure waveform. By incorporating a time-varying intracranial pressure waveform in place of constant intracranial pressures in the analysis of cerebral arteries helps in understanding their effects on arterial deformation and wall shear stress. To date, such a robust computational study on the effect of increasing intracranial pressures on the cerebral arterial wall has not been attempted to the best of our knowledge. In this work, fully coupled fluid-structure interaction simulations are carried out to investigate the effect of the variation in intracranial pressure waveforms on the cerebral arterial wall. Three different time-varying intracranial pressure waveforms and three constant intracranial pressure profiles acting on the cerebral arterial wall are analyzed and compared with specified inlet velocity and outlet pressure conditions. It has been found that the arterial wall experiences deformation depending on the time-varying intracranial pressure waveforms, while the wall shear stress changes at peak systole for all the intracranial pressure profiles. © IMechE 2015.

The deleterious effects of methamphetamine use on initial presentation and clinical outcomes in aneurysmal subarachnoid hemorrhage.

PubMed

Beadell, Noah C; Thompson, Eric M; Delashaw, Johnny B; Cetas, Justin S

2012-10-01

The objective of this study was to retrospectively look at methamphetamine (MA) use in patients with aneurysmal subarachnoid hemorrhage (SAH) to determine if MA use affects clinical presentation and outcomes after aneurysmal SAH. A retrospective review of patients admitted to the Oregon Health & Science University neurosurgical service with aneurysmal SAH during the past 6 years was undertaken. Variables analyzed included MA use, age, sex, cigarette use, Hunt and Hess grade, Fisher grade, admission blood pressure, aneurysm characteristics, occurrence of vasospasm, hospital length of stay (LOS), cerebral infarction, aneurysm treatment, and Glasgow Outcome Scale (GOS) score. Data differences between MA users and nonusers were statistically analyzed using multivariate logistic regression analysis. A separate comparison with randomly selected age-matched nonuser controls was also performed. Twenty-eight (7%) of 374 patients with aneurysmal SAH were identified as MA users. Methamphetamine users were younger than nonusers (45.2 vs 55.9 years, respectively; p <0.001). Despite a younger age, MA users had significantly higher Hunt and Hess grades than nonusers (3.0 vs 2.5, respectively; p <0.020) and age-matched controls (3.0 vs 2.0, respectively; p <0.001). Earliest available mean arterial pressure was significantly higher in MA users (122.1 vs 109.7, respectively; p = 0.005) than all nonusers but not age-matched controls. Methamphetamine users had significantly higher vasospasm rates than nonusers (92.9% vs 71.1%, respectively; p = 0.008) but similar rates as age-matched controls (92.9% vs 89.3%, respectively; p = 0.500). Glasgow Outcome Scale score did not differ significantly between users and nonusers (3 vs 4, respectively; p = 0.170), but users had significantly lower GOS scores than age-matched controls (3 vs 5, respectively; p <0.001). There was no statistically significant difference in the LOS between users and nonusers (18 days vs 16 days, respectively; p = 0.431) or users and age-matched controls (18 days vs 14 days, respectively; p = 0.250). In the multivariate analysis, MA use (OR 3.777, p = 0.018), age (p <0.001), Fisher grade (p = 0.011), Hunt and Hess grade (p <0.001), and cerebral infarction (p <0.001) were predictors of poor GOS score. The only predictor of vasospasm was age (p <0.001), although a strong predictive trend in MA use (p = 0.149) was found. Predictors of a hospital LOS >15 days included age (p = 0.002), Fisher grade (p = 0.002), Hunt and Hess grade (p <0.001), and cerebral infarction (p <0.001). Predictors of cerebral infarction include male sex (p = 0.022) and Hunt and Hess grade (p = 0.006), with vasospasm demonstrating a strong trend (p = 0.056). A history of MA use may predict poorer outcomes in patients who present with aneurysmal SAH. Methamphetamine users have significantly worse presentations and outcomes when compared with age-matched controls.

Microsurgical clipping for the true posterior communicating artery aneurysm in the distal portion of the posterior communicating artery

PubMed Central

Takeda, Masaru; Kashimura, Hiroshi; Chida, Kohei; Murakami, Toshiyuki

2015-01-01

Background: Aneurysms arising from the posterior communicating artery (PCoA) itself are rare in which aneurysms usually located in the proximal portion of the PCoA. The authors report a case of the true PCoA ruptured aneurysm in the distal portion of the PCoA. Case Description: The patient was an 83-year-old man who suffered subarachnoid hemorrhage. Cerebral angiography revealed a saccular aneurysm arising on the fetal type right PCoA itself in the distal portion of the PCoA. 2 days after the onset of symptoms, the patient underwent right interfascial pterional craniotomy, with anterior temporal approach. The aneurysm was successfully clipped with the preservation of both the PCoA and the thalamoperforating artery. Conclusion: We speculated that blood flow into the PCoA gradually increased after occlusion of the left vertebral artery, which induced tortuosity of the PCoA. As a result, hemodynamic stress might increase near the curvature and cause aneurysm formation. PMID:26110082

Microsurgical clipping for the true posterior communicating artery aneurysm in the distal portion of the posterior communicating artery.

PubMed

Takeda, Masaru; Kashimura, Hiroshi; Chida, Kohei; Murakami, Toshiyuki

2015-01-01

Aneurysms arising from the posterior communicating artery (PCoA) itself are rare in which aneurysms usually located in the proximal portion of the PCoA. The authors report a case of the true PCoA ruptured aneurysm in the distal portion of the PCoA. The patient was an 83-year-old man who suffered subarachnoid hemorrhage. Cerebral angiography revealed a saccular aneurysm arising on the fetal type right PCoA itself in the distal portion of the PCoA. 2 days after the onset of symptoms, the patient underwent right interfascial pterional craniotomy, with anterior temporal approach. The aneurysm was successfully clipped with the preservation of both the PCoA and the thalamoperforating artery. We speculated that blood flow into the PCoA gradually increased after occlusion of the left vertebral artery, which induced tortuosity of the PCoA. As a result, hemodynamic stress might increase near the curvature and cause aneurysm formation.

Fluid Structure Interaction Analysis on Sidewall Aneurysm Models

NASA Astrophysics Data System (ADS)

Hao, Qing

2016-11-01

Wall shear stress is considered as an important factor for cerebral aneurysm growth and rupture. The objective of present study is to evaluate wall shear stress in aneurysm sac and neck by a fluid-structure-interaction (FSI) model, which was developed and validated against the particle image velocimetry (PIV) data. In this FSI model, the flow characteristics in a straight tube with different asymmetric aneurysm sizes over a range of Reynolds numbers from 200 to 1600 were investigated. The FSI results agreed well with PIV data. It was found that at steady flow conditions, when Reynolds number above 700, one large recirculating vortex would be formed, occupying the entire aneurysm sac. The center of the vortex is located at region near to the distal neck. A pair of counter rotating vortices would however be formed at Reynolds number below 700. Wall shear stresses reached highest level at the distal neck of the aneurysmal sac. The vortex strength, in general, is stronger at higher Reynolds number. Fluid Structure Interaction Analysis on Sidewall Aneurysm Models.

Intracranial aneurysms: Review of current science and management.

PubMed

Toth, Gabor; Cerejo, Russell

2018-06-01

Unruptured intracranial aneurysms often have a relatively benign clinical course. Frequently, they are found incidentally during workup for an underlying, possibly related or unrelated, symptom or condition. Overall, brain aneurysms are considered to have a relatively low annual risk of rupture. However, should it occur, aneurysmal subarachnoid hemorrhage can lead to significant morbidity and mortality. Our understanding of the natural history and treatment outcomes of cerebral aneurysms has significantly increased over the last few decades, but choosing the optimal management for each patient requires the careful consideration of numerous medical, clinical and anatomic factors. The purpose of this review is to help physicians and caregivers, who may participate in the diagnosis, counseling and triage of patients with brain aneurysms, understand the basic elements of decision making. We discuss natural history, risk factors, screening, presentation, diagnosis, and their implications on aneurysm management and long-term follow-up. We also provide an overview of the risks and benefits of currently available treatment options.

The sea anchor technique: a novel method to aid in stent-assisted embolization of giant cerebral aneurysms.

PubMed

Edwards, Landon; Kota, Gopi; Morris, Padraig P

2013-11-01

Endovascular navigation past some large or giant intracranial aneurysms for the purpose of stent deployment can be difficult. Some of these lesions have a morphology which compels the operator to navigate through the aneurysm dome in order to gain distal access, a step which requires straightening of the delivery microcatheter before a stent can be deployed. In most patients this can be achieved by simply retracting the microcatheter and reducing the loop within the aneurysm. However, in certain patients the acute angle formed between aneurysm inflow and outflow tracts as well as the dynamics of tension within the microcatheter act together to prevent this from happening. Instead of retracting and straightening across the aneurysm neck, the microcatheter withdraws leaving the intra-aneurysm loop intact. This challenge can thwart attempts at stent placement and subsequent embolization. The authors describe a simple and safe technique to circumvent this problem, a way of stabilizing the distal tip of the microcatheter which they term the 'sea anchor'.

Combined Laser-Doppler Flowmetry and Spectrophotometry: Feasibility Study of a Novel Device for Monitoring Local Cortical Microcirculation during Aneurysm Surgery.

PubMed

Sommer, Björn; Kreuzer, Maximilian; Bischoff, Barbara; Wolf, Dennis; Schmitt, Hubert; Eyupoglu, Ilker Y; Rössler, Karl; Buchfelder, Michael; Ganslandt, Oliver; Wiendieck, Kurt

2017-01-01

Background  Monitoring of cortical cerebral perfusion is essential, especially in neurovascular surgery. Study Aims  To test a novel noninvasive laser-Doppler flowmetry and spectrophotometry device for feasibility during elective cerebral aneurysm surgery. Material and Methods  In this prospective single-institution nonrandomized trial, we studied local cerebral microcirculation using the noninvasive laser-Doppler spectrophotometer "Oxygen-to-see" (O2C) in 20 consecutive patients (15 female, 5 male; median age: 60.5 ± 11.7 years) who were operated on for incidental cerebral aneurysms. Capillary-venous oxygenation (oxygen saturation ["SO 2 "]), postcapillary venous filling pressures (relative hemoglobin content ["rHb"]), blood cell velocity ("velo"), and blood flow ("flow") were measured in 7-mm tissue depth using a subdural fiberoptic probe. Results  Representative recordings were acquired immediately after dural opening over a median time span of 88 ± 21.8 seconds (range: 60-128 seconds) before surgical manipulation. Baseline values (median ± 2 standard deviations) of brain perfusion as measured with the O2C device were SO 2 , 39 ± 16.6%; rHb, 53 ± 18.6 arbitrary units (AU); velo, 60 ± 20.4 AU; and flow, 311 ± 72.8 AU. Placement of the self-retaining retractor led to a decrease in SO 2 of 17% ± 29% ( p  < .05) and flow of 10% ± 11% ( p  < .01); rHb increased by 18% ± 20% ( p  < .01), and velo remained unchanged. Retractor removal caused the opposite with an increased flow of 10% ± 7% ( p  < 0.001) and velo (3% ± 6%, p  = 0.11), but a decrease in SO 2 of 24% ± 33% ( p  = 0.09) and rHb of 12% ± 20% ( p =0.18). No neurologic or surgical complications occurred. Conclusion  Using this novel noninvasive system, we were able to measure local cerebral microcirculation during aneurysm surgery. Our data indicate that this device is able to detect changes during routine neurosurgical maneuvers. Thus it may be useful for early detection of cerebral microcirculatory disturbances. Georg Thieme Verlag KG Stuttgart · New York.

Cerebral Aneurysms Fact Sheet

MedlinePlus

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Aneurysms of the anterior and posterior cerebral circulation: comparison of the morphometric features.

PubMed

Tykocki, Tomasz; Kostkiewicz, Bogusław

2014-09-01

Intracranial aneurysms (IAs) located in the posterior circulation are considered to have higher annual bleed rates than those in the anterior circulation. The aim of the study was to compare the morphometric factors differentiating between IAs located in the anterior and posterior cerebral circulation. A total number of 254 IAs diagnosed between 2009 and 2012 were retrospectively analyzed. All patients qualified for diagnostic, three-dimensional rotational angiography. IAs were assigned to either the anterior or posterior cerebral circulation subsets for the analysis. Means were compared with a t-test. The univariate and stepwise logistic regression analyses were used to determine the predictors of morphometric differences between the groups. For the defined predictors, ROC (receiver-operating characteristic) curves and interactive dot diagrams were calculated with the cutoff values of the morphometric factors. The number of anterior cerebral circulation IAs was 179 (70.5 %); 141 (55.5 %) aneurysms were ruptured. Significant differences between anterior and posterior circulation IAs were found for: the parent artery size (5.08 ± 1.8 mm vs. 3.95 ± 1.5 mm; p < 0.05), size ratio (2.22 ± 0.9 vs. 3.19 ± 1.8; p < 0.045) and aspect ratio (AR) (1.91 ± 0.8 vs. 2.75 ± 1.8; p = 0.02). Predicting factors differentiating anterior and posterior circulation IAs were: the AR (OR = 2.20; 95 % CI 1.80-270; Is 270 correct or should it be 2.70 and parent artery size (OR = 0.44; 95 % CI 0.38-0.54). The cutoff point in the ROC curve was 2.185 for the AR and 4.89 mm for parent artery size. Aspect ratio and parent artery size were found to be predictive morphometric factors in differentiating between anterior and posterior cerebral IAs.

In vitro simulator with numerical stress analysis for evaluation of stent-assisted coiling embolization in cerebral aneurysm treatments.

PubMed

Shi, Chaoyang; Kojima, Masahiro; Tercero, Carlos; Najdovski, Zoran; Ikeda, Seiichi; Fukuda, Toshio; Arai, Fumihito; Negoro, Makoto

2014-12-01

There are several complications associated with Stent-assisted Coil Embolization (SACE) in cerebral aneurysm treatments, due to damaging operations by surgeons and undesirable mechanical properties of stents. Therefore, it is necessary to develop an in vitro simulator that provides both training and research for evaluating the mechanical properties of stents. A new in vitro simulator for three-dimensional digital subtraction angiography was constructed, followed by aneurysm models fabricated with new materials. Next, this platform was used to provide training and to conduct photoelastic stress analysis to evaluate the SACE technique. The average interaction stress increasingly varied for the two different stents. Improvements for the Maximum-Likelihood Expectation-Maximization method were developed to reconstruct cross-sections with both thickness and stress information. The technique presented can improve a surgeon's skills and quantify the performance of stents to improve mechanical design and classification. This method can contribute to three-dimensional stress and volume variation evaluation and assess a surgeon's skills. Copyright © 2013 John Wiley & Sons, Ltd.

Cost-effectiveness analysis of endovascular versus neurosurgical treatment for ruptured intracranial aneurysms in the United States

PubMed Central

Maud, Alberto; Lakshminarayan, Kamakshi; Suri, M. Fareed K.; Vazquez, Gabriela; Lanzino, Giuseppe; Qureshi, Adnan I.

2009-01-01

Object The results of the International Subarachnoid Aneurysm Trial (ISAT) demonstrated lower rates of death and disability with endovascular treatment (coiling) than with open surgery (clipping) to secure the ruptured intracranial aneurysm. However, cost-effectiveness may not be favorable because of the greater need for follow-up cerebral angiograms and additional follow-up treatment with endovascular methods. In this study, the authors’ goal was to compare the cost-effectiveness of endovascular and neurosurgical treatments in patients with ruptured intracranial aneurysms who were eligible to undergo either type of treatment. Methods Clinical data (age, sex, frequency of retreatment, and rebleeding) and quality of life values were obtained from the ISAT. Total cost included those associated with disability, hospitalization, retreatment, and rebleeding. Cost estimates were derived from the Premier Perspective Comparative Database, data from long-term care in stroke patients, and relevant literature. Incremental cost-effectiveness ratios (ICERs) were estimated during a 1-year period. Parametric bootstrapping was used to determine the uncertainty of the estimates. Results The median estimated costs of endovascular and neurosurgical treatments (in US dollars) were $45,493 (95th percentile range $44,693–$46,365) and $41,769 (95th percentile range $41,094–$42,518), respectively. The overall quality-adjusted life years (QALY) in the endovascular group was 0.69, and for the neurosurgical group it was 0.64. The cost per QALY in the endovascular group was $65,424 (95th percentile range $64,178–$66,772), and in the neurosurgical group it was $64,824 (95th percentile range $63,679–$66,086). The median estimated ICER at 1 year for endovascular treatment versus neurosurgical treatment was $72,872 (95th percentile range $50,344–$98,335) per QALY gained. Given that most postprocedure angiograms and additional treatments occurred in the 1st year and the 1-year disability status is unlikely to change in the future, ICER for endovascular treatment will progressively decrease over time. Conclusions Using outcome and economic data obtained in the US at 1 year after the procedure, endovascular treatment is more costly but is associated with better outcomes than the neurosurgical alternative among patients with ruptured intracranial aneurysms who are eligible to undergo either procedure. With accrual of additional years with a better outcome status, the ICER for endovascular coiling would be expected to progressively decrease and eventually reverse. PMID:19199452

Modeling contrast agent flow in cerebral aneurysms: comparison of CFD with medical imaging

NASA Astrophysics Data System (ADS)

Rayz, Vitaliy; Vali, Alireza; Sigovan, Monica; Lawton, Michael; Saloner, David; Boussel, Loic

2016-11-01

PURPOSE: The flow in cerebral aneurysms is routinely assessed with X-ray angiography, an imaging technique based on a contrast agent injection. In addition to requiring a patient's catheterization and radiation exposure, the X-ray angiography may inaccurately estimate the flow residence time, as the injection alters the native blood flow patterns. Numerical modeling of the contrast transport based on MRI imaging, provides a non-invasive alternative for the flow diagnostics. METHODS: The flow in 3 cerebral aneurysms was measured in vivo with 4D PC-MRI, which provides time-resolved, 3D velocity field. The measured velocities were used to simulate a contrast agent transport by solving the advection-diffusion equation. In addition, the flow in the same patient-specific geometries was simulated with CFD and the velocities obtained from the Navier-Stokes solution were used to model the transport of a virtual contrast. RESULTS: Contrast filling and washout patterns obtained in simulations based on MRI-measured velocities were in agreement with those obtained using the Navier-Stokes solution. Some discrepancies were observed in comparison to the X-ray angiography data, as numerical modeling of the contrast transport is based on the native blood flow unaffected by the contrast injection. NIH HL115267.

Numerical predictions of hemodynamics following surgeries in cerebral aneurysms

NASA Astrophysics Data System (ADS)

Rayz, Vitaliy; Lawton, Michael; Boussel, Loic; Leach, Joseph; Acevedo, Gabriel; Halbach, Van; Saloner, David

2014-11-01

Large cerebral aneurysms present a danger of rupture or brain compression. In some cases, clinicians may attempt to change the pathological hemodynamics in order to inhibit disease progression. This can be achieved by changing the vascular geometry with an open surgery or by deploying a stent-like flow diverter device. Patient-specific CFD models can help evaluate treatment options by predicting flow regions that are likely to become occupied by thrombus (clot) following the procedure. In this study, alternative flow scenarios were modeled for several patients who underwent surgical treatment. Patient-specific geometries and flow boundary conditions were obtained from magnetic resonance angiography and velocimetry data. The Navier-Stokes equations were solved with a finite volume solver Fluent. A porous media approach was used to model flow-diverter devices. The advection-diffusion equation was solved in order to simulate contrast agent transport and the results were used to evaluate flow residence time changes. Thrombus layering was predicted in regions characterized by reduced velocities and shear stresses as well as increased flow residence time. The simulations indicated surgical options that could result in occlusion of vital arteries with thrombus. Numerical results were compared to experimental and clinical MRI data. The results demonstrate that image-based CFD models may help improve the outcome of surgeries in cerebral aneurysms. acknowledge R01HL115267.

Postmortem dynamic cerebral angiography for detecting aneurysm and bleeding sites in cases of subarachnoid hemorrhage.

PubMed

Inokuchi, Go; Yajima, Daisuke; Hayakawa, Mutsumi; Motomura, Ayumi; Chiba, Fumiko; Torimitsu, Suguru; Makino, Yohsuke; Iwase, Hirotaro

2014-12-01

One of the advantages of postmortem imaging is its ability to obtain diagnostic findings in a non-destructive manner when autopsy is either difficult or may destroy forensic evidence. In recent years, efforts have been made to incorporate computed tomography (CT) based postmortem angiography into forensic pathology; however, it is not currently clear how well the modality can determine sites of bleeding in cases of subarachnoid hemorrhage. Therefore, in this study, we investigated the utility of postmortem cerebral angiography using multi-detector row CT (MDCT) by injecting a contrast medium through a catheter inserted into the internal carotid and vertebral arteries of 10 subarachnoid hemorrhage cases. While postmortem MDCT angiography (PMCTA) was capable of detecting aneurysms in a non-destructive manner, it was sometimes difficult to identify the aneurysm and bleeding sites because of a large amount of contrast medium leaking into the extravascular space. To overcome this problem, we developed the novel contrast imaging method "dynamic cerebral angiography," which involves scanning the same area multiple times while injecting contrast medium to enable real-time observation of the contrasted vasculature. Using multiphase contrast images acquired by this method, we successfully captured the moment when contrast medium leaked from the hemorrhage site. This method will be useful for identifying exact bleeding sites on PMCTA.

The in situ side-to-side bypass technique: a comprehensive review of the technical characteristics, current anastomosis approaches and surgical experience.

PubMed

Wang, Long; Cai, Li; Qian, Hai; Lawton, Michael T; Shi, Xiang'en

2018-05-02

In situ side-to-side (STS) revascularization is an intracranial-intracranial (IC-IC) bypass technique that is increasingly used to treat complex aneurysms and cerebral ischemia. This sophisticated technique involves connecting two proximal parallel vessels to create an artificial conduit for blood flow. This study aims to provide a detailed description of the configuration of the STS bypass technique and extensive information regarding its technical characteristics, current anastomosis approaches and surgical significance. A literature search was performed using the PubMed, Medline, ScienceDirect, Embase, Wiley Online Library, Cambridge Journals, SAGE Journals, Oxford Journals, Research Gate, and Google Scholar databases. The terms "intracranial-intracranial bypass", "in situ bypass", "communicating bypass" and "STS anastomosis" were searched to identify pertinent articles. Articles involving in situ STS anastomosis combined with other bypass methods were excluded. Computer tablet-drawn illustrations of this technique are provided to enhance comprehension. In total, seventy articles that met our search and inclusion criteria were identified. Overall, the radiographical and clinical outcomes of one-hundred and thirty-two (125 aneurysm and 7 cerebral ischemia) patients who underwent in situ STS revascularization were analyzed. IC-IC bypass in the STS fashion can be a safe and effective strategy for the management of complex intracranial aneurysms and cerebral ischemia and is particularly attractive in rescue, anticipated and troubleshooting cases. Despite its extreme rarity, a de novo aneurysm may be observed following STS anastomosis; thus, long-term follow-up is mandatory. Vascular neurosurgeons should consider including this procedure in their treatment armamentarium. Copyright © 2018. Published by Elsevier Inc.

Non-ischemic cerebral enhancing lesions secondary to endovascular aneurysm therapy: nickel allergy or foreign body reaction? Case series and review of the literature.

PubMed

Shotar, Eimad; Law-Ye, Bruno; Baronnet-Chauvet, Flore; Zeidan, Sinead; Psimaras, Dimitri; Bielle, Franck; Pecquet, Catherine; Navarro, Soledad; Rosso, Charlotte; Cohen, Fleur; Chiras, Jacques; Di Maria, Federico; Sourour, Nader; Clarençon, Frédéric

2016-09-01

Delayed onset of non-ischemic cerebral enhancing (NICE) lesions is a rare complication of intracranial aneurysms' endovascular therapy (EVT). The purpose of this study is to report this rare complication and its potential pathophysiology in a single-center case series and review the relevant literature. After retrospective review of all patients managed by EVT at our institution from January 1, 2012 to December 31, 2014, 2 out of 374 patients (0.5 %) with such a complication were identified. Skin patch testing was performed with all endovascular devices used in the two patients and with the European baseline series, including nickel. All previously published cases in the English literature were reviewed based on exhaustive PubMed and Embase research. Patient no. 1 developed NICE lesions 1 month after balloon-assisted coiling of a ruptured anterior communicating artery aneurysm. Patient no. 2 developed NICE lesions 12 months (the longest delay reported to date for such a complication) after the treatment of a right carotid-ophthalmic aneurysm by loose coiling and flow diversion. Patient no. 2 demonstrated nickel skin reactivity, but none of the two patients presented allergic reaction to the devices used during interventions. Based on our observations and review of the literature, we hypothesize that delayed non-ischemic cerebral enhancing lesions after EVT are more likely related to foreign body emboli rather than nickel allergy. The two presented cases demonstrate the potential for recurrence and prolonged fluctuation of NICE lesions, warranting long-term follow-up for all patients presenting this complication.

Aneurysm Morphology and Prediction of Rupture: An International Study of Unruptured Intracranial Aneurysms Analysis.

PubMed

Mocco, J; Brown, Robert D; Torner, James C; Capuano, Ana W; Fargen, Kyle M; Raghavan, Madhavan L; Piepgras, David G; Meissner, Irene; Huston, John

2018-04-01

There are conflicting data between natural history studies suggesting a very low risk of rupture for small, unruptured intracranial aneurysms and retrospective studies that have identified a much higher frequency of small, ruptured aneurysms than expected. To use the prospective International Study of Unruptured Intracranial Aneurysms cohort to identify morphological characteristics predictive of unruptured intracranial aneurysm rupture. A case-control design was used to analyze morphological characteristics associated with aneurysm rupture in the International Study of Unruptured Intracranial Aneurysms database. Fifty-seven patients with ruptured aneurysms during follow-up were matched (by size and location) with 198 patients with unruptured intracranial aneurysms without rupture during follow-up. Twelve morphological metrics were measured from cerebral angiograms in a blinded fashion. Perpendicular height (P = .008) and size ratio (ratio of maximum diameter to the parent vessel diameter; P = .01) were predictors of aneurysm rupture on univariate analysis. Aspect ratio, daughter sacs, multiple lobes, aneurysm angle, neck diameter, parent vessel diameter, and calculated aneurysm volume were not statistically significant predictors of rupture. On multivariate analysis, perpendicular height was the only significant predictor of rupture (Chi-square 7.1, P-value .008). This study underscores the importance of other morphological factors, such as perpendicular height and size ratio, that may influence unruptured intracranial aneurysm rupture risk in addition to greatest diameter and anterior vs posterior location.

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms.

PubMed

Deshaies, Eric M; Villwock, Mark R; Singla, Amit; Toshkezi, Gentian; Padalino, David J

2015-08-11

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

A computational fluid dynamics (CFD) study of WEB-treated aneurysms: Can CFD predict WEB "compression" during follow-up?

PubMed

Caroff, Jildaz; Mihalea, Cristian; Da Ros, Valerio; Yagi, Takanobu; Iacobucci, Marta; Ikka, Léon; Moret, Jacques; Spelle, Laurent

2017-07-01

Recent reports have revealed a worsening of aneurysm occlusion between WEB treatment baseline and angiographic follow-up due to "compression" of the device. We utilized computational fluid dynamics (CFD) in order to determine whether the underlying mechanism of this worsening is flow related. We included data from all consecutive patients treated in our institution with a WEB for unruptured aneurysms located either at the middle cerebral artery or basilar tip. The CFD study was performed using pre-operative 3D rotational angiography. From digital subtraction follow-up angiographies patients were dichotomized into two groups: one with WEB "compression" and one without. We performed statistical analyses to determine a potential correlation between WEB compression and CFD inflow ratio. Between July 2012 and June 2015, a total of 22 unruptured middle cerebral artery or basilar tip aneurysms were treated with a WEB device in our department. Three patients were excluded from the analysis and the mean follow-up period was 17months. Eleven WEBs presented "compression" during follow-up. Interestingly, device "compression" was statistically correlated to the CFD inflow ratio (P=0.018), although not to aneurysm volume, aspect ratio or neck size. The mechanisms underlying the worsening of aneurysm occlusion in WEB-treated patients due to device compression are most likely complex as well as multifactorial. However, it is apparent from our pilot study that a high arterial inflow is, at least, partially involved. Further theoretical and animal research studies are needed to increase our understanding of this phenomenon. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

C-arm flat detector computed tomography parenchymal blood volume imaging: the nature of parenchymal blood volume parameter and the feasibility of parenchymal blood volume imaging in aneurysmal subarachnoid haemorrhage patients.

PubMed

Kamran, Mudassar; Byrne, James V

2015-09-01

C-arm flat detector computed tomography (FDCT) parenchymal blood volume (PBV) measurements allow assessment of cerebral haemodynamics in the neurointerventional suite. This paper explores the feasibility of C-arm computed tomography (CT) PBV imaging and the relationship between the C-arm CT PBV and the MR-PWI-derived cerebral blood volume (CBV) and cerebral blood flow (CBF) parameters in aneurysmal subarachnoid haemorrhage (SAH) patients developing delayed cerebral ischemia (DCI). Twenty-six patients with DCI following aneurysmal SAH underwent a research C-arm CT PBV scan using a biplane angiography system and contemporaneous MR-PWI scan as part of a prospective study. Quantitative whole-brain atlas-based volume-of-interest analysis in conjunction with Pearson correlation and Bland-Altman tests was performed to explore the agreement between C-arm CT PBV and MR-derived CBV and CBF measurements. All patients received medical management, while eight patients (31%) underwent selective intra-arterial chemical angioplasty. Colour-coded C-arm CT PBV maps were 91% sensitive and 100% specific in detecting the perfusion abnormalities. C-arm CT rPBV demonstrated good agreement and strong correlation with both MR-rCBV and MR-rCBF measurements; the agreement and correlation were stronger for MR-rCBF relative to MR-rCBV and improved for C-arm CT PBV versus the geometric mean of MR-rCBV and MR-rCBF. Analysis of weighted means showed that the C-arm CT PBV has a preferential blood flow weighting (≈ 60% blood flow and ≈ 40% blood volume weighting). C-arm CT PBV imaging is feasible in DCI following aneurysmal SAH. PBV is a composite perfusion parameter incorporating both blood flow and blood volume weightings. That PBV has preferential (≈ 60%) blood flow weighting is an important finding, which is of clinical significance when interpreting the C-arm CT PBV maps, particularly in the setting of acute brain ischemia.

[Peroperative risks in cerebral aneurysm surgery].

PubMed

Mustaki, J P; Bissonnette, B; Archer, D; Boulard, G; Ravussin, P

1996-01-01

The perioperative complications associated with cerebral aneurysm surgery require a specific anaesthetic management. Four major perioperative accidents are discussed in this review. The anaesthetic and surgical management in case of rebleeding subsequent to the re-rupture of the aneurysm is mainly prophylactic. It includes haemodynamic stability assurance, maintenance of mean arterial pressure (MAP) between 80-90 mmHg during stimulation of the patient such as endotracheal intubation, application of the skull-pin head-holder, incision, and craniotomy. The aneurysmal transmural pressure should be adequately maintained by avoiding an aggressive decrease of intracranial pressure. Once the skull is open, the brain must be kept slack in order to decrease pressure under the retractors and avoid the risks of stretching and tearing of the adjacent vessels. If, despite these precautions, the aneurysm ruptures again. MAP should be decreased to 60 mmHg and the brain rendered more slack, in order to allow direct clipping of the aneurysm, or temporary clipping of the adjacent vessels. The optimal agents in this situation are isoflurane (which decreases CMRO2), intravenous anaesthetic agents (inspite their negative inotropic effect, they may potentially protect the brain) and sodium nitroprusside. Vasospasm occurs usually between the 3rd and the 7th day after subarachnoid haemorrhage. It may be seen peroperatively. The optimal treatment, as well as prophylaxis, is moderate controlled hypertension (MAP > 100 mmHg), associated with hypervolaemia and haemodilution, the so-called triple H therapy, with strict control of the filling pressures. Other beneficial therapies are calcium antagonists (nimodipine and nicardipine), the removal of the blood accumulated around the brain and in the cisternae, and possibly local administration of papaverine. Abrupt MAP increases are controlled in order to maintain adequate aneurysmal transmural pressure. Beta-blockers, local anaesthetics administered locally or intravenously, a carefully titrated level of anaesthesia, a maintained volaemia play a protective role. Cerebral oedema is sometimes already present at the opening of the skull or may arise later, due to a high pressure under the retractors, to the surgical manipulations of the brain or to brain ischaemia subsequent to temporary clipping. Its treatment is aggressive, with intravenous agents, mannitol, deep hypocapnia and/or lumbar drainage. Prophylaxis, according to the "brain homeostasis concept", is the preferred method to avoid these four peroperative accidents. It includes normal blood volume, normoglycaemia, moderate hypocapnia, normotension, soft manipulation of the brain and optimal brain relaxation.

Intradural Procedural Time to Assess Technical Difficulty of Superciliary Keyhole and Pterional Approaches for Unruptured Middle Cerebral Artery Aneurysms

PubMed Central

Choi, Yeon-Ju; Son, Wonsoo; Park, Ki-Su

2016-01-01

Objective This study used the intradural procedural time to assess the overall technical difficulty involved in surgically clipping an unruptured middle cerebral artery (MCA) aneurysm via a pterional or superciliary approach. The clinical and radiological variables affecting the intradural procedural time were investigated, and the intradural procedural time compared between a superciliary keyhole approach and a pterional approach. Methods During a 5.5-year period, patients with a single MCA aneurysm were enrolled in this retrospective study. The selection criteria for a superciliary keyhole approach included : 1) maximum diameter of the unruptured MCA aneurysm <15 mm, 2) neck diameter of the MCA aneurysm <10 mm, and 3) aneurysm location involving the sphenoidal or horizontal segment of MCA (M1) segment and MCA bifurcation, excluding aneurysms distal to the MCA genu. Meanwhile, the control comparison group included patients with the same selection criteria as for a superciliary approach, yet who preferred a pterional approach to avoid a postoperative facial wound or due to preoperative skin trouble in the supraorbital area. To determine the variables affecting the intradural procedural time, a multiple regression analysis was performed using such data as the patient age and gender, maximum aneurysm diameter, aneurysm neck diameter, and length of the pre-aneurysm M1 segment. In addition, the intradural procedural times were compared between the superciliary and pterional patient groups, along with the other variables. Results A total of 160 patients underwent a superciliary (n=124) or pterional (n=36) approach for an unruptured MCA aneurysm. In the multiple regression analysis, an increase in the diameter of the aneurysm neck (p<0.001) was identified as a statistically significant factor increasing the intradural procedural time. A Pearson correlation analysis also showed a positive correlation (r=0.340) between the neck diameter and the intradural procedural time. When comparing the superciliary and pterional groups, no statistically significant between-group difference was found in terms of the intradural procedural time reflecting the technical difficulty (mean±standard deviation : 29.8±13.0 min versus 27.7±9.6 min). Conclusion A superciliary keyhole approach can be a useful alternative to a pterional approach for an unruptured MCA aneurysm with a maximum diameter <15 mm and neck diameter <10 mm, representing no more of a technical challenge. For both surgical approaches, the technical difficulty increases along with the neck diameter of the MCA aneurysm. PMID:27847568

Hemodynamic characterization of geometric cerebral aneurysm templates.

PubMed

Nair, Priya; Chong, Brian W; Indahlastari, Aprinda; Lindsay, James; DeJeu, David; Parthasarathy, Varsha; Ryan, Justin; Babiker, Haithem; Workman, Christopher; Gonzalez, L Fernando; Frakes, David

2016-07-26

Hemodynamics are currently considered to a lesser degree than geometry in clinical practices for evaluating cerebral aneurysm (CA) risk and planning CA treatment. This study establishes fundamental relationships between three clinically recognized CA geometric factors and four clinically relevant hemodynamic responses. The goal of the study is to develop a more combined geometric/hemodynamic basis for informing clinical decisions. Flows within eight idealized template geometries were simulated using computational fluid dynamics and measured using particle image velocimetry under both steady and pulsatile flow conditions. The geometric factor main effects were then analyzed to quantify contributions made by the geometric factors (aneurysmal dome size (DS), dome-to-neck ratio (DNR), and parent-vessel contact angle (PV-CA)) to effects on the hemodynamic responses (aneurysmal and neck-plane root-mean-square velocity magnitude (Vrms), aneurysmal wall shear stress (WSS), and cross-neck flow (CNF)). Two anatomical aneurysm models were also examined to investigate how well the idealized findings would translate to more realistic CA geometries. DNR made the greatest contributions to effects on hemodynamics including a 75.05% contribution to aneurysmal Vrms and greater than 35% contributions to all responses. DS made the next greatest contributions, including a 43.94% contribution to CNF and greater than 20% contributions to all responses. PV-CA and several factor interactions also made contributions of greater than 10%. The anatomical aneurysm models and the most similar idealized templates demonstrated consistent hemodynamic response patterns. This study demonstrates how individual geometric factors, and combinations thereof, influence CA hemodynamics. Bridging the gap between geometry and flow in this quantitative yet practical way may have potential to improve CA evaluation and treatment criteria. Agreement among results from idealized and anatomical models further supports the potential for a template-based approach to play a useful role in clinical practice. Copyright © 2015 Elsevier Ltd. All rights reserved.

Predictors of In-Hospital Death After Aneurysmal Subarachnoid Hemorrhage: Analysis of a Nationwide Database (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]).

PubMed

Stienen, Martin Nikolaus; Germans, Menno; Burkhardt, Jan-Karl; Neidert, Marian C; Fung, Christian; Bervini, David; Zumofen, Daniel; Röthlisberger, Michel; Marbacher, Serge; Maduri, Rodolfo; Robert, Thomas; Seule, Martin A; Bijlenga, Philippe; Schaller, Karl; Fandino, Javier; Smoll, Nicolas R; Maldaner, Nicolai; Finkenstädt, Sina; Esposito, Giuseppe; Schatlo, Bawarjan; Keller, Emanuela; Bozinov, Oliver; Regli, Luca

2018-02-01

To identify predictors of in-hospital mortality in patients with aneurysmal subarachnoid hemorrhage and to estimate their impact. Retrospective analysis of prospective data from a nationwide multicenter registry on all aneurysmal subarachnoid hemorrhage cases admitted to a tertiary neurosurgical department in Switzerland (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]; 2009-2015). Both clinical and radiological independent predictors of in-hospital mortality were identified, and their effect size was determined by calculating adjusted odds ratios (aORs) using multivariate logistic regression. Survival was displayed using Kaplan-Meier curves. Data of n=1866 aneurysmal subarachnoid hemorrhage patients in the Swiss SOS database were available. In-hospital mortality was 20% (n=373). In n=197 patients (10.6%), active treatment was discontinued after hospital admission (no aneurysm occlusion attempted), and this cohort was excluded from analysis of the main statistical model. In the remaining n=1669 patients, the rate of in-hospital mortality was 13.9% (n=232). Strong independent predictors of in-hospital mortality were rebleeding (aOR, 7.69; 95% confidence interval, 3.00-19.71; P <0.001), cerebral infarction attributable to delayed cerebral ischemia (aOR, 3.66; 95% confidence interval, 1.94-6.89; P <0.001), intraventricular hemorrhage (aOR, 2.65; 95% confidence interval, 1.38-5.09; P =0.003), and new infarction post-treatment (aOR, 2.57; 95% confidence interval, 1.43-4.62; P =0.002). Several-and among them modifiable-factors seem to be associated with in-hospital mortality after aneurysmal subarachnoid hemorrhage. Our data suggest that strategies aiming to reduce the risk of rebleeding are most promising in patients where active treatment is initially pursued. URL: http://www.clinicaltrials.gov. Unique identifier: NCT03245866. © 2018 American Heart Association, Inc.

Device and methods for "gold standard" registration of clinical 3D and 2D cerebral angiograms

NASA Astrophysics Data System (ADS)

Madan, Hennadii; Likar, Boštjan; Pernuš, Franjo; Å piclin, Žiga

2015-03-01

Translation of any novel and existing 3D-2D image registration methods into clinical image-guidance systems is limited due to lack of their objective validation on clinical image datasets. The main reason is that, besides the calibration of the 2D imaging system, a reference or "gold standard" registration is very difficult to obtain on clinical image datasets. In the context of cerebral endovascular image-guided interventions (EIGIs), we present a calibration device in the form of a headband with integrated fiducial markers and, secondly, propose an automated pipeline comprising 3D and 2D image processing, analysis and annotation steps, the result of which is a retrospective calibration of the 2D imaging system and an optimal, i.e., "gold standard" registration of 3D and 2D images. The device and methods were used to create the "gold standard" on 15 datasets of 3D and 2D cerebral angiograms, whereas each dataset was acquired on a patient undergoing EIGI for either aneurysm coiling or embolization of arteriovenous malformation. The use of the device integrated seamlessly in the clinical workflow of EIGI. While the automated pipeline eliminated all manual input or interactive image processing, analysis or annotation. In this way, the time to obtain the "gold standard" was reduced from 30 to less than one minute and the "gold standard" of 3D-2D registration on all 15 datasets of cerebral angiograms was obtained with a sub-0.1 mm accuracy.

Heroin Use Is Associated with Ruptured Saccular Aneurysms.

PubMed

Can, Anil; Castro, Victor M; Ozdemir, Yildirim H; Dagen, Sarajune; Dligach, Dmitriy; Finan, Sean; Yu, Sheng; Gainer, Vivian; Shadick, Nancy A; Savova, Guergana; Murphy, Shawn; Cai, Tianxi; Weiss, Scott T; Du, Rose

2017-11-04

While cocaine use is thought to be associated with aneurysmal rupture, it is not known whether heroin use increases the risk of rupture in patients with non-mycotic saccular aneurysms. Our goal was to investigate the association between heroin and cocaine use and the rupture of saccular non-mycotic aneurysms. The medical records of 4701 patients with 6411 intracranial aneurysms, including 1201 prospective patients, diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016 were reviewed and analyzed. Patients were separated into ruptured and non-ruptured groups. Univariable and multivariable logistic regression analyses were performed to determine the association between heroin, cocaine, and methadone use and the presence of ruptured intracranial aneurysms. In multivariable analysis, current heroin use was significantly associated with rupture status (OR 3.23, 95% CI 1.33-7.83) whereas former heroin use (with and without methadone replacement therapy), and current and former cocaine use were not significantly associated with intracranial aneurysm rupture. In the present study, heroin rather than cocaine use is significantly associated with intracranial aneurysm rupture in patients with non-mycotic saccular cerebral aneurysms, emphasizing the possible role of heroin in the pathophysiology of aneurysm rupture and the importance of heroin cessation in patients harboring unruptured intracranial aneurysms.

Prediction of vascular abnormalities on CT angiography in patients with acute headache.

PubMed

Alons, Imanda M E; Goudsmit, Ben F J; Jellema, Korné; van Walderveen, Marianne A A; Wermer, Marieke J H; Algra, Ale

2018-05-09

Patients with acute headache increasingly undergo CT-angiography (CTA) to evaluate underlying vascular causes. The aim of this study is to determine clinical and non-contrast CT (NCCT) criteria to select patients who might benefit from CTA. We retrospectively included patients with acute headache who presented to the emergency department of an academic medical center and large regional teaching hospital and underwent NCCT and CTA. We identified factors that increased the probability of finding a vascular abnormality on CTA, performed multivariable regression analyses and determined discrimination with the c-statistic. A total of 384 patients underwent NCCT and CTA due to acute headache. NCCT was abnormal in 194 patients. Among these, we found abnormalities in 116 cases of which 99 aneurysms. In the remaining 190 with normal NCCT we found abnormalities in 12 cases; four unruptured aneurysms, three cerebral venous thrombosis', two reversible cerebral vasoconstriction syndromes, two cervical arterial dissections and one cerebellar infarction. In multivariable analysis abnormal NCCT, lowered consciousness and presentation within 6 hr of headache onset were independently associated with abnormal CTA. The c-statistic of abnormal NCCT alone was 0.80 (95% CI: 0.75-0.80), that also including the other two variables was 0.84 (95% CI: 0.80-0.88). If NCCT was normal no other factors could help identify patients at risk for abnormalities. In patients with acute headache abnormal NCCT is the strongest predictor of a vascular abnormality on CTA. If NCCT is normal no other predictors increase the probability of finding an abnormality on CTA and diagnostic yield is low. © 2018 The Authors. Brain and Behavior published by Wiley Periodicals, Inc.

Safe Reentry for False Aneurysm Operations in High-Risk Patients.

PubMed

Martinelli, Gian Luca; Cotroneo, Attilio; Caimmi, Philippe Primo; Musica, Gabriele; Barillà, David; Stelian, Edmond; Romano, Angelo; Novelli, Eugenio; Renzi, Luca; Diena, Marco

2017-06-01

In the absence of a standardized safe surgical reentry strategy for high-risk patients with large or anterior postoperative aortic false aneurysm (PAFA), we aimed to describe an effective and safe approach for such patients. We prospectively analyzed patients treated for PAFA between 2006 and 2015. According to the preoperative computed tomography scan examination, patients were divided into two groups according to the anatomy and extension of PAFA: in group A, high-risk PAFA (diameter ≥3 cm) developed in the anterior mediastinum; in group B, low-risk PAFA (diameter <3 cm) was situated posteriorly. For group A, a safe surgical strategy, including continuous cerebral, visceral, and coronary perfusion was adopted before resternotomy; group B patients underwent conventional surgery. We treated 27 patients (safe reentry, n = 13; standard approach, n = 14). Mean age was 60 years (range, 29 to 80); 17 patients were male. Mean interval between the first operation and the last procedure was 4.3 years. Overall 30-day mortality rate was 7.4% (1 patient in each group). No aorta-related mortality was observed at 1 and 5 years in either group. The Kaplan-Meier overall survival estimates at 1 and 5 years were, respectively, 92.3% ± 7.4% and 73.4% ± 13.4% in group A, and 92.9% ± 6.9% and 72.2% ± 13.9% in group B (log rank test, p = 0.830). Freedom from reoperation for recurrent aortic disease was 100% at 1 year and 88% at 5 years. The safe reentry technique with continuous cerebral, visceral, and coronary perfusion for high-risk patients resulted in early and midterm outcomes similar to those observed for low-risk patients undergoing conventional surgery. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Successful Aortic Banding for Type IA Endoleak Due to Neck Dilatation after Endovascular Abdominal Aortic Aneurysm Repair: Case Report.

PubMed

Tashima, Yasushi; Tamai, Koichi; Shirasugi, Takehiro; Sato, Kenichiro; Yamamoto, Takahiro; Imamura, Yusuke; Yamaguchi, Atsushi; Adachi, Hideo; Kobinata, Toshiyuki

2017-09-25

A 69-year-old man with a type IA endoleak that developed approximately 21 months after endovascular abdominal aortic aneurysm repair (EVAR) of a 46 mm diameter aneurysm was referred to our department. He had impaired renal function, Parkinson's disease, and previous cerebral infarction. Computed tomography angiography showed a type IA endoleak with neck dilatation and that the aneurysm had grown to 60 mm in diameter. We decided to perform aortic banding. The type IA endoleak disappeared after banding and the patient was discharged on postoperative day 10. Aortic banding may be effective for type IA endoleak after EVAR and less invasive for high-risk patients in particular.

Erratum.

PubMed

2015-04-01

In issue 21.1 three of the DOIs were printed incorrectly, please see below for the correct information. Andrea Giorgianni, et al. Flow-diverter stenting of post-traumatic bilateral anterior cerebral artery pseudoaneurysm: A case report. Doi: 10.15274/INR-2014-10059 Correct: Doi: 10.1177/1591019915575441 Lee-Anne Slater, et al. Effect of flow diversion with silk on aneurysm size: A single center experience. Doi: 10.15274/INR-2014-10062 Correct DOI: 10.1177/1591019915576433 Robert J McDonald, et al. Periprocedural safety of Pipeline therapy for unruptured cerebral aneurysms: Analysis of 279 Patients in a multihospital database. Doi: 10.15274/INR-2014-10074 Correct DOI: 10.1177/1591019915576289. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Intrathecal application of the nimodipine slow-release microparticle system eg-1962 for prevention of delayed cerebral ischemia and improvement of outcome after aneurysmal subarachnoid hemorrhage.

PubMed

Etminan, Nima; Macdonald, R Loch; Davis, Cara; Burton, Kevin; Steiger, Hans-Jakob; Hänggi, Daniel

2015-01-01

The effective reduction of delayed cerebral ischemia (DCI), a main contributor for poor outcome following aneurysmal subarachnoid hemorrhage (SAH), remains challenging. Previous clinical trials on systemic pharmaceutical treatment of SAH mostly failed to improve outcome, probably because of insensitive pharmaceutical targets and outcome measures, small sample size, insufficient subarachnoid drug concentrations and also detrimental, systemic effects of the experimental treatment per se. Interestingly, in studies that are more recent, intrathecal administration of nicardipine pellets following surgical aneurysm repair was suggested to have a beneficial effect on DCI and neurological outcome. However, this positive effect remained restricted to patients who were treated surgically for a ruptured aneurysm. Because of the favorable results of the preclinical data on DCI and neurological outcome in the absence of neurotoxicity or systemic side effects, we are initiating clinical trials. The PROMISE (Prolonged Release nimOdipine MIcro particles after Subarachnoid hemorrhage) trial is designed as an unblinded, nonrandomized, single-center, single-dose, dose-escalation safety and tolerability phase 1 study in patients surgically treated for aSAH and will investigate the effect of intracisternal EG-1962 administration. The NEWTON (Nimodipine microparticles to Enhance recovery While reducing TOxicity after subarachNoid hemorrhage) trial is a phase 1/2a multicenter, controlled, randomized, open-label, dose-escalation, safety, tolerability, and pharmacokinetic study comparing EG-1962 and nimodipine in patients with aneurysmal SAH.

Vortex Imprints at the Wall, But Not in the Bulk, Distinguish Ruptured from Unruptured Intracranial Aneurysms

NASA Astrophysics Data System (ADS)

Varble, Nicole; Meng, Hui

2015-11-01

Intracranial aneurysms affect 3% of the population. Risk stratification of aneurysms is important, as rupture often leads to death or permanent disability. Image-based CFD analyses of patient-specific aneurysms have identified low and oscillatory wall shear stress to predict rupture. These stresses are sensed biologically at the luminal wall, but the flow dynamics related to aneurysm rupture requires further understanding. We have conducted two studies: one examines vortex dynamics, and the other, high frequency flow fluctuations in patient-specific aneurysms. In the first study, based on Q-criterion vortex identification, we developed two measures to quantify regions within the aneurysm where rotational flow is dominate: the ratio of volume or surface area where Q >0 vs. the total aneurysmal volume or surface area, respectively termed volume vortex fraction (VVF) and surface vortex fraction (SVF). Statistical analysis of 204 aneurysms shows that SVF, but not VVF, distinguishes ruptured from unruptured aneurysms, suggesting that once again, the local flow patterns on the wall is directly relevant to rupture. In the second study, high-resolution CFD (high spatial and temporal resolutions and second-order discretization schemes) on 56 middle cerebral artery aneurysms shows the presence of temporal fluctuations in 8 aneurysms, but such flow instability bears no correlation with rupture. Support for this work was partially provided by NIH grant (R01 NS091075-01) and a grant from Toshiba Medical Systems Corp.

PIV-measured versus CFD-predicted flow dynamics in anatomically realistic cerebral aneurysm models.

PubMed

Ford, Matthew D; Nikolov, Hristo N; Milner, Jaques S; Lownie, Stephen P; Demont, Edwin M; Kalata, Wojciech; Loth, Francis; Holdsworth, David W; Steinman, David A

2008-04-01

Computational fluid dynamics (CFD) modeling of nominally patient-specific cerebral aneurysms is increasingly being used as a research tool to further understand the development, prognosis, and treatment of brain aneurysms. We have previously developed virtual angiography to indirectly validate CFD-predicted gross flow dynamics against the routinely acquired digital subtraction angiograms. Toward a more direct validation, here we compare detailed, CFD-predicted velocity fields against those measured using particle imaging velocimetry (PIV). Two anatomically realistic flow-through phantoms, one a giant internal carotid artery (ICA) aneurysm and the other a basilar artery (BA) tip aneurysm, were constructed of a clear silicone elastomer. The phantoms were placed within a computer-controlled flow loop, programed with representative flow rate waveforms. PIV images were collected on several anterior-posterior (AP) and lateral (LAT) planes. CFD simulations were then carried out using a well-validated, in-house solver, based on micro-CT reconstructions of the geometries of the flow-through phantoms and inlet/outlet boundary conditions derived from flow rates measured during the PIV experiments. PIV and CFD results from the central AP plane of the ICA aneurysm showed a large stable vortex throughout the cardiac cycle. Complex vortex dynamics, captured by PIV and CFD, persisted throughout the cardiac cycle on the central LAT plane. Velocity vector fields showed good overall agreement. For the BA, aneurysm agreement was more compelling, with both PIV and CFD similarly resolving the dynamics of counter-rotating vortices on both AP and LAT planes. Despite the imposition of periodic flow boundary conditions for the CFD simulations, cycle-to-cycle fluctuations were evident in the BA aneurysm simulations, which agreed well, in terms of both amplitudes and spatial distributions, with cycle-to-cycle fluctuations measured by PIV in the same geometry. The overall good agreement between PIV and CFD suggests that CFD can reliably predict the details of the intra-aneurysmal flow dynamics observed in anatomically realistic in vitro models. Nevertheless, given the various modeling assumptions, this does not prove that they are mimicking the actual in vivo hemodynamics, and so validations against in vivo data are encouraged whenever possible.

Angiographic and epidemiological characteristics associated with aneurysm remnants after microsurgical clipping

PubMed Central

Dellaretti, Marcos; da Silva Martins, Warley Carvalho; Dourado, Jules Carlos; Faglioni, Wilson; Quadros, Ricardo Souza; de Souza Moraes, Vítor Vieira; de Souza Filho, Carlos Batista Alves

2017-01-01

Background: Despite new techniques for the treatment of cerebral aneurysms, the percentage of aneurysm remnants after surgical intervention seems to be relatively constant. The objective of this study was to assess angiographic and epidemiological features associated with aneurysm remnants after microsurgical clipping. Methods: This study was conducted from February 2009 to August 2012 on a series of 90 patients with 105 aneurysms referred to the Santa Casa of Belo Horizonte who were surgically treated and angiographically controlled. Results: Surgical clipping was considered incomplete in 13.3% of the aneurysms. The mean age of cases with an aneurysm remnant was 57.5 years, whereas the mean age without aneurysm remnant was 49.7 years (P = 0.02). Aneurysm remnants were detected more frequently on the internal carotid artery, nevertheless, no statistically significant differences were verified when comparing the locations. Aneurysm size in the preoperative angiography verified that the mean size of aneurysms operated was 6.56 mm, such that in cases showing a postoperative remnant, the mean size was 9.7 mm and in cases with complete clipping it was 6.08 mm (P = 0.02). Postoperative angiography showed that, in cases with residual aneurysm, the number of clips used was higher – a mean of 1.8 for complete clipping and 3.1 for incomplete clipping (P < 0.001). Conclusions: Aneurysm size and patient age showed significant correlations with residual intracranial aneurysm. The mean number of clips used was higher in cases with incomplete occlusion. PMID:28904825

Cerebral hemodynamic and metabolic changes caused by brain retraction after aneurysmal subarachnoid hemorrhage.

PubMed

Yundt, K D; Grubb, R L; Diringer, M N; Powers, W J

1997-03-01

The cerebral hemodynamic and metabolic effects of aneurysmal subarachnoid hemorrhage are complex. To investigate the impact of surgical retraction, we analyzed position emission tomography (PET) studies that measured the regional cerebral metabolic rate for oxygen, regional oxygen extraction fraction, and regional cerebral blood flow in four patients before and after right frontotemporal craniotomies for clipping of ruptured anterior circulation aneurysms. Preoperative studies were conducted 1 day before surgery and postoperative studies 6 to 17 days after surgery. No patient had hydrocephalus or intracerebral hematoma. At the time of the second PET study, none of the patients had signs of clinical vasospasm. Regional measurements were obtained from the right ventrolateral frontal and anterior temporal regions corresponding to the area of retraction and compared to the same regions in the opposite hemisphere. To establish a quantitative means to differentiate between hemodynamic and metabolic changes related to arterial vasospasm and those caused by brain retraction, we studied a second group of preoperative patients, who had undergone PET during angiographic and clinical vasospasm. There was a 45% reduction in regional cerebral metabolic rate for oxygen (1.87 +/- 0.22 to 1.04 +/- 0.28 ml 100 g-1 min-1) and 32% reduction in regional oxygen extraction fraction (0.41 +/- 0.04 to 0.28 +/- 0.03) in the region of retraction but no change in the opposite hemisphere (paired t test; P = 0.042 and 0.003, respectively). There was no change in regional cerebral blood flow in any region. Brain retraction produced a focal area of tissue injury at the site of retractor blade placement, as compared to more diffuse vascular territory changes produced by vasospasm. This reduction in the cerebral metabolic rate of oxygen and the oxygen extraction fraction indicates a primary reduction in metabolism and uncoupling of flow and metabolism (luxury perfusion). Similar findings of luxury perfusion have been reported after ischemic stroke and traumatic brain injury. Further studies will be necessary to fully understand the clinical and pathophysiological significance of these observations.

Ideal Internal Carotid Artery Trapping Technique without Bypass in a Patient with Insufficient Collateral Flow.

PubMed

Chung, Joon Ho; Shin, Yong Sam; Lim, Yong Cheol; Park, Minjung

2009-04-01

Internal carotid artery (ICA) trapping can be used for treating intracranial giant aneurysm, blood blister-like aneurysms and ICA rupture during the surgery. We present a novel ICA trapping technique which can be used with insufficient collaterals flow via anterior communicating artery (AcoA) and posterior communicating artery (PcoA). A patient was admitted with severe headache and the cerebral angiography demonstrated a typical blood blister-like aneurysm at the contralateral side of PcoA. For trapping the aneurysm, the first clip was placed at the ICA just proximal to the aneurysm whereas the distal clip was placed obliquely proximal to the origin of the PcoA to preserve blood flow from the PcoA to the distal ICA. The patient was completely recovered with good collaterals filling to the right ICA territories via AcoA and PcoA. This technique may be an effective treatment option for trapping the aneurysm, especially when the PcoA preservation is mandatory.

Endovascular Treatment of AICA Flow Dependent Aneurysms

PubMed Central

Mahmoud, M.; El Serwi, A.; Alaa Habib, M.; Abou Gamrah, S.

2012-01-01

Summary Peripheral anterior inferior cerebellar artery (AICA) aneurysms are rare, accounting for less than 1% of all cerebral aneurysms. To our knowledge 34 flow-related cases including the present study have been reported in the literature. Three patients harbouring four flow dependent aneurysms were referred to our institution. Two patients presented with subarachnoid hemorrhage, one presented with cerebellar manifestations. They were all treated by endovascular embolization of the aneurysm as well as the parent artery using liquid embolic material. Two cases were embolized using NBCA, Onyx was used in the third case. No bleeding or rebleeding were encountered during the follow-up period which ranged from five to nine months. One patient developed facial palsy, cerebellar symptoms and sensorineural hearing loss. The remaining two cases did not develop any post treatment neurological complications. Endovascular management of flow-dependent AICA aneurysms by parent artery occlusion is feasible and efficient in terms of rebleeding prevention. Post embolization neurological complications are unpredictable. This depends upon the adequacy of collaterals from other cerebellar arteries. PMID:23217640

Endovascular treatment of distal intracranial aneurysms with Onyx 18/34.

PubMed

Chalouhi, Nohra; Tjoumakaris, Stavropoula; Gonzalez, L Fernando; Hasan, David; Alkhalili, Kenan; Dumont, Aaron S; Rosenwasser, Robert; Jabbour, Pascal

2013-12-01

Surgical clipping and coil embolization of distally located intracranial aneurysms can be challenging. The goal of this study was to assess the feasibility, safety and efficacy of treatment of distal aneurysms with the liquid embolic agent Onyx 18/34. Sixteen patients were treated with Onyx 18/34 for distally located aneurysms in our institution between March 2009 and September 2012. The technique consists of occluding the aneurysm as well as the parent vessel at the level of aneurysm with Onyx 18 or 34. Candidates for this treatment were patients with distal aneurysms including mycotic aneurysms, dissecting aneurysms, and pseudoaneurysms in which coiling was considered impossible. Of the 16 patients, 12 presented with subarachnoid and/or intracerebral hemorrhage. Median aneurysm size was 4.6mm. Aneurysm locations were as follows: Posterior inferior cerebellar artery (n=5), distal anterior inferior cerebellar artery (n=3), distal pericallosal (n=3), distal anterior cerebral artery (n=3), lenticulostriate artery (n=1), and anterior ethmoidal artery (n=1). There were 4 mycotic aneurysms. Complete aneurysm obliteration was achieved in all 6 patients with available angiographic follow-up. There was only 1 (6.3%) symptomatic complication in the series. There were no instances of reflux or accidental migration of embolic material. Favorable outcomes were noted in 82% of patients at discharge. Two patients with mycotic aneurysms died from cardiac complications of endocarditis. No aneurysm recanalization or rehemorrhage were seen. Parent vessel trapping with Onyx 18/34 offers a simple, safe, and effective means of achieving obliteration of distal challenging aneurysms. Copyright © 2013 Elsevier B.V. All rights reserved.

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

PubMed Central

Deshaies, Eric M; Villwock, Mark R; Singla, Amit; Toshkezi, Gentian; Padalino, David J

2015-01-01

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average. PMID:26325337

IN VITRO QUANTIFICATION OF THE SIZE DISTRIBUTION OF INTRASACCULAR VOIDS LEFT AFTER ENDOVASCULAR COILING OF CEREBRAL ANEURYSMS.

PubMed

Sadasivan, Chander; Brownstein, Jeremy; Patel, Bhumika; Dholakia, Ronak; Santore, Joseph; Al-Mufti, Fawaz; Puig, Enrique; Rakian, Audrey; Fernandez-Prada, Kenneth D; Elhammady, Mohamed S; Farhat, Hamad; Fiorella, David J; Woo, Henry H; Aziz-Sultan, Mohammad A; Lieber, Baruch B

2013-03-01

Endovascular coiling of cerebral aneurysms remains limited by coil compaction and associated recanalization. Recent coil designs which effect higher packing densities may be far from optimal because hemodynamic forces causing compaction are not well understood since detailed data regarding the location and distribution of coil masses are unavailable. We present an in vitro methodology to characterize coil masses deployed within aneurysms by quantifying intra-aneurysmal void spaces. Eight identical aneurysms were packed with coils by both balloon- and stent-assist techniques. The samples were embedded, sequentially sectioned and imaged. Empty spaces between the coils were numerically filled with circles (2D) in the planar images and with spheres (3D) in the three-dimensional composite images. The 2D and 3D void size histograms were analyzed for local variations and by fitting theoretical probability distribution functions. Balloon-assist packing densities (31±2%) were lower ( p =0.04) than the stent-assist group (40±7%). The maximum and average 2D and 3D void sizes were higher ( p =0.03 to 0.05) in the balloon-assist group as compared to the stent-assist group. None of the void size histograms were normally distributed; theoretical probability distribution fits suggest that the histograms are most probably exponentially distributed with decay constants of 6-10 mm. Significant ( p <=0.001 to p =0.03) spatial trends were noted with the void sizes but correlation coefficients were generally low (absolute r <=0.35). The methodology we present can provide valuable input data for numerical calculations of hemodynamic forces impinging on intra-aneurysmal coil masses and be used to compare and optimize coil configurations as well as coiling techniques.

Microneurosurgical management of aneurysms at A4 and A5 segments and distal cortical branches of anterior cerebral artery.

PubMed

Lehecka, Martin; Dashti, Reza; Hernesniemi, Juha; Niemelä, Mika; Koivisto, Timo; Ronkainen, Antti; Rinne, Jaakko; Jääskeläinen, Juha

2008-10-01

Aneurysms originating distal to the A3 segment of the ACA, located on the A4 and the A5 segments or the distal cortical branches of the ACA (AdistAs) are rare, forming about 0.5% of all IAs. There are only few reports on management of AdistAs. In this article, we review the practical anatomy, preoperative planning, and avoidance of complications in the microsurgical dissection and clipping of AdistAs. This review, and the whole series on IAs, is mainly based on the personal microneurosurgical experience of the senior author (J. H.) in 2 Finnish centers (Helsinki and Kuopio), which serve without patient selection the catchment area in Southern and Eastern Finland. These 2 centers have treated more than 10000 patients with IAs since 1951. In the Kuopio Cerebral Aneurysm Database of 3005 patients and 4253 IAs, there were 26 patients carrying 26 AdistAs, forming 0.9% of all patients with IAs, 0.6% of all IAs, and 2% of all ACA aneurysms. A total of 10 (38%) patients presented with ruptured AdistAs, with ICH in 4 (40%) and IVH in 2 (20%); 16 patients (62%) had multiple aneurysms. AdistAs are small, even when ruptured, with relatively wide base, and they are frequently associated with ICHs. Our data suggest that AdistAs rupture at smaller size than IAs in general. The challenge is to locate the aneurysm inside the interhemispheric fissure and to clip the neck adequately without obstructing branching arteries at the base. Unruptured AdistAs also need microneurosurgical clipping even when they are small.

Image quality and artefact generation post-cerebral aneurysm clipping using a 64-row multislice computer tomography angiography (MSCTA) technology: A retrospective study and review of the literature.

PubMed

Zachenhofer, Iris; Cejna, Manfred; Schuster, Antonius; Donat, Markus; Roessler, Karl

2010-06-01

Computed tomography angiography (CTA) is a time and cost saving investigation for postoperative evaluation of clipped cerebral aneurysm patients. A retrospective study was conducted to analyse image quality and artefact generation due to implanted aneurysm clips using a new technology. MSCTA was performed pre- and postoperatively using a Philips Brilliance 64-detector-row CT scanner. Altogether, 32 clipping sites were analysed in 27 patients (11 female and 16 male, mean ages 52a, from 24 to 72 years). Clip number per aneurysm was 2.3 mean (from 1 to 4), 54 clips were made of titanium alloy and 5 of cobalt alloy. Altogether, image quality was rated 1.8 mean, using a scale from 1 (very good) to 5 (unserviceable) and clip artefacts were rated 2.4 mean, using a 5 point rating scale (1 no artefacts, 5 unserviceable due to artefacts). A significant loss of image quality and rise of artefacts was found when using cobalt alloy clips (1.4 versus 4.2 and 2.1 versus 4.0). In 72% of all investigations, an excellent image quality was found. Excluding the cobalt clip group, 85% of scans showed excellent image quality. Artefacts were absent or minimal (grade 1 or 2) in 69% of all investigations and in 81% in the pure titanium clip group. In 64-row MSCTA of good image quality with low artefacts, it was possible to detect small aneurysm remnants of 2mm size in individual patients. By using titanium alloy clips, in our study up to 85% of postoperative CTA images were of excellent quality with absent or minimal artefacts in 81% and seem adequate to detect small aneurysm remnants. Copyright 2010 Elsevier B.V. All rights reserved.

Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.

PubMed

Kumar, Gyanendra; Shahripour, Reza Bavarsad; Harrigan, Mark R

2016-05-01

OBJECT The impact of transcranial Doppler (TCD) ultrasonography evidence of vasospasm on patient-centered clinical outcomes following aneurysmal subarachnoid hemorrhage (aSAH) is unknown. Vasospasm is known to lead to delayed cerebral ischemia (DCI) and poor outcomes. This systematic review and meta-analysis evaluates the predictive value of vasospasm on DCI, as diagnosed on TCD. METHODS MEDLINE, Scopus, the Cochrane trial register, and clinicaltrials.gov were searched through September 2014 using key words and the terms "subarachnoid hemorrhage," "aneurysm," "aneurysmal," "cerebral vasospasm," "vasospasm," "transcranial Doppler," and "TCD." Sensitivities, specificities, and positive and negative predictive values were pooled by a DerSimonian and Laird random-effects model. RESULTS Seventeen studies (n = 2870 patients) met inclusion criteria. The amount of variance attributable to heterogeneity was significant (I(2) > 50%) for all syntheses. No studies reported the impact of TCD evidence of vasospasm on functional outcome or mortality. TCD evidence of vasospasm was found to be highly predictive of DCI. Pooled estimates for TCD diagnosis of vasospasm (for DCI) were sensitivity 90% (95% confidence interval [CI] 77%-96%), specificity 71% (95% CI 51%-84%), positive predictive value 57% (95% CI 38%-71%), and negative predictive value 92% (95% CI 83%-96%). CONCLUSIONS TCD evidence of vasospasm is predictive of DCI with high accuracy. Although high sensitivity and negative predictive value make TCD an ideal monitoring device, it is not a mandated standard of care in aSAH due to the paucity of evidence on clinically relevant outcomes, despite recommendation by national guidelines. High-quality randomized trials evaluating the impact of TCD monitoring on patient-centered and physician-relevant outcomes are needed.

A novel low profile wireless flow sensor to monitor hemodynamic changes in cerebral aneurysm

NASA Astrophysics Data System (ADS)

Chen, Yanfei; Jankowitz, Brian T.; Cho, Sung Kwon; Chun, Youngjae

2015-03-01

A proof of concept of low-profile flow sensor has been designed, fabricated, and subsequently tested to demonstrate its feasibility for monitoring hemodynamic changes in cerebral aneurysm. The prototype sensor contains three layers, i.e., a thin polyurethane layer was sandwiched between two sputter-deposited thin film nitinol layers (6μm thick). A novel superhydrophilic surface treatment was used to create hemocompatible surface of thin nitinol electrode layers. A finite element model was conducted using ANSYS Workbench 15.0 Static Structural to optimize the dimensions of flow sensor. A computational fluid dynamics calculations were performed using ANSYS Workbench Fluent to assess the flow velocity patterns within the aneurysm sac. We built a test platform with a z-axis translation stage and an S-beam load cell to compare the capacitance changes of the sensors with different parameters during deformation. Both LCR meter and oscilloscope were used to measure the capacitance and the resonant frequency shifts, respectively. The experimental compression tests demonstrated the linear relationship between the capacitance and applied compression force and decreasing the length, width and increasing the thickness improved the sensor sensitivity. The experimentally measured resonant frequency dropped from 12.7MHz to 12.48MHz, indicating a 0.22MHz shift with 200g ( 2N) compression force while the theoretical resonant frequency shifted 0.35MHz with 50g ( 0.5N). Our recent results demonstrated a feasibility of the low-profile flow sensor for monitoring haemodynamics in cerebral aneurysm region, as well as the efficacy of the use of the surface treated thin film nitinol for the low-profile sensor materials.

Endovascular treatment of cerebral aneurysm after renal transplantation in polycystic kidney disease.

PubMed

Demartini, Zeferino; Galdino, Jennyfer; Koppe, Gelson L; Bignelli, Alexandre T; Francisco, Alexandre N; Gatto, Luana Am

2018-06-01

Background Patients with polycystic kidney disease have a higher prevalence of intracranial aneurysms and may progress to renal failure requiring transplantation. The endovascular treatment of intracranial aneurysms may improve prognosis, since rupture often causes premature death or disability, but the nephrotoxicity risk associated with contrast medium must be always considered in cases of renal impairment. Methods A 55-year-old female patient with polycystic kidney disease and grafted kidney associated with anterior communicant artery aneurysm was successfully treated by embolization. Results The renal function remained normal after the procedure. To the authors' knowledge, this is the first case of endovascular treatment of brain aneurysm in a transplanted patient reported in the medical literature. Conclusions The endovascular procedure in renal transplant patients is feasible and can be considered to treat this population. Further studies and cases are needed to confirm its safety.

Onyx embolization for the endovascular treatment of infectious and traumatic aneurysms involving the cranial and cerebral vasculature.

PubMed

Jadhav, Ashutosh P; Pryor, Johnny C; Nogueira, Raul G

2013-11-01

Onyx is a liquid non-adhesive viscous embolic agent ideal for slow targeted injections which is currently approved for the treatment of intracranial aneurysms and arteriovenous malformations. We performed a single-center retrospective analysis of consecutive patients who underwent off-label use of Onyx as the single embolic agent for the treatment of traumatic or infectious pseudoaneurysms involving the cerebral or cranial vasculature. A total of nine pseudoaneurysms treated by Onyx embolization were identified. Six of the pseudoaneurysms were post-surgical, one of the pseudoaneurysms was traumatic and two were infectious in nature. The mean pseudoaneurysm size was 5.9 mm (range 2-10 mm). Onyx-34 was used in all cases. Following treatment there was complete exclusion of all pseudoaneurysms including their inflow and outflow zones. Our experience demonstrates the efficacy and applicability of the use of Onyx in the treatment of complex traumatic and mycotic pseudoaneurysms involving the cerebral and cranial vascular tree.

Computational Study of Intracranial Aneurysms with Flow Diverting Stent: Correlation with Surgical Outcome

NASA Astrophysics Data System (ADS)

Tang, Yik Sau; Chiu, Tin Lok; Tsang, Anderson Chun On; Leung, Gilberto Ka Kit; Chow, Kwok Wing

2016-11-01

Intracranial aneurysm, abnormal swelling of the cerebral artery, can cause massive internal bleeding in the subarachnoid space upon aneurysm rupture, leading to a high mortality rate. Deployment of a flow diverting stent through endovascular technique can obstruct the blood flow into the aneurysm, thus reducing the risk of rupture. Patient-specific models with both bifurcation and sidewall aneurysms have been investigated. Computational fluid dynamics analysis with physiological boundary conditions has been performed. Several hemodynamic parameters including volume flow rate into the aneurysm and the energy (sum of the fluid kinetic and potential energy) loss between the inlet and outlets were analyzed and compared with the surgical outcome. Based on the simulation results, we conjecture that a clinically successful case might imply less blood flow into the aneurysm after stenting, and thus a smaller amount of energy loss in driving the fluid flow in that portion of artery. This study might provide physicians with quantitative information for surgical decision making. (Partial financial support by the Innovation and Technology Support Program (ITS/011/13 & ITS/150/15) of the Hong Kong Special Administrative Region Government)

Aneurysm of the intradural artery of Adamkiewicz treated with muslin wrapping: technical case report.

PubMed

Vishteh, A G; Brown, A P; Spetzler, R F

1997-01-01

An exceedingly rare, isolated spinal arterial aneurysm and its management are presented. A 30-year-old man who presented with severe lower back pain and headache underwent a computed tomographic study of his head that disclosed nothing abnormal and a lumbar puncture that revealed bloody, xanthochromic cerebrospinal fluid. The findings from cerebral angiography were normal, and the results from spinal angiography were consistent with a diagnosis of an aneurysm of the artery of Adamkiewicz. A transthoracic approach with a partial T11 vertebrectomy gained exposure to this anteriorly located lesion. A fusiform aneurysm of the intradural portion of the artery of Adamkiewicz was discovered. Excision of the aneurysm with a vascular bypass was deemed impossible. The lesion was treated with muslin wrapping. One year after surgery, the patient remains at his baseline neurological condition. A review of the literature revealed only one other reported case of a ruptured aneurysm of the artery of Adamkiewicz, which was discovered postmortem. Therefore, this case represents the first report of a diagnosed and treated artery of Adamkiewicz aneurysm.

Electroencephalographic Response to Sodium Nitrite May Predict Delayed Cerebral Ischemia After Severe Subarachnoid Hemorrhage.

PubMed

Garry, Payashi S; Rowland, Matthew J; Ezra, Martyn; Herigstad, Mari; Hayen, Anja; Sleigh, Jamie W; Westbrook, Jon; Warnaby, Catherine E; Pattinson, Kyle T S

2016-11-01

Aneurysmal subarachnoid hemorrhage often leads to death and poor clinical outcome. Injury occurring during the first 72 hours is termed "early brain injury," with disruption of the nitric oxide pathway playing an important pathophysiologic role in its development. Quantitative electroencephalographic variables, such as α/δ frequency ratio, are surrogate markers of cerebral ischemia. This study assessed the quantitative electroencephalographic response to a cerebral nitric oxide donor (intravenous sodium nitrite) to explore whether this correlates with the eventual development of delayed cerebral ischemia. Unblinded pilot study testing response to drug intervention. Neuroscience ICU, John Radcliffe Hospital, Oxford, United Kingdom. Fourteen World Federation of Neurosurgeons grades 3, 4, and 5 patients (mean age, 52.8 yr [range, 41-69 yr]; 11 women). IV sodium nitrite (10 μg/kg/min) for 1 hour. Continuous electroencephalographic recording for 2 hours. The alpha/delta frequency ratio was measured before and during IV sodium nitrite infusion. Seven of 14 patients developed delayed cerebral ischemia. There was a +30% to +118% (range) increase in the alpha/delta frequency ratio in patients who did not develop delayed cerebral ischemia (p < 0.0001) but an overall decrease in the alpha/delta frequency ratio in those patients who did develop delayed cerebral ischemia (range, +11% to -31%) (p = 0.006, multivariate analysis accounting for major confounds). Administration of sodium nitrite after severe subarachnoid hemorrhage differentially influences quantitative electroencephalographic variables depending on the patient's susceptibility to development of delayed cerebral ischemia. With further validation in a larger sample size, this response may be developed as a tool for risk stratification after aneurysmal subarachnoid hemorrhage.

Vein graft aneurysms following popliteal aneurysm repair are more common than we think.

PubMed

Sharples, Alistair; Kay, Mark; Sykes, Timothy; Fox, Anthony; Houghton, Andrew

2015-10-01

True infrainguinal vein graft aneurysms are reported infrequently in the literature. We sought to identify the true incidence of these graft aneurysms after popliteal aneurysm repair and identify factors which may increase the risk of such aneurysms developing. Using a prospectively compiled database, we identified patients who underwent a popliteal aneurysm repair between January 1996 and January 2011 at a single district general hospital. Patients were routinely followed up in a graft surveillance programme. Out of 45 patients requiring repair of a popliteal aneurysm over a 15-year period, four (8.8%) patients developed aneurysmal graft disease. Of the patients who developed graft aneurysms, all had aneurysmal disease at other sites compared with 18 (45.0%) patients who did not develop graft aneurysms. Patients with graft aneurysms had a mean of 1.60 aneurysms elsewhere compared to 0.58 in patients with non-aneurysmal grafts (P = 0.005). True vein graft aneurysms occur in a significant number of patients following popliteal aneurysm repair. Our data would suggest this to be more likely in patients who have aneurysms elsewhere and therefore a predisposition to aneurysmal disease. It may be appropriate for patients with aneurysms at other sites to undergo more prolonged post-operative graft surveillance. © The Author(s) 2014.

Cellular responses of bioabsorbable polymeric material and Guglielmi detachable coil in experimental aneurysms.

PubMed

Murayama, Yuichi; Viñuela, Fernando; Tateshima, Satoshi; Gonzalez, Nestor R; Song, Joon K; Mahdavieh, Haleh; Iruela-Arispe, Luisa

2002-04-01

Acceleration of healing mechanisms is a promising approach to improve current limitations of endovascular aneurysm therapy with the use of platinum coils. We evaluated a new endovascular therapeutic, bioabsorbable polymeric material (BPM), which may promote cellular reaction in the aneurysms. Four different concentrations of lactide/glycolic acid copolymer [poly(D-L-lactic-co-glycolic acid)] (PLGA), 85/15, 75/25, 65/35, and 50/50, were used as BPMs. Sixteen experimental aneurysms were created in 8 swine. Eight-millimeter-long spiral-shaped BPMs were surgically implanted in the aneurysms without tight packing (n=3 for each BPM). Guglielmi detachable coils (GDCs) were used as control (n=4). The animals were killed 14 days after embolization, and angiographic, histological, and immunohistochemical analyses were performed. Despite loose packing of aneurysms with BPMs, faster BPMs such as 50/50 or 65/35 PLGA demonstrated more mature collagen formation and fibrosis in the sac and neck of the aneurysm. One aneurysm treated with 65/35 PLGA, 1 treated with 75/25 PLGA, and all 3 treated with 85/15 PLGA showed a neck remnant on angiography. There was a linear relationship between collagen levels and polymer degradation properties (r=-0.9513). This preliminary animal study indicates that acceleration of aneurysm healing with the use of BPM is feasible. This concept can be applied to decrease and perhaps prevent aneurysmal recanalization after endovascular treatment of cerebral aneurysms.

Use of flow-diverting stents as salvage treatment following failed stent-assisted embolization of intracranial aneurysms.

PubMed

Heiferman, Daniel M; Billingsley, Joshua T; Kasliwal, Manish K; Johnson, Andrew K; Keigher, Kiffon M; Frudit, Michel E; Moftakhar, Roham; Lopes, Demetrius K

2016-07-01

Flow-diverting stents, including the Pipeline embolization device (PED) and Silk, have been beneficial in the treatment of aneurysms previously unable to be approached via endovascular techniques. Recurrent aneurysms for which stent-assisted embolization has failed are a therapeutic challenge, given the existing intraluminal construct with continued blood flow into the aneurysm. We report our experience using flow-diverting stents in the repair of 25 aneurysms for which stent-assisted embolization had failed. Nineteen (76%) of these aneurysms at the 12-month follow-up showed improved Raymond class occlusion, with 38% being completely occluded, and all aneurysms demonstrated decreased filling. One patient developed a moderate permanent neurologic deficit. Appropriate stent sizing, proximal and distal construct coverage, and preventing flow diverter deployment between the previously deployed stent struts are important considerations to ensure wall apposition and prevention of endoleak. Flow diverters are shown to be a reasonable option for treating previously stented recurrent cerebral aneurysms. 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/

Association of statins with aortic, peripheral, and visceral artery aneurysm development.

PubMed

Mansi, Ishak A; Frei, Christopher R; Halm, Ethan A; Mortensen, Eric M

2017-08-01

Objectives Prior studies examining the effects of statins on arterial aneurysm development and progression yielded conflicting results due to their smaller size and presence of residual confounders. The objective of this study is to examine the association of statins with risk of being diagnosed with aortic, peripheral, and visceral artery aneurysm. Methods This was a retrospective cohort study of Tricare enrollees (from 1 October 2003 to 31 March 2012). Main outcomes were diagnosis of aortic, peripheral, or visceral artery aneurysm and undergoing aortic aneurysm repair procedure during follow-up period. Using 115 baseline characteristics, we generated a propensity score to match statin users and nonusers and examine the odds of outcomes (primary analysis). Secondary analysis examined outcomes at various subcohorts. Results Out of 10,910 statin users and 49,545 nonusers, we propensity score-matched 6728 pairs of statin users and nonusers. Statin users and nonusers had similar odds of being diagnosed with aortic, peripheral, and visceral artery aneurysms (odds ratio [OR]: 1.06, 95% confidence interval [95% CI]: 0.85-1.33) and of undergoing aortic aneurysm repair procedures (OR: 0.54, 95% CI: 0.22-1.35). Secondary analysis showed a tendency toward fewer aortic aneurysm procedures among statin users that did not reach statistical significance. However, high-intensity statin users in comparison to non-intensive statin users had higher adjusted odds of aortic, peripheral, and visceral artery aneurysms (OR: 1.76, 95% CI: 1.37-2.25, p < .0001). Conclusions This study does not support a clinically significant benefit or harm from statins regarding development of arterial aneurysm. However, secondary analyses may support the hypothesis proposed by previous research proposing a bidirectional role for statins.

Cerebellar hematoma in a patient with Marfan syndrome.

PubMed

Passalacqua, Marcello; Grasso, Giovanni; Alafaci, Concetta; Collufio, Domenicantonio; Morabito, Antonio; Salpietro, Francesco M; Tomasello, Francesco

2003-08-01

Marfan syndrome is a connective tissue disorder affecting many structures, including the skeleton, lungs, eyes, heart and blood vessels. It is an autosomal dominant inherited disorder due to a mutation of a gene encoding fibrillin-1, which affects connective tissue. Few case reports have associated Marfan syndrome with vascular malformations of the brain and spinal cord. In this regard, association with intracranial aneurysm has been vaguely proposed. We report here a patient with Marfan syndrome who was admitted because of a sudden loss of consciousness. The patient underwent computed tomography (CT) examination, which disclosed a right intracerebellar hematoma. Cerebral angiogram did not demonstrate aneurysm or arteriovenous malformation (AVM), or evidence of any other vascular lesions or neoplasms in the posterior fossa. Conservative treatment was undertaken. The clinical course was uneventful and after 6 weeks the patient was discharged free of symptoms. Although patients with Marfan syndrome are at high risk of vascular abnormalities, a clear association with cerebral aneurysm has not yet been established. Our experience and the contrasting reports available in the medical literature strongly warrant further studies in order to better clarify this controversial association.

Rehabilitation after Clipping of Cerebral Aneurysms without Acute Subarachnoid Hemorrhage: Outcome Analysis of 100 Consecutive Cases.

PubMed

Jödicke, Andreas; Bauer, Karsten; Hajdukova, Andrea

2018-06-11

 Discharge to rehabilitation is reported in large studies as one important outcome parameter based on hospital codes. Because neurologic outcome scores (e.g., the modified Rankin Scale [mRS]) are missing in International Classification of Diseases (ICD) databases, rehabilitation indirectly serves as a kind of surrogate parameter for overall outcome. Reported fractions of patients with rehabilitation, however, largely differ between studies and seem high for patients with aneurysm clipping. Variances in rehabilitation fractions seem to largely differ between treatments (clipping versus coiling) for unruptured intracranial aneurysms, so we analyzed our patients for percentage of and potential factors predicting rehabilitation.  From July 2007 to September 2013, 100 consecutive patients with at least one cerebral aneurysm underwent aneurysm clipping. Aneurysms were classified as incidental, associated, pretreated (coil compaction after subarachnoid hemorrhage), and symptomatic (oculomotor nerve compression, microemboli), and they were assigned to their anatomical location. Complications (infection, hemorrhage, cerebrospinal fluid fistula, transient and permanent neurologic deficit, reoperation) and outcome (mRS at 6 months; clip occlusion rate by postoperative digital subtraction angiography) as well as frequency and type of rehabilitation were analyzed and correlated retrospectively. Multiple aneurysms clipped in one procedure were not counted separately regarding complications or outcome (i.e., one patient, one outcome).  The overall complication rate was 17% including 10% early and 3% permanent neurologic deficits and 7% reoperations. There were no deaths. Overall, 98% of patients had a good outcome (mRS 0-2). Clip occlusion rate was 97.9%. Multivariate logistic regression analysis identified aneurysm location as the only significant independent factor for risk of complication ( p  < 0.001) and complication as the only significant independent risk factor for rehabilitation ( p  = 0.003). Rehabilitation was indicated or requested by the patient as early neurologic rehabilitation (5%), inpatient follow-up (15%), and outpatient follow-up (15%). The long-term care rate was 2%.  Microsurgery of unruptured and not acutely ruptured aneurysms (including post-coil and associated aneurysms) has a low rate of rehabilitation with a low risk of a permanent neurologic deficit, long-term care, or early neurologic rehabilitation. The rate of rehabilitation is well below reported risks from studies based on ICD-based health care analysis. Rehabilitation per se is not a good indicator for outcome. Georg Thieme Verlag KG Stuttgart · New York.

Advanced technical skills are required for microsurgical clipping of posterior communicating artery aneurysms in the endovascular era.

PubMed

Sanai, Nader; Caldwell, Nolan; Englot, Dario J; Lawton, Michael T

2012-08-01

Many neurosurgeons feel competent clipping posterior communicating artery (PCoA) aneurysms and include this lesion in their practice. However, endovascular therapy removes simple aneurysms that would have been easiest to clip with the best results. What remains are aneurysms with complex anatomy and technical challenges that are not well described. A contemporary surgical series with PCoA aneurysms is reviewed to define the patients, microsurgical techniques, and outcomes in current practice. A total of 218 patients had 218 PCoA aneurysms that were treated microsurgically during an 11-year period. Complexities influencing aneurysm management included (1) large/giant size; (2) fetal posterior cerebral artery; (3) previous coiling; (4) anterior clinoidectomy; (5) adherence of the anterior choroidal artery (AChA); (6) intraoperative aneurysm rupture; (7) complex clipping; and (8) atherosclerotic calcification. Simple PCoA aneurysms were encountered in 113 patients (51.8%) and complex aneurysms in 105 (48.2%). Adherent AChA (13.8%) and intraoperative rupture (11.5%) were the most common complexities. Simple aneurysms had favorable outcomes in 86.6% of patients, whereas aneurysms with 1 or multiple complexities had favorable outcomes in 78.2% and 75.0%, respectively. Intraoperative rupture (P < .01), large/giant size (P = .04), and complex clipping (P = .05) were associated with increased neurological worsening. Because endovascular therapy alters the surgical population, neurosurgeons should recalibrate their expectations with this once straightforward aneurysm. The current mix of PCoA aneurysms requires advanced techniques including clinoidectomy, AChA microdissection, complex clipping, and facility with intraoperative rupture. Microsurgery is recommended for recurrent aneurysms after coiling, complex branches, aneurysms causing oculomotor nerve palsy, multiple aneurysms, and patients with hematomas.

A Modified Method for Creating Elastase-Induced Aneurysms by Ligation of Common Carotid Arteries in Rabbits and Its Effect on Surrounding Arteries.

PubMed

Kainth, Daraspreet; Salazar, Pascal; Safinia, Cyrus; Chow, Ricky; Bachour, Ornina; Andalib, Sasan; McKinney, Alexander M; Divani, Afshin A

2017-01-01

Rabbit models of intracranial aneurysms are frequently used in pre-clinical settings. This study aimed to demonstrate an alternative, extravascular method for creating elastase-induced aneurysms, and how ligation of the right common carotid arteries (RCCA) can impact flow redistribution into left CCA (LCCA). Elastase-induced aneurysms in 18 New Zealand rabbits (4.14 ± 0.314 kg) were created by applying 3-5 U of concentrated elastase solution to the exterior of the right and left CCA roots (RCCA and LCCA). After the induction of the aneurysm, the aneurysm was either kept intact to the rest of the corresponding CCA, severed from the rest of the CCA to allow for a free standing aneurysm, or was anchored to nearby tissue to influence the angle and orientation of the aneurysm with respect to the parent vessel. Ultrasound studies were performed before and after creation of aneurysms to collect blood flow measurements inside the aneurysm pouch and surrounding arteries. Prior to sacrificing the animals, computed tomography angiography studies were performed. Harvested aneurysmal tissues were used for histological analysis. Elastase-induced aneurysms were successfully created by the extravascular approach. Histological studies showed that the biological response was similar to human cerebral aneurysms and previously published elastase-induced rabbit aneurysm models. Ultrasound measurements indicated that after the RCCA was ligated, blood flow significantly increased in the LCCA at one-month follow-up. An alternate method for creating elastase-induced aneurysms has been demonstrated. The novel aspects of our method allow for ligation of one or both common carotid arteries to create a single or bilateral aneurysm with an ability to control the orientation of the induced aneurysm.

Interactive knowledge discovery with the doctor-in-the-loop: a practical example of cerebral aneurysms research.

PubMed

Girardi, Dominic; Küng, Josef; Kleiser, Raimund; Sonnberger, Michael; Csillag, Doris; Trenkler, Johannes; Holzinger, Andreas

2016-09-01

Established process models for knowledge discovery find the domain-expert in a customer-like and supervising role. In the field of biomedical research, it is necessary to move the domain-experts into the center of this process with far-reaching consequences for both their research output and the process itself. In this paper, we revise the established process models for knowledge discovery and propose a new process model for domain-expert-driven interactive knowledge discovery. Furthermore, we present a research infrastructure which is adapted to this new process model and demonstrate how the domain-expert can be deeply integrated even into the highly complex data-mining process and data-exploration tasks. We evaluated this approach in the medical domain for the case of cerebral aneurysms research.

Fluid-structure interaction of patient-specific Circle of Willis with aneurysm: Investigation of hemodynamic parameters.

PubMed

Jahed, Mahsa; Ghalichi, Farzan; Farhoudi, Mehdi

2018-01-01

Circle of Willis (COW) is a network of cerebral artery which continually supplies the brain with blood. Any disturbance in this supply will result in trauma or even death. One of these damages is known as brain Aneurysm. Clinical methods for diagnosing aneurysm can only measure blood velocity; while, in order to understand the causes of these occurrences it is necessary to have information about the amount of pressure and wall shear stress, which is possible through computational models. In this study purpose is achieving exact information of hemodynamic blood flow in COW with an aneurysm and investigation of effective factors on growth and rupture of aneurysm. Here, realistic three-dimensional models have been produced from angiography images. Considering fluid-structure interaction have been simulated by the ANSYS.CFX software. Hemodynamic Studying of the COW and intra-aneurysm showed that the WSS and wall tension in the neck of aneurysms for case A are 129.5 Pa, and 12.2 kPa and for case B they are 53.3 Pa and 56.2 kPa, and more than their fundus, thus neck of aneurysm is prone to rupture. This study showed that the distribution of parameters was dependent on the geometry of the COW, and maximum values are seen in areas prone to aneurysm formation.

Automatic aneurysm neck detection using surface Voronoi diagrams.

PubMed

Cárdenes, Rubén; Pozo, José María; Bogunovic, Hrvoje; Larrabide, Ignacio; Frangi, Alejandro F

2011-10-01

A new automatic approach for saccular intracranial aneurysm isolation is proposed in this work. Due to the inter- and intra-observer variability in manual delineation of the aneurysm neck, a definition based on a minimum cost path around the aneurysm sac is proposed that copes with this variability and is able to make consistent measurements along different data sets, as well as to automate and speedup the analysis of cerebral aneurysms. The method is based on the computation of a minimal path along a scalar field obtained on the vessel surface, to find the aneurysm neck in a robust and fast manner. The computation of the scalar field on the surface is obtained using a fast marching approach with a speed function based on the exponential of the distance from the centerline bifurcation between the aneurysm dome and the parent vessels. In order to assure a correct topology of the aneurysm sac, the neck computation is constrained to a region defined by a surface Voronoi diagram obtained from the branches of the vessel centerline. We validate this method comparing our results in 26 real cases with manual aneurysm isolation obtained using a cut-plane, and also with results obtained using manual delineations from three different observers by comparing typical morphological measures. © 2011 IEEE

Treatment Challenges of a Primary Vertebral Artery Aneurysm Causing Recurrent Ischemic Strokes.

PubMed

Strambo, Davide; Peruzzotti-Jametti, Luca; Semerano, Aurora; Fanelli, Giovanna; Simionato, Franco; Chiesa, Roberto; Rinaldi, Enrico; Martinelli, Vittorio; Comi, Giancarlo; Bacigaluppi, Marco; Sessa, Maria

2017-01-01

Background . Extracranial vertebral artery aneurysms are a rare cause of embolic stroke; surgical and endovascular therapy options are debated and long-term complication may occur. Case Report . A 53-year-old man affected by neurofibromatosis type 1 (NF1) came to our attention for recurrent vertebrobasilar embolic strokes, caused by a primary giant, partially thrombosed, fusiform aneurysm of the left extracranial vertebral artery. The aneurysm was treated by endovascular approach through deposition of Guglielmi Detachable Coils in the proximal segment of the left vertebral artery. Six years later the patient presented stroke recurrence. Cerebral angiography and Color Doppler Ultrasound well characterized the unique hemodynamic condition developed over the years responsible for the new embolic event: the aneurysm had been revascularized from its distal portion by reverse blood flow coming from the patent vertebrobasilar axis. A biphasic Doppler signal in the left vertebral artery revealed a peculiar behavior of the blood flow, alternately directed to the aneurysm and backwards to the basilar artery. Surgical ligation of the distal left vertebral artery and excision of the aneurysm were thus performed. Conclusion . This is the first described case of NF1-associated extracranial vertebral artery aneurysm presenting with recurrent embolic stroke. Complete exclusion of the aneurysm from the blood circulation is advisable to achieve full resolution of the embolic source.

Intracranial aneurysms: optimized diagnostic tools call for thorough interdisciplinary treatment strategies.

PubMed

Mueller, Oliver M; Schlamann, Marc; Mueller, Daniela; Sandalcioglu, I Erol; Forsting, Michael; Sure, Ulrich

2011-09-01

Intracranial aneurysms (IAs) require deliberately selected treatment strategies as they are incrementally found prior to rupture and deleterious subarachnoid haemorrhage (SAH). Multiple and recurrent aneurysms necessitate both neurointerventionalists and neurosurgeons to optimize aneurysmal occlusion in an interdisciplinary effort. The present study was conducted to condense essential strategies from a single neurovascular centre with regard to the lessons learned. Medical charts of 321 consecutive patients treated for IAs at our centre from September 2008 until December 2010 were retrospectively analysed for clinical presentation of the aneurysms, multiplicity and treatment pathways. In addition, a selective Medline search was performed. A total of 321 patients with 492 aneurysms underwent occlusion of their symptomatic aneurysm: 132 (41.1%) individuals were treated surgically, 189 (58.2%) interventionally; 138 patients presented with a SAH, of these 44.2% were clipped and 55.8% were coiled. Aneurysms of the middle cerebral artery were primarily occluded surgically (88), whereas most of the aneurysms of the internal carotid artery and anterior communicating artery (114) were treated endovascularly. Multiple aneurysms (range 2-5 aneurysms/individual) were diagnosed in 98 patients (30.2%). During the study period 12 patients with recurrent aneurysms were allocated to another treatment modality (previously clip to coil and vice versa). Our data show that successful interdisciplinary occlusion of IAs is based on both neurosurgical and neurointerventional therapy. In particular, multiple and recurrent aneurysms require tailored individual approaches to aneurysmal occlusion. This is achieved by a consequent interdisciplinary pondering of the optimal strategy to occlude IAs in order to prevent SAH.

Surgical treatment for a ruptured true posterior communicating artery aneurysm arising on the fetal-type posterior communicating artery--two case reports and review of the literature.

PubMed

Nakano, Yoshiteru; Saito, Takeshi; Yamamoto, Junkoh; Takahashi, Mayu; Akiba, Daisuke; Kitagawa, Takehiro; Miyaoka, Ryo; Ueta, Kunihiro; Kurokawa, Toru; Nishizawa, Shigeru

2011-12-01

Only a small number of aneurysms arising on the posterior communicating artery itself (true Pcom aneurysm) have been reported. We report two cases of ruptured true Pcom aneurysms with some characteristic features of true Pcom aneurysm. A 43 year old man suffering from subarachnoid hemorrhage (SAH) had an aneurysm arising on the fetal-type Pcom artery itself, and underwent surgery for clipping. Most of the aneurysm was buried in the temporal lobe, so retraction of the temporal lobe was mandatory. During the retraction, premature rupture was encountered. After tentative dome clipping and the control of bleeding, complete clipping was achieved. Another patient, a 71 year old woman presenting with consciousness disturbance due to SAH, had an aneurysm on the fetal-type Pcom artery itself, and underwent surgery for clipping. It has been generally considered that hemodynamic factor plays an important role in the formation, the growth, and the rupture of the cerebral aneurysm. This factor is especially significant in true Pcom aneurysm formation and rupture. According to the literature, a combination of fetal type Pcom and formation of the true Pcom aneurysm has been reported in most cases (81.8%). Most of the aneurysm can be buried in the temporal lobe, and the retraction of the temporal lobe during the dissection of the neck would be necessary, which causes premature rupture of the true Pcom aneurysm. In the surgery for a true Pcom aneurysm, we should be aware of possible premature rupture when temporal lobe retraction is necessary.

Impact of Aneurysm Projection on Intraoperative Complications During Surgical Clipping of Ruptured Posterior Communicating Artery Aneurysms.

PubMed

Fukuda, Hitoshi; Hayashi, Kosuke; Yoshino, Kumiko; Koyama, Takashi; Lo, Benjamin; Kurosaki, Yoshitaka; Yamagata, Sen

2016-03-01

Surgical clipping of ruptured posterior communicating artery (PCoA) aneurysms is a well-established procedure to date. However, preoperative factors associated with procedure-related risk require further elucidation. To investigate the impact of the direction of aneurysm projection on the incidence of procedure-related complications during surgical clipping of ruptured PCoA aneurysms. A total of 65 patients with ruptured PCoA aneurysms who underwent surgical clipping were retrospectively analyzed from a single-center, prospective, observational cohort database in this study. The aneurysms were categorized into lateral and posterior projection groups, depending on direction of the dome. Characteristics and operative findings of each projection group were identified. We also evaluated any correlation of aneurysm projection with the incidence of procedure-related complications. Patients with ruptured PCoA aneurysms with posterior projection more likely presented with good-admission-grade subarachnoid hemorrhage (P = .01, χ test) and were less to also have intracerebral hematoma (P = .01). These aneurysms were found to be associated with higher incidence of intraoperative rupture (P = .02), complex clipping with fenestrated clips (P = .02), and dense adherence to PCoA or its perforators (P = .04) by univariate analysis. Aneurysms with posterior projection were also correlated with procedure-related complications, including postoperative cerebral infarction or hematoma formation (odds ratio, 5.87; 95% confidence interval, 1.11-31.1; P = .04) by multivariable analysis. Ruptured PCoA aneurysms with posterior projection carried a higher risk of procedure-related complications of surgical clipping than those with lateral projection.

Treatment Strategies for Intracranial Mirror Aneurysms.

PubMed

Wang, Wen-Xin; Xue, Zhe; Li, Lin; Wu, Chen; Zhang, Yan-Yang; Lou, Xin; Ma, Lin; Sun, Zheng-Hui

2017-04-01

Intracranial mirror aneurysms are clinically rare and uncommonly reported in the literature. Therefore, the present study evaluated a series of mirror aneurysm cases with respect to the clinical features of the patients and the treatment strategies that were used. This study retrospectively reviewed and systematically analyzed the clinical features, imaging data, treatment methods, and treatment outcomes of 68 cases of mirror aneurysms (a total of 70 pairs) in patients who were admitted to our department between November 2007 and May 2016. The patient population included 24 male and 44 female patients, with a mean age of 52 years. The mirror aneurysms were primarily located in posterior communicating artery and middle cerebral artery and 65 of the aneurysms were large or giant (≧10 mm). Of the 68 patients, 28 were treated by the clipping or embolization of all aneurysms in one stage, 16 were treated in 2 stages, 16 were treated by treating part of the aneurysms, and 8 were observed. The modified Rankin Scale scores of the 60 patients that were treated indicated that 52 had a good recovery (modified Rankin Scale score ≦2; 86.7%), and 1 patient died. Treatment strategies for mirror aneurysms should be determined individually according to the location, size, and morphology of the aneurysm, as well as the clinical manifestations of each patient. Furthermore, the responsible ruptured aneurysm should be given treatment priority, whereas the contralateral unruptured aneurysm should be observed or treated in either 1 or 2 stages. Copyright © 2017 Elsevier Inc. All rights reserved.

Hemodynamic differences between unstable and stable unruptured aneurysms independent of size and location: a pilot study.

PubMed

Brinjikji, Waleed; Chung, Bong Jae; Jimenez, Carlos; Putman, Christopher; Kallmes, David F; Cebral, Juan R

2017-04-01

While clinical and angiographic risk factors for intracranial aneurysm instability are well established, it is reasonable to postulate that intra-aneurysmal hemodynamics also have a role in aneurysm instability. To identify hemodynamic characteristics that differ between radiologically unstable and stable unruptured intracranial aneurysms. 12 pairs of unruptured intracranial aneurysms with a 3D rotational angiographic set of images and followed up longitudinally without treatment were studied. Each pair consisted of one stable aneurysm (no change on serial imaging) and one unstable aneurysm (demonstrated growth of at least 1 mm diameter or ruptured during follow-up) of matching size (within 10%) and locations. Patient-specific computational fluid dynamics models were created and run under pulsatile flow conditions. Relevant hemodynamic and geometric variables were calculated and compared between groups using the paired Wilcoxon test. The area of the aneurysm under low wall shear stress (low shear stress area (LSA)) was 2.26 times larger in unstable aneurysms than in stable aneurysms (p=0.0499). The mean aneurysm vorticity was smaller by a factor of 0.57 in unstable aneurysms compared with stable aneurysms (p=0.0499). No statistically significant differences in geometric variables or shape indices were found. This pilot study suggests there may be hemodynamic differences between unstable and stable unruptured cerebral aneurysms. In particular, the area under low wall shear stress was larger in unstable aneurysms. These findings should be considered tentative until confirmed by future larger studies. 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/.

Cerebral Aneurysms

MedlinePlus

... Strategy Current Research Research Funded by NINDS Basic Neuroscience Clinical Research Translational Research Research at NINDS Focus ... Diversity Resources Jobs at NINDS Director, Division of Neuroscience Director, NIH BRAIN Initiative® Health Scientist Administrator Channels ...

Colorectal cancer associated with abdominal aortic aneurysm: results of EVAR followed by colectomy.

PubMed

Illuminati, Giulio; Ceccanei, Gianluca; Pacilè, Maria A; Pizzardi, Giulia; Palumbo, Piergaspare; Vietri, Francesco

2013-01-01

The association of colorectal cancer and abdominal aortic aneurysm (AAA) is infrequent but poses special problems of priority of treatment under elective circumstances. The purpose of this study was to retrospectively evaluate the outcome of 16 consecutive patients undergoing endovascular aneurysm repair (EVAR) followed by colectomy. Operative mortality was nil. Operative morbidity included two transient rise of serum creatinine level and one extraperitoneal anastomotic leakage which evolved favourably with conservative treatment. EVAR allowed a very short delay of treatment of colorectal cancer after aneurysm repair, minimizing operative complications.

Surgical and medical management of extracranial carotid artery aneurysms.

PubMed

Fankhauser, Grant T; Stone, William M; Fowl, Richard J; O'Donnell, Mark E; Bower, Thomas C; Meyer, Fredric B; Money, Samuel R

2015-02-01

Extracranial carotid artery aneurysms (ECCAs) are extremely rare with limited information about management options. Our purpose was to review our institution's experience with ECCAs during 15 years and to discuss the presentation and treatment of these aneurysms. A retrospective review of patients diagnosed with ECCAs from 1998 to 2012 was performed. Symptoms, risk factors, etiology, diagnostic methods, treatments, and outcomes were reviewed. During the study period, 141 aneurysms were diagnosed in 132 patients (mean age, 61 years; 69 men). There were 116 (82%) pseudoaneurysms and 25 (18%) true aneurysms; 69 (49%) aneurysms were asymptomatic, whereas 72 (52%) had symptoms (28 painless masses; 10 transient ischemic attacks; 10 vision symptoms; 9 ruptures; 8 strokes; 4 painful mass; 1 dysphagia; 1 tongue weakness; 1 bruit). Causes of true aneurysms included fibromuscular dysplasia in 15 patients, Ehlers-Danlos syndrome in three, Marfan syndrome in one, and uncharacterized connective tissue diseases in two. Of 25 true aneurysms, 11 (44%) were symptomatic; 15 (60%) true aneurysms underwent open surgical treatment, whereas 10 (40%) were managed nonoperatively. Postoperative complications included one stroke during a mean follow-up of 31 months (range, 0-166 months). No aneurysms managed nonoperatively required intervention during a mean follow-up of 77 months (range, 1-115 months). Of 116 pseudoaneurysms, 60 (52%) were symptomatic; 33 (29%) pseudoaneurysms underwent open surgery, 18 (15%) underwent endovascular intervention, and 65 (56%) were managed medically. Pseudoaneurysm after endarterectomy (28 patients; 24%) presented at a mean of 82 months from the surgical procedure. Mean follow-up for all aneurysms was 33.9 months. One (0.7%) aneurysm-related death occurred (rupture treated palliatively). No patient undergoing nonoperative management suffered death or major morbidity related to the aneurysm. Nonoperative management was more common in asymptomatic patients (71%) than in symptomatic patients (31%). ECCAs are uncommon and may be manifested with varying symptoms. All segments of the carotid artery are susceptible, although the internal is most commonly affected. Open surgical intervention was more common in patients with symptoms and with true aneurysms. Patients with pseudoaneurysms were more likely to undergo endovascular intervention. Nonoperative treatment is safe in selected patients. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Four-year trends in the treatment of cerebral aneurysms in Poland in 2009-2012.

PubMed

Tykocki, Tomasz; Kostyra, Kacper; Czyż, Marcin; Kostkiewicz, Bogusław

2014-05-01

The dilemma concerning the appropriate treatment of the intracranial aneurysms (IAs) has not yet been resolved and still remains under fierce debate. This study refers to the recent trends in the use of and outcomes related to coiling compared with clipping for unruptured and ruptured IAs in Poland over a 4-year period. The analysis refers to treatment of IAs performed in Poland between 2009-2012. Patients' records were cross-matched by ICD-9 codes for ruptured SAH (430) or unruptured cerebral aneurysm (437.3) along with codes for clipping (39.51) and coiling (39.79, 39.72, or 39.52). Multivariable logistic regression was used to compare in-hospital deaths, hospital length of stay (LOS), therapy allocation and aneurysm locations in unruptured vs. ruptured and clipped vs. coiled groups. Differences in the number of procedures between 16 administrative regions were standardized per 100,000 people. In 2009-2012, 11,051 procedures were identified, including 5,968 ruptured and 5,083 unruptured aneurysms. Overall increase was 2.3 % in clipping and 13.1 % in coiling; a significant trend was found in endovascular procedures (p = 0.044). Ruptured aneurysms were clipped more frequently (OR = 1.66;); in unruptured IAs, endovascular procedure was preferred 3.5 times more than clipping. The annual in-hospital mortality was 7.6 % in clipping and 6.7 % in endovascular treatment. LOS was two times longer after clipping in unruptured aneurysms (OR = 2.013). After the procedures were standardized per 100,000 people, the average for Poland was established as 9.09 in 2009, 10.86 in 2010, 10.55 in 2011, and 11.49 in 2012. This index had the highest values in Mazovia (12.9, 2009; 15.4, 2010; 17.4, 2011; 18.6, 2012. Data analysis revealed an increase in overall number of IAs treated in Poland between 2009-2012. A significant upward trend of endovascular procedures was found, whereas the number of clipped aneurysms remained relatively steady over the study period.

Intrasylvian/Intracerebral Hematomas Associated with Ruptured Middle Cerebral Artery Aneurysms: A Single-Center Series and Literature Review.

PubMed

Zhang, Yupeng; Hu, Quan; Xue, Hao; Zhang, Mingran; Shen, Jie; Deng, Lin; Liu, Qinglin; Li, Gang

2017-02-01

Ruptured middle cerebral artery (MCA) aneurysms usually lead to subarachnoid hemorrhage (SAH), and several cases have shown concomitant intrasylvian or intracerebral hematomas. The objective of this study was to compare the clinical and radiographic characteristics with their different outcomes. The charts of 30 consecutive patients with ruptured MCA aneurysm-related intracranial hematoma were retrospectively reviewed. These patients were dichotomized into an intrasylvian hematoma (ISH) group and an intracerebral hematoma (ICH) group by the presence of intrahematomal contrast-enhancing vessel; for patients under open surgery, hematoma type was further confirmed by intraoperative observation. The characteristics were compared between these 2 groups (ie, age, gender, history of hypertension, history of smoking, systolic pressure at admission, hematoma volume, size and side of aneurysms, the angle between the pointing direction of the aneurysm and the MCA trunk [denoted as α], middle line shifting, treatment modality, and outcome). All the angles are measured in the anterior-posterior projection. In our series, only hematoma volume, the angle α, and the middle line shift showed statistical significance regarding prognosis between 2 hematoma groups. An angle α between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range indicates ICH. In our series, patients in the ICH group had a larger hematoma volume compared with the ISH patients (33.3 ± 17.6 vs. 11.5 ± 10.5; P = 0.002). There exists no statistical difference regarding prognosis between these 2 groups, even although there is a trend toward worse recovery for patients in the ISH group (Glasgow Outcome Scale score, 3.0 ± 1.3 vs. 3.8 ± 1.9; P = 0.07). In our series, the prognosis of patients with ICH was worse than that of patients with ISH. Early discrimination of these 2 types of hematoma helps to predict future outcome; an angle (between the pointing direction of aneurysm and the MCA trunk) between 109.0°and 216.0° is associated with ISH, whereas aneurysm with an angle beyond this range suggests ICH. Copyright © 2016 Elsevier Inc. All rights reserved.

Mechanical properties and fibrin characteristics of endovascular coil–clot complexes: relevance to endovascular cerebral aneurysm repair paradigms

PubMed Central

Haworth, Kevin J; Weidner, Christopher R; Abruzzo, Todd A; Shearn, Jason T; Holland, Christy K

2015-01-01

Background Although coil embolization is known to prevent rebleeding from acutely ruptured cerebral aneurysms, the underlying biological and mechanical mechanisms have not been characterized. We sought to determine if microcoil-dependent interactions with thrombus induce structural and mechanical changes in the adjacent fibrin network. Such changes could play an important role in the prevention of aneurysm rebleeding. Methods The stiffness of in vitro human blood clots and coil–clot complexes implanted into aneurysm phantoms were measured immediately after formation and after retraction for 3 days using unconfined uniaxial compression assays. Scanning electron microscopy of the coil–clot complexes showed the effect of coiling on clot structure. Results The coil packing densities achieved were in the range of clinical practice. Bare platinum coils increased clot stiffness relative to clot alone (Young’s modulus 6.9 kPa and 0.83 kPa, respectively) but did not affect fibrin structure. Hydrogel-coated coils prevented formation of a clot and had no significant effect on clot stiffness (Young’s modulus 2 kPa) relative to clot alone. Clot age decreased fiber density by 0.2 fibers/µm2 but not the stiffness of the bare platinum coil–clot complex. Conclusions The stiffness of coil–clot complexes is related to the summative stiffness of the fibrin network and associated microcoils. Hydrogel-coated coils exhibit significantly less stiffness due to the mechanical properties of the hydrogel and the inhibition of fibrin network formation by the hydrogel. These findings have important implications for the design and engineering of aneurysm occlusion devices. PMID:24668257

Ruptured intracranial aneurysm in patients with osteogenesis imperfecta: 2 familial cases and a systematic review of the literature.

PubMed

Gaberel, T; Rochey, A; di Palma, C; Lucas, F; Touze, E; Emery, E

2016-12-01

Osteogenesis imperfecta is an inherited connective tissue disorder that causes bone fragility. Vascular complications have been described, but only few cases of ruptured intracranial aneurysm have been reported. We first described 2 familial cases of ruptured intracranial aneurysm and then conducted a systematic review of the literature. A mother and her daughter with a typical history of osteogenesis imperfecta presented with subarachnoid hemorrhage, which was related to a posterior communicating artery aneurysm in both cases. The mother had early rebleeding and died. The aneurysm was excluded by coiling in the daughter. Despite occurrence of hydrocephalus and delayed cerebral ischemia, she had an excellent functional outcome. A systematic review of the literature identified seven additional cases. None of the cases were in fact familial. All patients had a previous medical history of multiple fractures. Seven aneurysms were resolved, three by surgical clipping and four by endovascular procedure. No periprocedural complication was reported. One patient died prematurely and 6 experienced good functional outcome. We report the first familial cases of aneurysmal subarachnoid hemorrhage in osteogenesis imperfecta patients. Intracranial aneurysms are probably linked to a collagen pathology, which is at the origin of osteogenesis imperfecta. In cases of aneurysmal subarachnoid hemorrhage in an osteogenesis imperfecta family, intracranial aneurysm screenings in the relatives showing osteogenesis imperfecta should be considered. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Aneurysm in the brain

MedlinePlus

... ruptured: Clipping is done during open brain surgery (craniotomy) . Endovascular repair is most often done. It usually ... unit (ICU) Complete bed rest and activity restrictions Drainage of blood from the brain area (cerebral ventricular ...

Higher leukocyte count predicts 3-month poor outcome of ruptured cerebral aneurysms.

PubMed

Yao, Pei-Sen; Chen, Guo-Rong; Xie, Xue-Ling; Shang-Guan, Huang-Cheng; Gao, Jin-Zhen; Lin, Yuan-Xiang; Zheng, Shu-Fa; Lin, Zhang-Ya; Kang, De-Zhi

2018-04-11

It is not fully established whether leukocyte can predict the poor outcome for ruptured cerebral aneurysms (CA) or not. Here, we retrospectively analyzed the clinical data of 428 patients with ruptured CA between 2010 and 2015. Patients' demographic data, including gender, age, history of smoking, alcohol, hypertension, diabetes and hypercholesterolemia, Hunt-Hess and Fisher grade, occurrence of hydrocephalus, aneurysm location, time to surgery, delayed ischemic neurological deficit (DIND) and peak leukocyte of blood test from day 1 to 3 after aneurysmal rupture were recorded and analyzed. In the multivariable analysis model, gender, Fisher grade, time to surgery and hydrocephalus were not relevant to poor outcome. However, Hunt-Hess grade, DIND and preoperative leukocyte count (>13.84 × 10 9 /L) were significantly associated with adverse outcome. The respective increased risks were 5.2- (OR5.24, 95% CI 1.67-16.50, p = 0.005), 6.2-(OR 6.24, 95% CI 3.55-10.99, p < 0.001) and 10.9-fold (OR 9.35, 95% CI 5.98-19.97, p < 0.001). The study revealed that Hunt-Hess grade, DIND and preoperative leukocyte count (>13.84 × 10 9 /L) were independent risk factors for poor outcome of ruptured CA at 3 months. Higher leukocyte count is a convenient and useful marker to predict 3-month poor outcome for ruptured CA.

Does specialization improve outcome in abdominal aortic aneurysm surgery?

PubMed

Rosenthal, Rachel; von Känel, Oliver; Eugster, Thomas; Stierli, Peter; Gürke, Lorenz

2005-01-01

Specialization and high volume are reported to be related to a better outcome after abdominal aortic aneurysm repair. The aim of this study was to compare, in patients undergoing abdominal aortic aneurysm repair, the outcomes of those whose surgery was done by general surgeons with the outcomes of those whose surgery was done by specialist vascular surgeons. All patients undergoing abdominal aortic aneurysm repair at the Basel University Hospital (referral center) from January 1990 to December 2000 were included. Patients with endovascular treatment were excluded. Operations in group A (n = 189), between January 1990 and May 1995, were done by general surgeons. Operations in group B (n = 291), between June 1995 and December 2000, were done by vascular surgeons. In-hospital mortality and local and systemic complications were assessed. In-hospital mortality rates were significantly lower for group B (with specialist surgeons) than for group A, both overall (group B, 11.7%; group A, 21.7%; p = .003) and for emergency interventions (group B, 28.1%; group A, 41.9%; p = .042). The reduction in mortality for elective surgery in group B was not statistically significant (group B, 1.1%; group A, 4.9%; p = .054). There were significantly fewer pulmonary complications in group B compared with group A (p = .000). We conclude that in patients undergoing abdominal aortic aneurysm repair, those whose surgery is done by a specialized team have a significantly better outcome than those whose surgery is done by general surgeons.

The Woven EndoBridge (WEB) as primary treatment for unruptured intracranial aneurysms.

PubMed

van Rooij, Sanne Bt; van Rooij, Willem Jan; Peluso, Jo P; Sluzewski, Menno

2018-01-01

Purpose The intrasaccular flow disruptor Woven EndoBridge (WEB) device is developed for the treatment of wide-necked aneurysms without supportive devices. We used the WEB as primary treatment for unruptured aneurysms suitable for the device, regardless of neck size. Methods Between February 2015 and June 2017, 59 aneurysms in 51 patients were selectively treated with the WEB. There were 15 men and 36 women with a mean age of 59 years. Mean aneurysm size was 7.0 mm (range 3-22 mm). Of 59 aneurysms, 45 (76%) had a wide neck defined as ≥4 mm or dome-neck ratio ≤1.5. No stents or supporting balloons were used. Results Initial WEB position was judged good in all 59 unruptured aneurysms. One patient with a basilar tip aneurysm had a late thrombotic posterior cerebral artery occlusion by protrusion of the WEB over the artery. There were no procedural ruptures. Overall complication rate was 2.0% (1 of 51, 95% CI 0.01-11.3%). Imaging follow-up was available in 55 of 59 aneurysms (93%). At 3 months, 41 of 57 aneurysms (72%) were completely occluded, 12 (21%) had a neck remnant and 4 (7%) were incompletely occluded. Conclusion WEB treatment is safe and effective in selected unruptured aneurysms suitable for the device, regardless of neck size or location. There was no need for supportive devices. Three-quarters of all unruptured small aneurysms could be treated with the WEB. In our opinion, the WEB is a valuable alternative to coils, especially in wide-necked aneurysms.

Cerebral Taurine Levels are Associated with Brain Edema and Delayed Cerebral Infarction in Patients with Aneurysmal Subarachnoid Hemorrhage.

PubMed

Kofler, Mario; Schiefecker, Alois; Ferger, Boris; Beer, Ronny; Sohm, Florian; Broessner, Gregor; Hackl, Werner; Rhomberg, Paul; Lackner, Peter; Pfausler, Bettina; Thomé, Claudius; Schmutzhard, Erich; Helbok, Raimund

2015-12-01

Cerebral edema and delayed cerebral infarction (DCI) are common complications after aneurysmal subarachnoid hemorrhage (aSAH) and associated with poor functional outcome. Experimental data suggest that the amino acid taurine is released into the brain extracellular space secondary to cytotoxic edema and brain tissue hypoxia, and therefore may serve as a biomarker for secondary brain injury after aSAH. On the other hand, neuroprotective mechanisms of taurine treatment have been described in the experimental setting. We analyzed cerebral taurine levels using high-performance liquid chromatography in the brain extracellular fluid of 25 consecutive aSAH patients with multimodal neuromonitoring including cerebral microdialysis (CMD). Patient characteristics and clinical course were prospectively recorded. Associations with CMD-taurine levels were analyzed using generalized estimating equations with an autoregressive process to handle repeated observations within subjects. CMD-taurine levels were highest in the first days after aSAH (11.2 ± 3.2 µM/l) and significantly decreased over time (p < 0.001). Patients with brain edema on admission or during hospitalization (N = 20; 80 %) and patients developing DCI (N = 5; 20 %) had higher brain extracellular taurine levels compared to those without (Wald = 7.3, df = 1, p < 0.01; Wald = 10.1, df = 1, p = 0.001, respectively) even after adjusting for disease severity and CMD-probe location. There was no correlation between parenteral taurine supplementation and brain extracellular taurine (p = 0.6). Moreover, a significant correlation with brain extracellular glutamate (r = 0.82, p < 0.001), lactate (r = 0.56, p < 0.02), pyruvate (r = 0.39, p < 0.01), potassium (r = 0.37, p = 0.01), and lactate-to-pyruvate ratio (r = 0.24, p = 0.02) was found. Significantly higher CMD-taurine levels were found in patients with brain edema or DCI after aneurysmal subarachnoid hemorrhage. Its value as a potential biomarker deserves further investigation.

Adaptive grid generation in a patient-specific cerebral aneurysm

NASA Astrophysics Data System (ADS)

Hodis, Simona; Kallmes, David F.; Dragomir-Daescu, Dan

2013-11-01

Adapting grid density to flow behavior provides the advantage of increasing solution accuracy while decreasing the number of grid elements in the simulation domain, therefore reducing the computational time. One method for grid adaptation requires successive refinement of grid density based on observed solution behavior until the numerical errors between successive grids are negligible. However, such an approach is time consuming and it is often neglected by the researchers. We present a technique to calculate the grid size distribution of an adaptive grid for computational fluid dynamics (CFD) simulations in a complex cerebral aneurysm geometry based on the kinematic curvature and torsion calculated from the velocity field. The relationship between the kinematic characteristics of the flow and the element size of the adaptive grid leads to a mathematical equation to calculate the grid size in different regions of the flow. The adaptive grid density is obtained such that it captures the more complex details of the flow with locally smaller grid size, while less complex flow characteristics are calculated on locally larger grid size. The current study shows that kinematic curvature and torsion calculated from the velocity field in a cerebral aneurysm can be used to find the locations of complex flow where the computational grid needs to be refined in order to obtain an accurate solution. We found that the complexity of the flow can be adequately described by velocity and vorticity and the angle between the two vectors. For example, inside the aneurysm bleb, at the bifurcation, and at the major arterial turns the element size in the lumen needs to be less than 10% of the artery radius, while at the boundary layer, the element size should be smaller than 1% of the artery radius, for accurate results within a 0.5% relative approximation error. This technique of quantifying flow complexity and adaptive remeshing has the potential to improve results accuracy and reduce computational time for patient-specific hemodynamics simulations, which are used to help assess the likelihood of aneurysm rupture using CFD calculated flow patterns.

Increased Prevalence of Cerebrovascular Disease in Hospitalized Patients with Ehlers-Danlos Syndrome.

PubMed

Kim, Sarasa T; Cloft, Harry; Flemming, Kelly D; Kallmes, David F; Lanzino, Giuseppe; Brinjikji, Waleed

2017-08-01

Small studies have suggested that Ehlers-Danlos syndrome (EDS) is associated with a number of cerebrovascular complications. We sought to determine whether a clinical diagnosis of EDS is associated with a higher prevalence of cerebrovascular diseases than the general population by performing a case-control study of hospitalized patients in the Nationwide Inpatient Sample (NIS). Using the 2000-2012 NIS, we performed a case-control study matching cases of EDS to controls without such a diagnosis. The prevalence of various cerebrovascular diseases between the 2 groups was compared, and multivariate logistic regression was used to adjust for suspected comorbidities. Between 2000 and 2012, there were a total of 9067 discharges carrying a diagnosis of EDS. On univariate analysis, patients with EDS were more likely to be hospitalized for carotid dissection (.2% versus .01%, odds ratio [OR] = 18.0, confidence interval [CI] = 2.41-135.12, P < .0001), vertebral dissection (.1% versus 0%, P = .008), cervical artery aneurysm (.1% versus .01%, OR = 9.01, CI = 1.14-71.11, P < .0001), cerebral aneurysm (.4% versus .09%, OR = 4.89, CI = 2.28-10.47, P < .0001), and cerebrovascular malformation (.1% versus .02%, OR = 5, CI = 1.10-22.85, P = .021), compared to the controls. On multivariate analysis adjusted for age, race, and comorbidities, EDS patients had significantly higher odds of carotid dissection (OR = 15.02, CI = 3.08-270.87, P < .0001), vertebral dissection (OR = 2406539.5, P = .0037), cervical artery aneurysm (OR = 11.75, CI = 2.11-220.71, P = .0026), cerebral aneurysm (OR = 5.59, CI = 2.69-13.18, P < .0001), and cerebrovascular malformation (OR = 4.67, CI = 1.20-30.87, P = .0243). Carotid and vertebral dissections, cervical and cerebral aneurysms, as well as other cerebrovascular malformations are more common in hospitalized patients with EDS compared to controls. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Non-Newtonian blood flow dynamics in a right internal carotid artery with a saccular aneurysm

NASA Astrophysics Data System (ADS)

Valencia, Alvaro; Zarate, Alvaro; Galvez, Marcelo; Badilla, Lautaro

2006-02-01

Flow dynamics plays an important role in the pathogenesis and treatment of cerebral aneurysms. The temporal and spatial variations of wall shear stress in the aneurysm are hypothesized to be correlated with its growth and rupture. In addition, the assessment of the velocity field in the aneurysm dome and neck is important for the correct placement of endovascular coils. This work describes the flow dynamics in a patient-specific model of carotid artery with a saccular aneurysm under Newtonian and non-Newtonian fluid assumptions. The model was obtained from three-dimensional rotational angiography image data and blood flow dynamics was studied under physiologically representative waveform of inflow. The three-dimensional continuity and momentum equations for incompressible and unsteady laminar flow were solved with a commercial software using non-structured fine grid with 283 115 tetrahedral elements. The intra-aneurysmal flow shows complex vortex structure that change during one pulsatile cycle. The effect of the non-Newtonian properties of blood on the wall shear stress was important only in the arterial regions with high velocity gradients, on the aneurysmal wall the predictions with the Newtonian and non-Newtonian blood models were similar.

Endovascular treatment of AICA flow dependent aneurysms. A report of three cases and review of the literature.

PubMed

Mahmoud, M; El Serwi, A; Alaa Habib, M; Abou Gamrah, S

2012-12-01

Peripheral anterior inferior cerebellar artery (AICA) aneurysms are rare, accounting for less than 1% of all cerebral aneurysms. To our knowledge 34 flow-related cases including the present study have been reported in the literature. Three patients harbouring four flow dependent aneurysms were referred to our institution. Two patients presented with subarachnoid hemorrhage, one presented with cerebellar manifestations. They were all treated by endovascular embolization of the aneurysm as well as the parent artery using liquid embolic material. Two cases were embolized using NBCA, Onyx was used in the third case. No bleeding or rebleeding were encountered during the follow-up period which ranged from five to nine months. One patient developed facial palsy, cerebellar symptoms and sensorineural hearing loss. The remaining two cases did not develop any post treatment neurological complications. Endovascular management of flow-dependent AICA aneurysms by parent artery occlusion is feasible and efficient in terms of rebleeding prevention. Post embolization neurological complications are unpredictable. This depends upon the adequacy of collaterals from other cerebellar arteries.

Ticagrelor for Neuroendovascular Procedures: A Case Series.

PubMed

Davis, Kyle; Morrison, Christopher

2018-02-01

The development of thromboembolism is one of the most common complications of neuroendovascular procedures. Although several small studies have deemed clopidogrel safe and effective in the prevention of intracranial stent thrombosis, ticagrelor has yet to be assessed in this setting. The objective of this study was to retrospectively evaluate the safety and efficacy of ticagrelor in patients undergoing neuroendovascular procedures. A retrospective review of patients receiving ticagrelor following neuroendovascular aneurysm repair. A total of 5 patients undergoing neuroendovascular aneurysm repair received ticagrelor for a median of 5 days while hospitalized. Three patients were treated with stent-assisted coiling, while 2 received pipeline embolization devices. All patients received additional low-dose aspirin therapy. One patient received ticagrelor after experiencing a thrombotic event on clopidogrel, while a second patient was treated with ticagrelor after developing a dermatologic reaction to clopidogrel. Three (60%) patients were successfully treated and discharged on ticagrelor therapy. Two patients experienced cerebrovascular accidents following aneurysm repair while receiving ticagrelor, one of which was potentially due to medication omission. One (20%) patient receiving ticagrelor experienced a small retroperitoneal hematoma; however, ticagrelor therapy was continued without further complication. Therapy with ticagrelor may be a safe and effective treatment option for patients undergoing neuroendovascular aneurysm repair. However, future studies are warranted to substantiate these findings.

Flexible Ultrathin Endoscope Integrated with Irrigation Suction Apparatus for Assisting Microneurosurgery.

PubMed

Otani, Naoki; Morimoto, Yuji; Fujii, Kazuya; Toyooka, Terushige; Wada, Kojiro; Mori, Kentaro

2017-12-01

Endoscopy can observe the anatomical components in a deeply located and/or hidden area during neurosurgical procedures under the operating microscope. We have newly developed a flexible ultrathin endoscope integrated with irrigation suction apparatus (FUEISA) to visualize deeply located and/or hidden areas for assisting microneurosurgery. The present study investigated the usefulness of the FUEISA system for direct clipping surgery of cerebral aneurysms. Twenty-one patients underwent microneurosurgery assisted with the FUEISA system for direct clipping of cerebral aneurysms. The flexible ultrathin endoscope (outer diameter 0.75mm) consists of an image guide (6000 dpi) and a light guide, integrated with the irrigation suction apparatus. This endoscopic system was inserted before and after clipping to observe the anatomical conditions surrounding the lesions. In all cases, handling and operation of the FUEISA was technically successful during the surgical procedure. The ultrathin endoscope was adequately integrated with the irrigation suction apparatus in all cases. General anatomy visualization including the lenticulostriate arteries, medial striate arteries, and/or internal carotid artery perforators was possible, and the correct clip positioning and vessel conditions were easily checked. The endoscope revealed that the clip had been positioned incorrectly in one case. No complications associated with the endoscopic system occurred. The FUEISA system can be applied with safe manipulation, which was remarkably useful for confirmation of the presence of perforators and cranial nerves behind the lesions, particularly anatomical components located in deep and/or hidden areas during clipping of cerebral aneurysms. Copyright © 2017 Elsevier Inc. All rights reserved.

Brain interstitial fluid TNF-α after subarachnoid hemorrhage

PubMed Central

Hanafy, Khalid A.; Grobelny, Bartosz; Fernandez, Luis; Kurtz, Pedro; Connolly, ES; Mayer, Stephan A.; Schindler, Christian; Badjatia, Neeraj

2010-01-01

Objective: TNF-α is an inflammatory cytokine that plays a central role in promoting the cascade of events leading to an inflammatory response. Recent studies have suggested that TNF-α may play a key role in the formation and rupture of cerebral aneurysms, and that the underlying cerebral inflammatory response is a major determinate of outcome following subrarachnoid hemorrhage (SAH). Methods: We studied 14 comatose SAH patients who underwent multimodality neuromonitoring with intracranial pressure (ICP) and cerebral microdialysis as part of their clinical care. Continuous physiological variables were time-locked every 8 hours and recorded at the same point that brain interstitial fluid TNF-α was measured in brain microdialysis samples. Significant associations were determined using generalized estimation equations. Results: Each patient had a mean of 9 brain tissue TNF-α measurements obtained over an average of 72 hours of monitoring. TNF-α levels rose progressively over time. Predictors of elevated brain interstitial TNF-α included higher brain interstitial fluid glucose levels (β=0.066, P<0.02), intraventricular hemorrhage (β=0.085, P<0.021), and aneurysm size >6 mm (β=0.14, p<0.001). There was no relationship between TNF-α levels and the burden of cisternal SAH; concurrent measurements of serum glucose, or lactate-pyruvate ratio. Interpretation: Brain interstitial TNF-α levels are elevated after SAH, and are associated with large aneurysm size, the burden of intraventricular blood, and elevation brain interstitial glucose levels. PMID:20110094

Anti-fibrinolytic treatment in the pre-operative management of subarachnoid haemorrhage caused by ruptured intracranial aneurysm.

PubMed Central

Ameen, A A; Illingworth, R

1981-01-01

One hundred consecutive patients treated with epsilon aminocaproic acid 24 grams daily prior to surgery for ruptured intracranial aneurysms have been compared with the previous 100 patients managed similarly but without anti-fibrinolytic drugs. No other alterations in management were made and the two series are closely comparable in all other respects. Fewer episodes of recurrent haemorrhage and deaths from this cause occurred in the treated patients, but more cases of cerebral ischaemia occurred. Neither difference is statistically significant and overall more deaths occurred in the patients treated with antifibrinolytic drugs. The value of this method of treatment in the management of aneurysmal subarachnoid haemorrhage is questioned. PMID:7229645

Innovative Chimney-Graft Technique for Endovascular Repair of a Pararenal Abdominal Aortic Aneurysm

PubMed Central

Galiñanes, Edgar Luis; Hernandez-Vila, Eduardo A.

2015-01-01

After abdominal aortic aneurysm repair, progressive degeneration of the aneurysm can be challenging to treat. Multiple comorbidities and previous operations place such patients at high risk for repeat surgery. Endovascular repair is a possible alternative; however, challenging anatomy can push the limits of available technology. We describe the case of a 71-year-old man who presented with a 5.3-cm pararenal aneurysm 4 years after undergoing open abdominal aortic aneurysm repair. To avoid reoperation, we excluded the aneurysm by endovascular means, using visceral-artery stenting, a chimney-graft technique. Low-profile balloons on a monorail system enabled the rapid exchange of coronary wires via a buddy-wire technique. This novel approach facilitated stenting and simultaneous angioplasty of multiple visceral vessels and the abdominal aorta. PMID:25873796

Innovative chimney-graft technique for endovascular repair of a pararenal abdominal aortic aneurysm.

PubMed

Galiñanes, Edgar Luis; Hernandez-Vila, Eduardo A; Krajcer, Zvonimir

2015-02-01

After abdominal aortic aneurysm repair, progressive degeneration of the aneurysm can be challenging to treat. Multiple comorbidities and previous operations place such patients at high risk for repeat surgery. Endovascular repair is a possible alternative; however, challenging anatomy can push the limits of available technology. We describe the case of a 71-year-old man who presented with a 5.3-cm pararenal aneurysm 4 years after undergoing open abdominal aortic aneurysm repair. To avoid reoperation, we excluded the aneurysm by endovascular means, using visceral-artery stenting, a chimney-graft technique. Low-profile balloons on a monorail system enabled the rapid exchange of coronary wires via a buddy-wire technique. This novel approach facilitated stenting and simultaneous angioplasty of multiple visceral vessels and the abdominal aorta.

Size ratio performance in detecting cerebral aneurysm rupture status is insensitive to small vessel removal.

PubMed

Lauric, Alexandra; Baharoglu, Merih I; Malek, Adel M

2013-04-01

The variable definition of size ratio (SR) for sidewall (SW) vs bifurcation (BIF) aneurysms raises confusion for lesions harboring small branches, such as carotid ophthalmic or posterior communicating locations. These aneurysms are considered SW by many clinicians, but SR methodology classifies them as BIF. To evaluate the effect of ignoring small vessels and SW vs stringent BIF labeling on SR ruptured aneurysm detection performance in borderline aneurysms with small branches, and to reconcile SR-based labeling with clinical SW/BIF classification. Catheter rotational angiographic datasets of 134 consecutive aneurysms (60 ruptured) were automatically measured in 3-dimensional. Stringent BIF labeling was applied to clinically labeled aneurysms, with 21 aneurysms switching label from SW to BIF. Parent vessel size was evaluated both taking into account, and ignoring, small vessels. SR was defined accordingly as the ratio between aneurysm and parent vessel sizes. Univariate and multivariate statistics identified significant features. The square of the correlation coefficient (R(2)) was reported for bivariate analysis of alternative SR calculations. Regardless of SW/BIF labeling method, SR was equally significant in discriminating aneurysm ruptured status (P < .001). Bivariate analysis of alternative SR had a high correlation of R(2) = 0.94 on the whole dataset, and R = 0.98 on the 21 borderline aneurysms. Ignoring small branches from SR calculation maintains rupture status detection performance, while reducing postprocessing complexity and removing labeling ambiguity. Aneurysms adjacent to these vessels can be considered SW for morphometric analysis. It is reasonable to use the clinical SW/BIF labeling when using SR for rupture risk evaluation.

Delayed aneurysm rupture due to residual blood flow at the inflow zone of the intracranial paraclinoid internal carotid aneurysm treated with the Pipeline embolization device: Histopathological investigation

PubMed Central

Ikeda, Hiroyuki; Kikuchi, Takayuki; Ando, Mitsushige; Chihara, Hideo; Arai, Daisuke; Hattori, Etsuko; Miyamoto, Susumu

2015-01-01

Cerebral aneurysm rupture is a serious complication that can occur after flow diverter (FD) placement, but the underlying mechanisms remain unclear. We encountered a case in which direct stress on the aneurysm wall caused by residual blood flow at the inflow zone near the neck during the process of thrombosis after FD placement appeared associated with aneurysm rupture. The patient was a 67-year-old woman with progressive optic nerve compression symptoms caused by a large intracranial paraclinoid internal carotid aneurysm. The patient had undergone treatment with a Pipeline embolization device (PED) with satisfactory adherence between the PED and vessel wall. Surgery was completed without complications, and optic nerve compression symptoms improved immediately after treatment. Postoperative clinical course was satisfactory, but the patient suddenly died 34 days postoperatively. Autopsy confirmed the presence of subarachnoid hemorrhage caused by rupture of the internal carotid aneurysm that had been treated with PED. Although the majority of the aneurysm lumen including the outflow zone was thrombosed, a non-thrombosed area was observed at the inflow zone. Perforation was evident in the aneurysm wall at the inflow zone near the neck, and this particular area of aneurysm wall was not covered in thrombus. Macrophage infiltration was not seen on immunohistochemical studies of the aneurysm wall near the perforation. A hemodynamically unstable period during the process of complete thrombosis of the aneurysm lumen after FD placement may be suggested, and blood pressure management and appropriate management with antiplatelet therapy may be important. PMID:26500232

Lateral supraorbital approach to ipsilateral PCA-P1 and ICA-PCoA aneurysms.

PubMed

Goehre, Felix; Jahromi, Behnam Rezai; Elsharkawy, Ahmed; Lehto, Hanna; Shekhtman, Oleg; Andrade-Barazarte, Hugo; Munoz, Francisco; Hijazy, Ferzat; Makhkamov, Makhkam; Hernesniemi, Juha

2015-01-01

Aneurysms of the posterior cerebral artery (PCA) are rare and often associated with anterior circulation aneurysms. The lateral supraorbital approach allows for a very fast and safe approach to the ipsilateral lesions Circle of Willis. A technical note on the successful clip occlusion of two aneurysms in the anterior and posterior Circle of Willis via this less invasive approach has not been published before. The objective of this technical note is to describe the simultaneous microsurgical clip occlusion of an ipsilateral PCA-P1 and an internal carotid artery - posterior communicating artery (ICA-PCoA) aneurysm via the lateral supraorbital approach. The authors present a technical report of successful clip occlusions of ipsilateral located PCA-P1 and ICA-PCoA aneurysms. A 59-year-old female patient was diagnosed with a PCA-P1 and an ipsilateral ICA-PCoA aneurysm by computed tomography angiography (CTA) after an ischemic stroke secondary to a contralateral ICA dissection. The patient underwent microsurgical clipping after a lateral supraorbital craniotomy. The intraoperative indocyanine green (ICG) videoangiography and the postoperative CTA showed a complete occlusion of both aneurysms; the parent vessels (ICA and PCA) were patent. The patient presents postoperative no new neurologic deficit. The lateral supraorbital approach is suitable for the simultaneous microsurgical treatment of proximal anterior circulation and ipsilateral proximal PCA aneurysms. Compared to endovascular treatment, direct visual control of brainstem perforators is possible.

F2-isoprostanes and F4-neuroprostanes as markers of intracranial aneurysm development.

PubMed

Syta-Krzyżanowska, Anna; Jarocka-Karpowicz, Iwona; Kochanowicz, Jan; Turek, Grzegorz; Rutkowski, Robert; Gorbacz, Krzysztof; Mariak, Zenon; Skrzydlewska, Elżbieta

2018-04-24

Intracranial aneurysms are common, occurring in about 1-2% of the population. Saccular aneurysm is a pouch-like pathological dilatation of an intracranial artery that develops when the cerebral artery wall becomes too weak to resist hemodynamic pressure and distends. The aim of this study was to determine whether the development of intracranial aneurysms and subarachnoid hemorrhage (SAH) affects neuronal phospholipid metabolism, and what influence different invasive treatments have on brain free radical phospholipid metabolism. The level of polyunsaturated fatty acid (PUFA) cyclization products - F2-isoprostanes and F4-neuroprostanes - was examined using liquid chromatography - mass spectrometry (LC-MS) in the plasma of patients with brain aneurysm and resulting subarachnoid hemorrhage. It was revealed that an aneurysm leads to the enhancement of lipid peroxidation with a significant increase in plasma F2-isoprostanes and F4-neuroprostanes (more than 3-fold and 11-fold, respectively) in comparison to healthy subjects. The rupture of an aneurysm results in hemorrhage and an additional increase in examined prostaglandin derivatives. The embolization and clipping of aneurysms contribute to a gradual restoration of metabolic homeostasis in brain cells, which is visible in the decrease in PUFA cyclization products. The results indicate that aneurysm development is associated with enhanced inflammation and oxidative stress, factors which favor lipid peroxidation, particularly in neurons, whose membranes are rich in docosahexaenoic acid, a precursor of F4-neuroprostanes.

Effectiveness of diagnostic strategies in suspected delayed cerebral ischemia: a decision analysis.

PubMed

Rawal, Sapna; Barnett, Carolina; John-Baptiste, Ava; Thein, Hla-Hla; Krings, Timo; Rinkel, Gabriel J E

2015-01-01

Delayed cerebral ischemia (DCI) is a serious complication after aneurysmal subarachnoid hemorrhage. If DCI is suspected clinically, imaging methods designed to detect angiographic vasospasm or regional hypoperfusion are often used before instituting therapy. Uncertainty in the strength of the relationship between imaged vasospasm or perfusion deficits and DCI-related outcomes raises the question of whether imaging to select patients for therapy improves outcomes in clinical DCI. Decision analysis was performed using Markov models. Strategies were either to treat all patients immediately or to first undergo diagnostic testing by digital subtraction angiography or computed tomography angiography to assess for angiographic vasospasm, or computed tomography perfusion to assess for perfusion deficits. According to current practice guidelines, treatment consisted of induced hypertension. Outcomes were survival in terms of life-years and quality-adjusted life-years. When treatment was assumed to be ineffective in nonvasospasm patients, Treat All and digital subtraction angiography were equivalent strategies; when a moderate treatment effect was assumed in nonvasospasm patients, Treat All became the superior strategy. Treating all patients was also superior to selecting patients for treatment via computed tomography perfusion. One-way sensitivity analyses demonstrated that the models were robust; 2- and 3-way sensitivity analyses with variation of disease and treatment parameters reinforced dominance of the Treat All strategy. Imaging studies to test for the presence of angiographic vasospasm or perfusion deficits in patients with clinical DCI do not seem helpful in selecting which patients should undergo treatment and may not improve outcomes. Future directions include validating these results in prospective cohort studies. © 2014 American Heart Association, Inc.

Endovascular Treatments in Combination with Extracranial-Intracranial Bypass for Complex Intracranial Aneurysms.

PubMed

Sato, Kenichi; Endo, Hidenori; Fujimura, Miki; Endo, Toshiki; Matsumoto, Yasushi; Shimizu, Hiroaki; Tominaga, Teiji

2018-05-01

Although most intracranial aneurysms can be treated with microsurgery or endovascular procedure alone, a subset of aneurysms may require a combined approach. The purpose of this study was to assess the efficacy of endovascular interventions combined with bypass surgery for the treatment of complex intracranial aneurysms. We retrospectively reviewed medical records from a prospectively maintained patient database to identify patients who underwent endovascular treatment of an intracranial aneurysm at our institutes between 2007 and 2017. We recruited patients who received a preplanned combination of endovascular treatment and extracranial-intracranial bypass surgery. Forty-four patients (44 aneurysms) were treated with a combined approach. Twenty-four patients presented with subarachnoid hemorrhage. Treatment strategies included endovascular parent artery occlusion with the bypass surgery to restore cerebral blood flow (n = 12), endovascular trapping with bypass surgery to isolate incorporated branches (n = 12), and intra-aneurysmal coil embolization with bypass surgery to isolate incorporated branches (n = 20). During a mean period of 35.6 months, follow-up catheter angiography was performed in 35 of 44 patients (79.5%) and demonstrated complete aneurysm obliteration in 29 patients (82.9%) and bypass patency in 33 (94.3%). The postoperative aneurysm-related mortality and morbidity rates were 6.8% and 13.6%, respectively. Combined endovascular and surgical bypass procedures are useful for the treatment of complex intracranial aneurysms when conventional surgical or endovascular techniques are not feasible and show acceptable rates of morbidity and mortality. Copyright © 2018 Elsevier Inc. All rights reserved.

Temporary subclavian steal to reduce intraprocedural embolic risk during detachable balloon occlusion of vertebrobasilar aneurysms: technical note with two case reports.

PubMed

Eckard, D A; O'Boynick, P L; Han, P P

1996-11-01

Unintentional intracerebral embolization is a serious, ever present threat during neurointerventional procedures. We have devised a method to reduce this intraprocedural risk in vertebral artery interventions by creating a temporary subclavian steal. For this technique, a temporary balloon occlusion catheter is advanced into the proximal subclavian artery via a femoral artery approach, while a second introducer catheter is passed into the target vertebral artery via an axillary artery access. The temporary occluding balloon is then inflated within the proximal subclavian artery, establishing a subclavian steal that diverts blood flow into the arm. Permanent balloon occlusion of the vertebral artery can then be accomplished without fear of intracerebral embolization. Two patients with vertebrobasilar junction aneurysms were successfully treated with detachable balloon embolization using this cerebral protection technique. The permanent occlusion balloons were easily passed through the introducer catheter without difficulty despite reversed vertebral artery flow. No complications were encountered, and the aneurysms were successfully occluded in both patients. Temporary subclavian steal can be easily created to reduce the risk of cerebral embolic complications when performing interventional neuroradiological procedures in the vertebral artery.

Wall shear stress in intracranial aneurysms and adjacent arteries☆

PubMed Central

Wang, Fuyu; Xu, Bainan; Sun, Zhenghui; Wu, Chen; Zhang, Xiaojun

2013-01-01

Hemodynamic parameters play an important role in aneurysm formation and growth. However, it is difficult to directly observe a rapidly growing de novo aneurysm in a patient. To investigate possible associations between hemodynamic parameters and the formation and growth of intracranial aneurysms, the present study constructed a computational model of a case with an internal carotid artery aneurysm and an anterior communicating artery aneurysm, based on the CT angiography findings of a patient. To simulate the formation of the anterior communicating artery aneurysm and the growth of the internal carotid artery aneurysm, we then constructed a model that virtually removed the anterior communicating artery aneurysm, and a further two models that also progressively decreased the size of the internal carotid artery aneurysm. Computational simulations of the fluid dynamics of the four models were performed under pulsatile flow conditions, and wall shear stress was compared among the different models. In the three aneurysm growth models, increasing size of the aneurysm was associated with an increased area of low wall shear stress, a significant decrease in wall shear stress at the dome of the aneurysm, and a significant change in the wall shear stress of the parent artery. The wall shear stress of the anterior communicating artery remained low, and was significantly lower than the wall shear stress at the bifurcation of the internal carotid artery or the bifurcation of the middle cerebral artery. After formation of the anterior communicating artery aneurysm, the wall shear stress at the dome of the internal carotid artery aneurysm increased significantly, and the wall shear stress in the upstream arteries also changed significantly. These findings indicate that low wall shear stress may be associated with the initiation and growth of aneurysms, and that aneurysm formation and growth may influence hemodynamic parameters in the local and adjacent arteries. PMID:25206394

Alteration of intraaneurysmal hemodynamics by placement of a self-expandable stent. Laboratory investigation.

PubMed

Tateshima, Satoshi; Tanishita, Kazuo; Hakata, Yasuhiro; Tanoue, Shin-ya; Viñuela, Fernando

2009-07-01

Development of a flexible self-expanding stent system and stent-assisted coiling technique facilitates endovascular treatment of wide-necked brain aneurysms. The hemodynamic effect of self-expandable stent placement across the neck of a brain aneurysm has not been well documented in patient-specific aneurysm models. Three patient-specific silicone aneurysm models based on clinical images were used in this study. Model 1 was constructed from a wide-necked internal carotid artery-ophthalmic artery aneurysm, and Models 2 and 3 were constructed from small wide-necked middle cerebral artery aneurysms. Neuroform stents were placed in the in vitro aneurysm models, and flow structures were compared before and after the stent placements. Flow velocity fields were acquired with particle imaging velocimetry. In Model 1, a clockwise, single-vortex flow pattern was observed in the aneurysm dome before stenting was performed. There were multiple vortices, and a very small fast flow stream was newly formed in the aneurysm dome after stenting. The mean intraaneurysmal flow velocity was reduced by approximately 23-40%. In Model 2, there was a clockwise vortex flow in the aneurysm dome and another small counterclockwise vortex in the tip of the aneurysm dome before stenting. The small vortex area disappeared after stenting, and the mean flow velocity in the aneurysm dome was reduced by 43-64%. In Model 3, a large, counterclockwise, single vortex was seen in the aneurysm dome before stenting. Multiple small vortices appeared in the aneurysm dome after stenting, and the mean flow velocity became slower by 22-51%. The flexible self-expandable stents significantly altered flow velocity and also flow structure in these aneurysms. Overall flow alterations by the stent appeared favorable for the long-term durability of aneurysm embolization. The possibility that the placement of a low-profile self-expandable stent might induce unfavorable flow patterns such as a fast flow stream in the aneurysm dome cannot be excluded.

Endovascular treatment of bifurcation intracranial aneurysms with the WEB SL/SLS: 6-month clinical and angiographic results

PubMed Central

Bozzetto Ambrosi, Patricia; Sivan-Hoffmann, Rotem; Riva, Roberto; Signorelli, Francesco; Labeyrie, Paul-Emile; Eldesouky, Islam; Sadeh-Gonike, Udi; Armoiry, Xavier; Turjman, Francis

2015-01-01

Background The WEB device is a recent intrasaccular flow disruption technique developed for the treatment of wide-necked intracranial aneurysms. To date, a single report on the WEB Single-Layer (SL) treatment of intracranial aneurysms has been published with 1-months' safety results. The aim of this study is to report our experience and 6-month clinical and angiographic follow-up of endovascular treatment of wide-neck aneurysm with the WEB SL. Methods Ten patients with 10 unruptured wide-necked aneurysms were prospectively enrolled in this study. Feasibility, intraoperative and postoperative complications, and outcomes were recorded. Immediate and 6-month clinical and angiographic results were evaluated. Results Failure of WEB SL placement occurred in two cases. Eight aneurysms were successfully treated using one WEB SL without additional treatment. Three middle cerebral artery, four anterior communicating artery, and one basilar artery aneurysms were treated. Average dome width was 7.5 mm (range 5.4–10.7 mm), and average neck size was 4.9 mm (range 2.6–6.5 mm). No periprocedural complication was observed, and morbi-mortality at discharge and 6 months was 0.0%. Angiographic follow-up at 6 months demonstrated complete aneurysm occlusion in 2/8 aneurysms, neck remnant in 5/8 aneurysms, and aneurysm remnant in 1/8 aneurysm. Conclusions From this preliminary study, treatment of bifurcation intracranial aneurysms using WEB SL is feasible. WEB SL treatment seems safe at 6 months; however, the rate of neck remnants is not negligible due to compression of the WEB SL. Further technical improvements may be needed in order to ameliorate the occlusion in the WEB SL treatment. PMID:26111987

Protocol Based Real-Time Continuous Electroencephalography for Detecting Vasospasm in Subarachnoid Hemorrhage.

PubMed

Hong, Jeong-Ho; Bang, Jae Seung; Chung, Jin-Heon; Han, Moon-Ku

2016-03-01

A continuous electroencephalography (cEEG) can be helpful in detecting vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage (SAH). We describe a patient with an aneurysmal SAH whose symptomatic vasospasm was detected promptly by using a real-time cEEG. Patient was immediately treated by intraarterial vasodilator therapy. A 50-year-old woman without any significant medical history presented with a severe bifrontal headache due to acute SAH with a ruptured aneurysm on the anterior communicating artery (Fisher grade 3). On bleed day 6, she developed a sudden onset of global aphasia and left hemiparesis preceded by cEEG changes consistent with vasospasm. A stat chemical dilator therapy was performed and she recovered without significant neurological deficits. A real-time and protocol-based cEEG can be utilized in order to avoid any delay in detection of vasospasm in aneurysmal SAH and thereby improve clinical outcomes.

Does the gravity orientation of saccular aneurysms influence hemodynamics? An experimental study with and without flow diverter stent.

PubMed

Chodzyński, Kamil J; Eker, Omer F; Vanrossomme, Axel E; de Sousa, Daniel Ribeiro; Coussement, Grégory; Vanhamme, Luc; Dubois, Frank; Bonafé, Alain; Chopard, Bastien; Courbebaisse, Guy; Zouaoui Boudjeltia, Karim

2016-12-08

Most intracranial aneurysms morphologic studies focused on characterization of size, location, aspect ratio, relationship to the surrounding vasculature and hemodynamics. However, the spatial orientation with respect to the gravity direction has not been taken into account although it could trigger various hemodynamic conditions. The present work addresses this possibility. It was divided in two parts: 1) the orientations of 18, 3D time-of-flight MRI (3D TOF MRI), scans of saccular aneurysms were analyzed. This investigation suggested that there was no privileged orientation for cerebral aneurysms. The aneurysms were oriented in the brain as follows: 9 - down, 9 - up; 11 - right, 7 - left; 6 - front, 12 - back. 2) Based on these results, subsidiary in vitro experiments were performed, analyzing the behavior of red blood cells (RBCs) within a silicone model of aneurysm before and after flow diverter stent (FDS) deployment in the parent vessel. These experiments used a test bench that reproduces physiological pulsatile flow conditions for two orientations: an aneurysm sack pointing either up (opposite to gravitational force) and down (along the gravitational force). The results showed that the orientation of an aneurysm significantly affects the intra-aneurysmal RBCs behavior after stenting, and therefore that gravity can affect the intra-aneurysm behavior of RBCs. This suggests that the patient׳s aneurysm orientation could impact the outcome of the FDS treatment. The implementation of this effect in patient-specific numerical and preoperative decision support techniques could contribute to better understand the intrasaccular biological and hemodynamic events induced by FDS. Copyright © 2016 Elsevier Ltd. All rights reserved.

Gene expression profile of blood cells for the prediction of delayed cerebral ischemia after intracranial aneurysm rupture: a pilot study in humans.

PubMed

Baumann, Antoine; Devaux, Yvan; Audibert, Gérard; Zhang, Lu; Bracard, Serge; Colnat-Coulbois, Sophie; Klein, Olivier; Zannad, Faiez; Charpentier, Claire; Longrois, Dan; Mertes, Paul-Michel

2013-01-01

Delayed cerebral ischemia (DCI) is a potentially devastating complication after intracranial aneurysm rupture and its mechanisms remain poorly elucidated. Early identification of the patients prone to developing DCI after rupture may represent a major breakthrough in its prevention and treatment. The single gene approach of DCI has demonstrated interest in humans. We hypothesized that whole genome expression profile of blood cells may be useful for better comprehension and prediction of aneurysmal DCI. Over a 35-month period, 218 patients with aneurysm rupture were included in this study. DCI was defined as the occurrence of a new delayed neurological deficit occurring within 2 weeks after aneurysm rupture with evidence of ischemia either on perfusion-diffusion MRI, CT angiography or CT perfusion imaging, or with cerebral angiography. DCI patients were matched against controls based on 4 out of 5 criteria (age, sex, Fisher grade, aneurysm location and smoking status). Genome-wide expression analysis of blood cells obtained at admission was performed by microarrays. Transcriptomic analysis was performed using long oligonucleotide microarrays representing 25,000 genes. Quantitative PCR: 1 µg of total RNA extracted was reverse-transcribed, and the resulting cDNA was diluted 10-fold before performing quantitative PCR. Microarray data were first analyzed by 'Significance Analysis of Microarrays' software which includes the Benjamini correction for multiple testing. In a second step, microarray data fold change was compared using a two-tailed, paired t test. Analysis of receiver-operating characteristic (ROC) curves and the area under the ROC curves were used for prediction analysis. Logistic regression models were used to investigate the additive value of multiple biomarkers. A total of 16 patients demonstrated DCI. Significance Analysis of Microarrays software failed to retrieve significant genes, most probably because of the heterogeneity of the patients included in the microarray experiments and the small size of the DCI population sample. Standard two-tailed paired t test and C-statistic revealed significant associations between gene expression and the occurrence of DCI: in particular, the expression of neuroregulin 1 was 1.6-fold upregulated in patients with DCI (p = 0.01) and predicted DCI with an area under the ROC curve of 0.96. Logistic regression analyses revealed a significant association between neuroregulin 1 and DCI (odds ratio 1.46, 95% confidence interval 1.02-2.09, p = 0.02). This pilot study suggests that blood cells may be a reservoir of prognostic biomarkers of DCI in patients with intracranial aneurysm rupture. Despite an evident lack of power, this study elicited neuroregulin 1, a vasoreactivity-, inflammation- and angiogenesis-related gene, as a possible candidate predictor of DCI. Larger cohort studies are needed but genome-wide microarray-based studies are promising research tools for the understanding of DCI after intracranial aneurysm rupture. © 2013 S. Karger AG, Basel.

Sedation of Patients with Acute Aneurysmal Subarachnoid Hemorrhage with Ketamine Is Safe and Might Influence the Occurrence of Cerebral Infarctions Associated with Delayed Cerebral Ischemia.

PubMed

Von der Brelie, Christian; Seifert, Michael; Rot, Sergej; Tittel, Anja; Sanft, Carsten; Meier, Ullrich; Lemcke, Johannes

2017-01-01

Ketamine has neuroprotective characteristics as well as beneficial cardiocirculatory properties and may thus reduce vasopressor consumption. In contrast, sedation with ketamine (like any other sedative drug) has side effects. This study assesses the influence of ketamine on intracranial pressure (ICP), on the consumption of vasopressors in induced hypertension therapy, and on the occurrence of delayed cerebral ischemia (DCI)-associated cerebral infarctions, with particular focus on the complications of sedation in patients with aneurysmal subarachnoid hemorrhage (SAH). This is a retrospective, observational study. Sixty-five patients with SAH who underwent a period of sedation were included. The clinical course variables (Richmond Agitation and Sedation scale score, ICP values, consumption of vasopressors, complications of sedation, outcome, and other clinical parameters) were analyzed. Cranial computed tomography results were analyzed. Forty-one patients underwent sedation including ketamine (63.1%). Ketamine decreased the ICP in 92.7% of the cases. Vasopressors was reduced in 53.6%. DCI-associated cerebral infarctions occurred significantly less often in the patient cohort being treated with sedation including ketamine (7.3% vs. 25% in the nonketamine group; P = 0.04). The rate of major complications was not higher in the ketamine group. Outcome was not different regarding the groups if they were sedated with or without ketamine. Ketamine decreases the ICP and is not associated with a higher rate of complications. The rate of DCI-associated cerebral infarctions was lower in the ketamine group. Ketamine administration led to a reduction of vasopressors used for induced hypertension. Copyright © 2016 Elsevier Inc. All rights reserved.

Grid convergence errors in hemodynamic solution of patient-specific cerebral aneurysms.

PubMed

Hodis, Simona; Uthamaraj, Susheil; Smith, Andrea L; Dennis, Kendall D; Kallmes, David F; Dragomir-Daescu, Dan

2012-11-15

Computational fluid dynamics (CFD) has become a cutting-edge tool for investigating hemodynamic dysfunctions in the body. It has the potential to help physicians quantify in more detail the phenomena difficult to capture with in vivo imaging techniques. CFD simulations in anatomically realistic geometries pose challenges in generating accurate solutions due to the grid distortion that may occur when the grid is aligned with complex geometries. In addition, results obtained with computational methods should be trusted only after the solution has been verified on multiple high-quality grids. The objective of this study was to present a comprehensive solution verification of the intra-aneurysmal flow results obtained on different morphologies of patient-specific cerebral aneurysms. We chose five patient-specific brain aneurysm models with different dome morphologies and estimated the grid convergence errors for each model. The grid convergence errors were estimated with respect to an extrapolated solution based on the Richardson extrapolation method, which accounts for the degree of grid refinement. For four of the five models, calculated velocity, pressure, and wall shear stress values at six different spatial locations converged monotonically, with maximum uncertainty magnitudes ranging from 12% to 16% on the finest grids. Due to the geometric complexity of the fifth model, the grid convergence errors showed oscillatory behavior; therefore, each patient-specific model required its own grid convergence study to establish the accuracy of the analysis. Copyright © 2012 Elsevier Ltd. All rights reserved.

Spontaneous dissecting aneurysm of the left atrium complicated by cerebral embolism: A report of two cases with review of literature.

PubMed

Mohan, Jagdish C; Shukla, Madhu; Mohan, Vishwas; Sethi, Arvind

2016-09-01

Left atrial dissection is a very uncommon complication of cardiac surgery and usually causes significant hemodynamic compromise. Little is known about spontaneous dissection of the left atrium. Two patients, one middle-aged man and another elderly woman were evaluated following stroke. Routine trans-thoracic echocardiogram showed vertical division of the left atrium with both chambers communicating with each other through an orifice. Detailed trans-oesophageal echocardiographic study revealed dissection of the left atrium producing an additional false chamber (pseudo-aneurysm) placed posterior to the left atrial appendage and above the postero-lateral aspect of mitral annulus. Spontaneous dissection of the left atrium is extremely rare, and there is no report of cerebral embolism associated with it. Review of literature reveals interesting facets of this rare entity. Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Outcomes for Symptomatic Abdominal Aortic Aneurysms in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)

PubMed Central

Soden, Peter A.; Zettervall, Sara L.; Ultee, Klaas H.J.; Darling, Jeremy D.; Buck, Dominique B.; Hile, Chantel N.; Hamdan, Allen D.; Schermerhorn, Marc L.

2016-01-01

Introduction Historically symptomatic AAAs were found to have intermediate mortality compared to asymptomatic and ruptured AAAs but, with wider EVAR use, a more recent study suggested mortality of symptomatic aneurysms were similar to asymptomatic AAAs. These prior studies were limited by small numbers. The purpose of this study is to evaluate the mortality and morbidity associated with symptomatic AAA repair in a large contemporary population. Methods All patients undergoing infrarenal AAA repair were identified in the 2011–2013 ACS-NSQIP, Vascular Surgery targeted module. We excluded acute conversions to open repair and those for whom the surgical indication was embolization, dissection, thrombosis, or not documented. We compared 30-day mortality and major adverse events (MAE) for asymptomatic, symptomatic, and ruptured AAA repair, stratified by EVAR and open repair, with univariate analysis and multivariable logistic regression. Results 5502 infrarenal AAAs were identified, 4495 asymptomatic (830 open repair, 3665 [82%] EVAR), 455 symptomatic (143 open, 312 [69%] EVAR), and 552 ruptured aneurysms (263 open, 289 [52%] EVAR). Aneurysm diameter was similar between asymptomatic and symptomatic AAAs, when stratified by procedure type, but larger for ruptured aneurysms (EVAR symptomatic 5.8cm ±1.6 vs. ruptured 7.5cm ±2.0, P<.001; open repair symptomatic 6.4cm ±1.9 vs. ruptured 8.0cm ±1.9, P<.001). The proportion of females was similar in symptomatic and ruptured AAA (27% vs. 23%, P=.14, respectively), but lower in asymptomatic AAA (20%, P<.001). Symptomatic AAAs had intermediate 30-day mortality compared to asymptomatic and ruptured aneurysms after both EVAR (asymptomatic 1.4% vs. symptomatic 3.8%, P=.001; symptomatic vs. 22% ruptured, P<.001) and open repair (asymptomatic 4.3% vs. symptomatic 7.7% , P=.08; symptomatic vs. 57% ruptured, P<.001). After adjustment for age, gender, repair type, dialysis dependence, and history of severe COPD, patients undergoing repair of symptomatic AAAs were twice as likely to die within 30-days compared to those with asymptomatic aneurysms (OR 2.1, 95%CI 1.3–3.5). When stratified by repair type the effect size and direction of the odds ratios were similar (EVAR OR 2.4, CI 1.2–4.7; open repair OR 1.8, CI 0.86–3.9), although not significant for open repair. Patients with ruptured aneurysms had a sevenfold increased risk of 30-day mortality compared to symptomatic patients (OR 6.5, CI 4.1–10.6). Conclusion Patients with symptomatic AAAs had a two-fold increased risk of perioperative mortality, compared to asymptomatic aneurysms undergoing repair. Furthermore, patients with ruptured aneurysms have a seven-fold increased risk of mortality compared to symptomatic aneurysms. PMID:27146791

Retreatment of recanalized aneurysms after Y-stent-assisted coil embolization with double enterprise stents: case report and systematic review of the literature.

PubMed

Kono, Kenichi; Shintani, Aki; Terada, Tomoaki

2014-01-01

It is necessary to consider possibility of recanalization and retreatment after coil embolization for cerebral aneurysms. There is concern that retreatment for recanalized aneurysms after Y-stent-assisted coil embolization may be difficult because of double stents, especially in Y-stents with double closed-cell stents owing to narrowed structures. However, no detailed reports of retreatment after Y-stent have been reported. Between July 2010 and June 2013, we treated four aneurysms with Y-stent-assisted coil embolization using Enterprise closed-cell stents. Recanalization occurred in one case (25%), and retreatment was performed. We easily navigated a microcatheter into the target portions of the aneurysm through the Y-stent and occluded the aneurysm with coils. Additionally, by systematically searching in PubMed, we found 105 cases of Y-stent-assisted coil embolization using Enterprise stents or Neuroform stents with more than 6 months of follow-up. Among them, retreatment was performed in 10 cases (9.5%). There were no significant differences in retreatment rates among different stent combinations (P=0.91; Fisher's exact test). In conclusion, navigation of a microcatheter into the aneurysm through the Y-stent with double Enterprise stents was feasible, and retreatment rates after Y-stent-assisted coiling may not depend on stent combinations.

Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms.

PubMed

Elsharkawy, Ahmed; Niemelä, Mika; Lehečka, Martin; Lehto, Hanna; Jahromi, Behnam Rezai; Goehre, Felix; Kivisaari, Riku; Hernesniemi, Juha

2014-01-01

A wide sylvian opening, with either a proximal or distal start, has been standard for microsurgical management of middle cerebral artery (MCA) aneurysms. However, extensive sylvian dissection is potentially associated with increased incidence of iatrogenic injury to the brain and neurovascular structures. The aim of the present study was to describe the technique of focused opening of the sylvian fissure for microsurgical management of MCA aneurysms with additional tips on handling difficulties which may be encountered with this technique. A 3D image-based anatomic orientation, clipping field-focused surgical planning, slack brain, and high magnification are the basic requirements for this approach. A 10-15 mm sylvian opening is placed so that it allows safe access and a good surgical view of the MCA aneurysm clipping field. Under proximal control of the MCA, the aneurysm neck can be dissected and clipped effectively and safely, in this small surgical field. The presented technique has been developed and refined by the senior author during the surgery of 1,097 aneurysms over the last 13 years. It has proved to be safe, and effective for clipping of both ruptured and unruptured MCA aneurysms. Its greatest advantages are a shorter operative time and less brain and vessel manipulation compared to more extensive approaches. The focused sylvian opening is a less-invasive alternative to the classical wide sylvian opening for the microsurgical management of most MCA aneurysms.

The result of surgical treatment in patients with cerebral aneurysms in Maharaj Nakorn Chiang Mai Hospital: a report of 225 cases.

PubMed

Watcharasaksilp, Wanarak; Limpastan, Kriengsak; Norasathada, Tanya; Vaniyapong, Tanat

2013-07-01

Evaluate the result of intracranial aneurysm surgery in Maharaj Nakorn Chiang Mai Hospital. A retrospective study ofpatients who underwent surgery for intracranial aneurysms between 2003 and 2007. The patients'age, gender, signs and symptoms, CT brain findings, Subarachnoid hemorrhage (SAH), World Federation of Neurosurgical Society grading (WFNS), and aneurysm location were studied and correlated with outcome after surgery. Two hundred twenty five patients ofintracranial aneurysm were operated on between 2003 and 2007. Two hundred nine patients (92%) had anterior circulation aneurysms and 18 (8%) had posterior circulation aneurysms. The outcome, as evaluated by Glasgow Outcome Scale (GOS), showed good recovery and moderate disability patients (142, 62.9%) were classified as favorable outcome group whereas patients with severe disability, vegetative state, and dead (83, 36.9%) were classified as unfavorable outcome. According to WFNS grading, the patients with unruptured aneurysm and WFNS grade 1-2 had favorable outcome in 116 patients (78.37%) and unfavorable outcome in 32 patients (21.62%). Whereas the patients with WFNS grade 3-5 had favorable outcome in 32 patients (33.76%) and unfavorable outcome in 51 patients (66.23%). This study of 225 cases revealed 142 cases with favorable outcome and 83 cases with unfavorable outcome. Factors that affected the outcome were WFNS grading and age.

The study of flow diversion effects on aneurysm using multiple enterprise stents and two flow diverters

PubMed Central

Kojima, Masahiro; Irie, Keiko; Fukuda, Toshio; Arai, Fumihito; Hirose, Yuichi; Negoro, Makoto

2012-01-01

Background: Computer-based simulation is necessary to clarify the hemodynamics in brain aneurysm. Specifically for endovascular treatments, the effects of indwelling intravascular devices on blood stream need to be considered. The most recent technology used for cerebral aneurysm treatment is related to the use of flow diverters to reduce the amount of flow entering the aneurysm. To verify the differences of flow reduction, we analyzed multiple Enterprise stents and two kinds of flow diverters. Materials and Methods: In this research, we virtually modeled three kinds of commercial intracranial stents (Enterprise, Silk, and Pipeline) and mounted to fit into the vessel wall, and deployed across the neck of an IC-ophthalmic artery aneurysm. Also, we compared the differences among multiple Enterprise stents and two flow diverters in a standalone mode. Results: From the numerical results, the values of wall shear stress and pressure are reduced in proportion to the size of mesh, especially in the inflow area. However, the reduced velocity within the aneurysm sac by the multiple stents is not as significant as the flow diverters. Conclusions: This is the first study analyzing the flow alterations among multiple Enterprise stents and flow diverters. The placement of small meshed stents dramatically reduced the aneurysmal fluid movement. However, compared to the flow diverters, we did not observe the reduction of flow velocity within the aneurysm by the multiple stents. PMID:23559981

Postoperative Aortic Neck Dilation: Myth or Fact?

PubMed

Ribner, A S; Tassiopoulos, A K

2018-06-01

The abdominal aorta is the most common site of an aortic aneurysm. The visceral and most proximal infrarenal segment (aneurysm neck) are usually spared and considered more resistant to aneurysmal degeneration. However, if an abdominal aortic aneurysm (AAA) is left untreated, the natural history of the aortic neck is progressive dilatation and shortening. This may have significant implications for patients undergoing endovascular repair of AAAs (EVAR) as endograft stability and integrity of the repair are dependent on an intact proximal seal zone. Compromised seal zones, caused by progressive diameter enlargement and foreshortening of the aortic neck, may lead to distal endograft migration, type Ia endoleak, aortic sac repressurization, and, ultimately, aortic rupture.

Safety and efficacy of aneurysm treatment with WEB in the cumulative population of three prospective, multicenter series.

PubMed

Pierot, Laurent; Moret, Jacques; Barreau, Xavier; Szikora, Istvan; Herbreteau, Denis; Turjman, Francis; Holtmannspötter, Markus; Januel, Anne-Christine; Costalat, Vincent; Fiehler, Jens; Klisch, Joachim; Gauvrit, Jean-Yves; Weber, Werner; Desal, Hubert; Velasco, Stéphane; Liebig, Thomas; Stockx, Luc; Berkefeld, Joachim; Molyneux, Andrew; Byrne, James; Spelle, Laurent

2018-06-01

Flow disruption with the WEB is an innovative endovascular approach for treatment of wide-neck bifurcation aneurysms. Initial studies have shown a low complication rate with good efficacy. To report clinical and anatomical results of the WEB treatment in the cumulative population of three Good Clinical Practice (GCP) studies: WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm), French Observatory, and WEBCAST-2. WEBCAST, French Observatory, and WEBCAST-2 are single-arm, prospective, multicenter, GCP studies dedicated to the evaluation of WEB treatment. Clinical data were independently evaluated. Postoperative and 1-year aneurysm occlusion was independently evaluated using the 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant. The cumulative population comprised 168 patients with 169 aneurysms, including 112 female subjects (66.7%). The patients' ages ranged between 27 and 77 years (mean 55.5±10.2 years). Aneurysm locations were middle cerebral artery in 86/169 aneurysms (50.9%), anterior communicating artery in 36/169 (21.3%), basilar artery in 30/169 (17.8%), and internal carotid artery terminus in 17/169 (10.1%). The aneurysm was ruptured in 14/169 (8.3%). There was no mortality at 1 month and procedure/device-related morbidity was 1.2% (2/168). At 1 year, complete aneurysm occlusion was observed in 81/153 aneurysms (52.9%), neck remnant in 40/153 aneurysms (26.1%), and aneurysm remnant in 32/153 aneurysms (20.9%). Re-treatment was carried out in 6.9%. This series is at the moment the largest prospective, multicenter, GCP series of patients with aneurysms treated with WEB. It shows the high safety and good mid-term efficacy of this treatment. French Observatory: Unique identifier (NCT18069); WEBCAST and WEBCAST-2: Unique identifier (NCT01778322). © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Parametric Characterization of Flow Inside Cererbal Aneurysms Treated with Flow-Diverting Stents

NASA Astrophysics Data System (ADS)

Barbour, Michael; Levitt, Michael; Geindreau, Christian; Johnson, Luke; Chivukula, Keshav; Aliseda, Alberto

2017-11-01

Cerebral aneurysms are often treated with a flow-diverting stent (FDS) to reduce blood flow into the aneurysm sac, promoting the development of a stable thrombus. Successful treatment is highly dependent on the degree of flow reduction and the altered hemodynamics inside the aneurysm sac following treatment. Establishing a causal connection between hemodynamic metrics of FDS-treated CAs and long-term clinical outcomes requires a rigorous parametric characterization of this flow environment. We use 3D particle image velocimetry (PIV) to measure the flow inside idealized aneurysm models treated with FDS. Physiologically realistic Reynolds numbers and increasing levels of parent vessel curvature are analyzed to understand the effect of inertia on flow development. The flow velocity into the aneurysm and the topology of the flow inside the sac is shown to be highly dependent on parent vessel Dean number (De). The role of flow pulsatility is then added to the study via time-dependent waveforms. Velocity measurements at 2 values of parent vessel Womersley number (Wo) allow us to parameterize flow inside of CAs treated with FDS as a function of De, Re and Wo, improving the fundamental understanding of how FDS alter CA hemodynamics and aiding in the development of new treatments.

Lateral supraorbital approach to ipsilateral PCA-P1 and ICA-PCoA aneurysms

PubMed Central

Goehre, Felix; Jahromi, Behnam Rezai; Elsharkawy, Ahmed; Lehto, Hanna; Shekhtman, Oleg; Andrade-Barazarte, Hugo; Munoz, Francisco; Hijazy, Ferzat; Makhkamov, Makhkam; Hernesniemi, Juha

2015-01-01

Background: Aneurysms of the posterior cerebral artery (PCA) are rare and often associated with anterior circulation aneurysms. The lateral supraorbital approach allows for a very fast and safe approach to the ipsilateral lesions Circle of Willis. A technical note on the successful clip occlusion of two aneurysms in the anterior and posterior Circle of Willis via this less invasive approach has not been published before. The objective of this technical note is to describe the simultaneous microsurgical clip occlusion of an ipsilateral PCA-P1 and an internal carotid artery - posterior communicating artery (ICA-PCoA) aneurysm via the lateral supraorbital approach. Case Description: The authors present a technical report of successful clip occlusions of ipsilateral located PCA-P1 and ICA-PCoA aneurysms. A 59-year-old female patient was diagnosed with a PCA-P1 and an ipsilateral ICA-PCoA aneurysm by computed tomography angiography (CTA) after an ischemic stroke secondary to a contralateral ICA dissection. The patient underwent microsurgical clipping after a lateral supraorbital craniotomy. The intraoperative indocyanine green (ICG) videoangiography and the postoperative CTA showed a complete occlusion of both aneurysms; the parent vessels (ICA and PCA) were patent. The patient presents postoperative no new neurologic deficit. Conclusion: The lateral supraorbital approach is suitable for the simultaneous microsurgical treatment of proximal anterior circulation and ipsilateral proximal PCA aneurysms. Compared to endovascular treatment, direct visual control of brainstem perforators is possible. PMID:26060600

Microneurosurgical management of anterior choroid artery aneurysms.

PubMed

Lehecka, Martin; Dashti, Reza; Laakso, Aki; van Popta, Jouke S; Romani, Rossana; Navratil, Ondrej; Kivipelto, Leena; Kivisaari, Riku; Foroughi, Mansoor; Kokuzawa, Jouji; Lehto, Hanna; Niemelä, Mika; Rinne, Jaakko; Ronkainen, Antti; Koivisto, Timo; Jääskelainen, Juha E; Hernesniemi, Juha

2010-05-01

Anterior choroid artery aneurysms (AChAAs) constitute 2%-5% of all intracranial aneurysms. They are usually small, thin walled with one or several arteries originating at their base, and often associated with multiple aneurysms. In this article, we review the practical microsurgical anatomy, the preoperative imaging, surgical planning, and the microneurosurgical steps in the dissection and the clipping of AChAAs. This review, and the whole series on intracranial aneurysms (IAs), are mainly based on the personal microneurosurgical experience of the senior author (J.H.) in two Finnish centers (Helsinki and Kuopio) that serve, without patient selection, the catchment area in Southern and Eastern Finland. These two centers have treated more than 10,000 patients with IAs since 1951. In the Kuopio Cerebral Aneurysm Database of 3005 patients with 4253 IAs, 831 patients (28%) had altogether 980 internal carotid artery (ICA) aneurysms, of whom 95 patients had 99 (2%) AChAAs. Ruptured AChAAs, found in 39 patients (41%), with median size of 6 mm (range = 2-19 mm), were associated with intracerebral hematoma (ICH) in only 1 (3%) patient. Multiple aneurysms were seen in 58 (61%) patients. The main difficulty in microneurosurgical management of AChAAs is to preserve flow in the anterior choroid artery originating at the base and often attached to the aneurysm dome. This necessitates perfect surgical strategy based on preoperative knowledge of 3 dimensional angioarchitecture and proper orientation during the microsurgical dissection. Copyright © 2010 Elsevier Inc. All rights reserved.

True posterior communicating artery aneurysms: are they more prone to rupture? A biomorphometric analysis.

PubMed

He, Wenzhuan; Hauptman, Jason; Pasupuleti, Latha; Setton, Avi; Farrow, Maria G; Kasper, Lydia; Karimi, Reza; Gandhi, Chirag D; Catrambone, Jeffrey E; Prestigiacomo, Charles J

2010-03-01

Posterior communicating artery (PCoA) aneurysms can occur at the junction with the internal carotid artery, posterior cerebral artery (PCA), or the proximal PCoA itself. Hemodynamic stressors contribute to aneurysm formation and may be associated with parent vessel size and aneurysm location. This study evaluates the correlation of various biomorphometric characteristics in 2 of the aforementioned types of PCoA aneurysms. Patients with PCoA aneurysms were analyzed using CT angiography. Source images and reconstructions were used to determine which aneurysms originated purely from the PCoA and those that originated from the internal carotid artery/PCoA junction. Morphometric analysis was performed on the aneurysm, the precommunicating segment of the PCA (P(1)), the ambient segment of the PCA (P(2)), and both PCoA arteries and were correlated to clinical presentation. Parametric and nonparametric analyses were performed to test for significance. A total of 77 PCoA aneurysms were analyzed, and 10 were found to be true PCoA aneurysms (13.0%). The ipsilateral PCoA/P(1) ratio (1.77 +/- 0.44 vs 0.82 +/- 0.46, p = 0.0001) and ipsilateral P(2)/P(1) ratio (1.73 +/- 0.40 vs 1.22 +/- 0.41, p = 0.0003) were significantly larger in true PCoA aneurysms. Interestingly, aneurysm size was statistically larger in the junctional aneurysms (0.14 +/- 0.1 vs 0.072 +/- 0.04 cm(3), p = 0.03). The prevalence of ruptured aneurysms was similar in both groups (approximately 80%, p value not significant). These data suggest that true PCoA aneurysms have a larger PCoA relative to the ipsilateral P(1) segment. To the authors' knowledge, this represents the first such biomorphometric comparison of these different types of PCoA aneurysms. Although statistically smaller in size, true PCoA aneurysms also have a similar prevalence of presenting as a ruptured aneurysm, suggesting that they might be more prone to rupture than a junctional aneurysms of similar size. Further analysis will be required to determine the biophysical factors affecting rupture rates.

A primitive study of voxel feature generation by multiple stacked denoising autoencoders for detecting cerebral aneurysms on MRA

NASA Astrophysics Data System (ADS)

Nemoto, Mitsutaka; Hayashi, Naoto; Hanaoka, Shouhei; Nomura, Yukihiro; Miki, Soichiro; Yoshikawa, Takeharu; Ohtomo, Kuni

2016-03-01

The purpose of this study is to evaluate the feasibility of a novel feature generation, which is based on multiple deep neural networks (DNNs) with boosting, for computer-assisted detection (CADe). It is hard and time-consuming to optimize the hyperparameters for DNNs such as stacked denoising autoencoder (SdA). The proposed method allows using SdA based features without the burden of the hyperparameter setting. The proposed method was evaluated by an application for detecting cerebral aneurysms on magnetic resonance angiogram (MRA). A baseline CADe process included four components; scaling, candidate area limitation, candidate detection, and candidate classification. Proposed feature generation method was applied to extract the optimal features for candidate classification. Proposed method only required setting range of the hyperparameters for SdA. The optimal feature set was selected from a large quantity of SdA based features by multiple SdAs, each of which was trained using different hyperparameter set. The feature selection was operated through ada-boost ensemble learning method. Training of the baseline CADe process and proposed feature generation were operated with 200 MRA cases, and the evaluation was performed with 100 MRA cases. Proposed method successfully provided SdA based features just setting the range of some hyperparameters for SdA. The CADe process by using both previous voxel features and SdA based features had the best performance with 0.838 of an area under ROC curve and 0.312 of ANODE score. The results showed that proposed method was effective in the application for detecting cerebral aneurysms on MRA.

Experimental validation of numerical simulations on a cerebral aneurysm phantom model

PubMed Central

Seshadhri, Santhosh; Janiga, Gábor; Skalej, Martin; Thévenin, Dominique

2012-01-01

The treatment of cerebral aneurysms, found in roughly 5% of the population and associated in case of rupture to a high mortality rate, is a major challenge for neurosurgery and neuroradiology due to the complexity of the intervention and to the resulting, high hazard ratio. Improvements are possible but require a better understanding of the associated, unsteady blood flow patterns in complex 3D geometries. It would be very useful to carry out such studies using suitable numerical models, if it is proven that they reproduce accurately enough the real conditions. This validation step is classically based on comparisons with measured data. Since in vivo measurements are extremely difficult and therefore of limited accuracy, complementary model-based investigations considering realistic configurations are essential. In the present study, simulations based on computational fluid dynamics (CFD) have been compared with in situ, laser-Doppler velocimetry (LDV) measurements in the phantom model of a cerebral aneurysm. The employed 1:1 model is made from transparent silicone. A liquid mixture composed of water, glycerin, xanthan gum and sodium chloride has been specifically adapted for the present investigation. It shows physical flow properties similar to real blood and leads to a refraction index perfectly matched to that of the silicone model, allowing accurate optical measurements of the flow velocity. For both experiments and simulations, complex pulsatile flow waveforms and flow rates were accounted for. This finally allows a direct, quantitative comparison between measurements and simulations. In this manner, the accuracy of the employed computational model can be checked. PMID:24265876

Majewski osteodysplastic primordial dwarfism type II (MOPD II): expanding the vascular phenotype.

PubMed

Bober, Michael B; Khan, Nadia; Kaplan, Jennifer; Lewis, Kristi; Feinstein, Jeffrey A; Scott, Charles I; Steinberg, Gary K

2010-04-01

Majewski Osteodysplastic Primordial Dwarfism, Type II (MOPD II) is a rare, autosomal recessive disorder. Features include severe intrauterine growth retardation (IUGR), poor postnatal growth (adult stature approximately 100 cm), severe microcephaly, skeletal dysplasia, characteristic facial features, and normal or near normal intelligence. An Institutional Review Board (IRB) approved registry was created and currently follows 25 patients with a diagnosis of MOPD II. Based on previous studies, a neurovascular screening program was implemented and 13 (52%) of these patients have been found to have cerebral neurovascular abnormalities including moyamoya angiopathy and/or intracranial aneurysms. The typical moyamoya pathogenesis begins with vessel narrowing in the supraclinoid internal carotid artery, anterior cerebral (A1) or middle cerebral (M1) artery segments. The narrowing may predominate initially on one side, progresses to bilateral stenosis, with subsequent occlusion of the vessels and collateral formation. We present four patients who, on neurovascular screening, were found to have cerebrovascular changes. Two were asymptomatic, one presented with a severe headache and projectile vomiting related to a ruptured aneurysm, and one presented after an apparent decline in cognitive functioning. Analysis of the registry suggests screening for moyamoya disease be performed at the time of MOPD II diagnosis and at least every 12-18 months using MRA or computerized tomographic angiography (CTA). We believe this is imperative. If diagnosed early enough, re-vascularization and aneurysm treatment in skilled hands can be performed safely and prevent or minimize long-term sequelae in this population. Emergent evaluation is also needed when other neurologic or cardiac symptoms are present. (c) 2010 Wiley-Liss, Inc.

Advances in open microsurgery for cerebral aneurysms.

PubMed

Davies, Jason M; Lawton, Michael T

2014-02-01

Endovascular techniques introduced strong extrinsic forces that provoked reactive changes in aneurysm surgery. Microsurgery has become less invasive, more appealing to patients, lower risk, and efficacious for complex aneurysms, particularly those unfavorable for or failing endovascular therapy. To review specific advances in open microsurgery for aneurysms. A university-based, single-surgeon practice was examined for the use of minimally invasive craniotomies, surgical management of recurrence after coiling, the use of intracranial-intracranial bypass techniques, and cerebrovascular volume-outcome relationships. The mini-pterional, lateral supraorbital, and orbital-pterional craniotomies are minimally invasive alternatives to standard craniotomies. Mini-pterional and lateral supraorbital craniotomies were used in one-fourth of unruptured patients, increasing from 22% to 28%, whereas 15% of patients underwent orbital-pterional craniotomies and trended upward from 11% to 20%. Seventy-four patients were treated for coil recurrences (2.3% of all aneurysms) with direct clip occlusion (77%), clip occlusion after coil extraction (7%), or parent artery occlusion with bypass (16%). Intracranial-intracranial bypass (in situ bypass, reimplantation, reanastomosis, and intracranial grafts) transformed the management of giant aneurysms and made the surgical treatment of posterior inferior cerebellar artery aneurysms competitive with endovascular therapy. Centralization maximized the volume-outcome relationships observed with clipping. Aneurysm microsurgery has embraced minimalism, tailoring the exposure to the patient's anatomy with the smallest possible craniotomy that provides adequate exposure. The development of intracranial-intracranial bypasses is an important advancement that makes microsurgery a competitive option for complex and recurrent aneurysms. Trends toward centralizing aneurysm surgery in tertiary centers optimize results achievable with open microsurgery.

Influence of hemodynamic factors on rupture of intracranial aneurysms: patient-specific 3D mirror aneurysms model computational fluid dynamics simulation.

PubMed

Lu, G; Huang, L; Zhang, X L; Wang, S Z; Hong, Y; Hu, Z; Geng, D Y

2011-08-01

Hemodynamics factors play an important role in the rupture of cerebral aneurysms. The purpose of this study was to evaluate the impact of hemodynamic factors on the rupture of the MANs with 3D reconstruction model CFD simulation. RDSA was performed in 9 pairs of intracranial MANs. Each pair was divided into ruptured and unruptured groups. The hemodynamic factors of the aneurysms and their parent arteries were compared. There was a significant difference in the WSS at peak systole between the regions of the aneurysms and their parent arteries in the ruptured group (ie, 6.49 ± 3.48 Pa versus 8.78 ± 3.57 Pa, P =.015) but not in the unruptured group (ie, 9.80 ± 4.12 Pa versus 10.17 ± 7.48 Pa, P =.678). The proportion of the low WSS area to the whole area of the aneurysms was 12.20 ± 18.08% in the ruptured group and 3.96 ± 6.91% in the unruptured group; the difference between the 2 groups was statistically significant (P =.015). The OSI was 0.0879 ± 0.0764 in the ruptured group, which was significantly higher than that of the unruptured group (ie, 0.0183 ± 0.0191, P =.008). MANs may be a useful disease model to investigate possible causes linked to ruptured aneurysms. The ruptured aneurysms manifested lower WSS compared with their parent arteries, a higher proportion of the low WSS area to the whole area of aneurysm, and higher OSI compared with the unruptured aneurysms.

Endovascular Treatment of Cerebral Aneurysms in Relation to Their Parent Artery Wall: A Single Center Study

PubMed Central

Mitsos, A.P.; Giannakopoulou, M.D.; Kaklamanos, I.G.; Kapritsou, M.; Konstantinou, M.I.; Fotis, T.; Mamoura, K.V.; Mariolis-Sapsakos, T.; Ntountas, I.T.; Konstantinou, E.A.

2013-01-01

We report our two-year experience in the endovascular treatment of brain aneurysms in relation to their parent artery wall. We prospectively recorded patients with intracranial aneurysms (107 ruptured - 38 unruptured) treated with coiling during a two-year period: 145 patients, 94 females and 51 males - mean age 56 years. The aneurysms were divided into side-wall (A) and bifurcation (B) groups. A total occlusion rate was noted in post-embolization angiograms in 101 aneurysms (70%) with a morbidity of 4%. No angiographic recurrence arose in the six-month follow-up. The two groups had a similar total occlusion rate (68.31% and 71.8% respectively), while the complication rate was 3% in group A and 4.7% in group B. Significant differences between the two groups were noted in the number of assisted coiling cases: 28 out of 60 cases (46.7%) in group A - 14 out of 85 cases (16.5%) in group B. Further statistical analysis showed strong dependencies for the type of endovascular procedure between the ruptured and unruptured aneurysms in both groups (p 0.000<0.05), but no dependencies between the aneurysm occlusion rate and the ruptured or non-ruptured aneurysms, or between the occlusion rate and the type of endovascular procedure (p 0.552 >0.05 and 0.071 >0.05 respectively). In conclusion, the anatomic relation of the aneurysm sac with the wall of the parent artery is important, as significant differences in endovascular practice, devices and techniques were noted between side-wall and bifurcation aneurysms. PMID:23859171

Unraveling the relationship between arterial flow and intra-aneurysmal hemodynamics.

PubMed

Morales, Hernán G; Bonnefous, Odile

2015-02-26

Arterial flow rate affects intra-aneurysmal hemodynamics but it is not clear how their relationship is. This uncertainty hinders the comparison among studies, including clinical evaluations, like a pre- and post-treatment status, since arterial flow rates may differ at each time acquisition. The purposes of this work are as follows: (1) To study how intra-aneurysmal hemodynamics changes within the full physiological range of arterial flow rates. (2) To provide characteristic curves of intra-aneurysmal velocity, wall shear stress (WSS) and pressure as functions of the arterial flow rate. Fifteen image-based aneurysm models were studied using computational fluid dynamics (CFD) simulations. The full range of physiological arterial flow rates reported in the literature was covered by 11 pulsatile simulations. For each aneurysm, the spatiotemporal-averaged blood flow velocity, WSS and pressure were calculated. Spatiotemporal-averaged velocity inside the aneurysm linearly increases as a function of the mean arterial flow (minimum R(2)>0.963). Spatiotemporal-averaged WSS and pressure at the aneurysm wall can be represented by quadratic functions of the arterial flow rate (minimum R(2)>0.996). Quantitative characterizations of spatiotemporal-averaged velocity, WSS and pressure inside cerebral aneurysms can be obtained with respect to the arterial flow rate. These characteristic curves provide more information of the relationship between arterial flow and aneurysm hemodynamics since the full range of arterial flow rates is considered. Having these curves, it is possible to compare experimental studies and clinical evaluations when different flow conditions are used. Copyright © 2015 Elsevier Ltd. All rights reserved.

Stent-assisted coil embolization of aneurysms with small parent vessels: safety and efficacy analysis.

PubMed

Kühn, Anna Luisa; Hou, Samuel Y; Puri, Ajit S; Silva, Christine F; Gounis, Matthew J; Wakhloo, Ajay K

2016-06-01

Stent-assisted coil embolization (SACE) is a viable therapeutic approach for wide-neck intracranial aneurysms. However, it can be technically challenging in small cerebral vessels (≤2 mm). To present our experience with stents approved for SACE in aneurysms with small parent arteries. All patients who underwent stent-assisted aneurysm treatment with either a Neuroform or an Enterprise stent device at our institution between June 2006 and October 2012 were identified. Additionally, we evaluated each patient's vascular risk factors, aneurysm characteristics (ruptured vs non-ruptured, incidental finding, recanalized) and follow-up angiography data. A total of 41 patients with 44 aneurysms met our criteria, including 31 women and 10 men. Most of the aneurysms were located in the anterior circulation (75%). Stent placement in vessels 1.2-2 mm in diameter was successful in 93.2%. Thromboembolic complications occurred in 6 cases and vessel straightening was seen in 1 case only. Initial nearly complete to complete aneurysm obliteration was achieved in 88.6%. Six-month follow-up angiography showed coil compaction in three cases, one asymptomatic in-stent stenosis and stent occlusion. Twelve to 20-months' follow-up showed stable coil compaction in two patients compared with previous follow-up, and aneurysm recanalization in two patients. Twenty-four to 36-months' follow-up showed further coil compaction in one of these patients and aneurysm recanalization in a previous case of stable coil compaction on mid-term follow-up. Our results suggest that SACE of aneurysms with small parent vessels is feasible in selected cases and shows good long-term patency rates of parent arteries. 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/

Predictors of Recurrence, Progression, and Retreatment in Basilar Tip Aneurysms: A Location-Controlled Analysis.

PubMed

Abecassis, Isaac Josh; Sen, Rajeev D; Barber, Jason; Shetty, Rakshith; Kelly, Cory M; Ghodke, Basavaraj V; Hallam, Danial K; Levitt, Michael R; Kim, Louis J; Sekhar, Laligam N

2018-06-14

Endovascular treatment of intracranial aneurysms is associated with higher rates of recurrence and retreatment, though contemporary rates and risk factors for basilar tip aneurysms (BTAs) are less well-described. To characterize progression, retreatement, and retreated progression of BTAs treated with microsurgical or endovascular interventions. We retrospectively reviewed records for 141 consecutive BTA patients. We included 158 anterior communicating artery (ACoA) and 118 middle cerebral artery (MCA) aneurysms as controls. Univariate and multivariate analyses were used to calculate rates of progression (recurrence of previously obliterated aneurysms and progression of known residual aneurysm dome or neck), retreatment, and retreated progression. Kaplan-Meier analysis was used to characterize 24-mo event rates for primary outcome prediction. Of 141 BTA patients, 62.4% were ruptured and 37.6% were unruptured. Average radiographical follow-up was 33 mo. Among ruptured aneurysms treated with clipping, there were 2 rehemorrhages due to recurrence (6.1%), and none in any other cohorts. Overall rates of progression (28.9%), retreatment (28.9%), and retreated progression (24.7%) were not significantly different between surgical and endovascular subgroups, though ruptured aneurysms had higher event rates. Multivariate modeling confirmed rupture status (P = .003, hazard ratio = 0.14) and aneurysm dome width (P = .005, hazard ratio = 1.23) as independent predictors of progression requiring retreatment. In a separate multivariate analysis with ACoA and MCA aneurysms, basilar tip location was an independent predictor of progression, retreatment, and retreated progression. BTAs have higher rates of progression and retreated progression than other aneurysm locations, independent of treatment modality. Rupture status and dome width are risk factors for progression requiring retreatment.

Characteristics of intracranial aneurysms in the else kröner-fresenius registry of autosomal dominant polycystic kidney disease.

PubMed

Neumann, Hartmut P H; Malinoc, Angelica; Bacher, Janina; Nabulsi, Zinaida; Ivanovas, Vera; Bruechle, Nadine Ortiz; Mader, Irina; Hoffmann, Michael M; Riegler, Peter; Kraemer-Guth, Annette; Burchardi, Christian; Schaeffner, Elke; Martin, Rodolfo S; Azurmendi, Pablo J; Zerres, Klaus; Jilg, Cordula; Eng, Charis; Gläsker, Sven

2012-01-01

Patients who harbor intracranial aneurysms (IAs) run a risk for aneurysm rupture and subsequent subarachnoid hemorrhage which frequently results in permanent deficits or death. Prophylactic treatment of unruptured aneurysms is possible and recommended depending on the size and location of the aneurysm as well as patient age and condition. IAs are major manifestations of autosomal dominant polycystic kidney disease (ADPKD). Current guidelines do not suggest surveillance of IAs in ADPKD except in the setting of family history if IA was known in any relative with ADPKD. Management of IAs in ADPKD is problematic because limited data exist from large studies. We established the Else Kröner-Fresenius Registry for ADPKD in Germany. Clinical data were assessed for age at diagnosis of IAs, stage of renal insufficiency, and number, location and size of IAs as well as family history of cerebral events. Patients with symptomatic or asymptomatic IAs were included. All patients with ADPKD-related IAs were offered mutation scanning of the susceptibility genes for ADPKD, the PKD1 and PKD2 genes. Of 463 eligible ADPKD patients from the population base of Germany, 32 (7%) were found to have IAs, diagnosed at the age of 2-71 years, 19 females and 13 males. Twenty (63%) of these 32 patients were symptomatic, whereas IAs were detected in an asymptomatic stage in 12 patients. IAs were multifocal in 12 and unifocal in 20 patients. In 26 patients (81%), IAs were diagnosed before end-stage renal failure. Twenty-five out of 27 unrelated index cases (93%) had no IAs or cerebral events documented in their relatives with ADPKD. In 16 unrelated index patients and 3 relatives, we detected germline mutations. The mutations were randomly distributed across the PKD1 gene in 14 and the PKD2 gene in 2 index cases. Questionnaires answered for 320/441 ADPKD patients without IAs revealed that only 45/320 (14%) had MR angiography. In ADPKD, rupture of IAs occurs frequently before the start of dialysis, is only infrequently associated with a family history of IAs or subarachnoid hemorrhage, and is associated with mutations either of the PKD1 or the PKD2 gene of any type. Screening for IAs is widely insufficiently performed, should not be restricted to families with a history of cerebral events and should be started before end-stage renal failure.

Long-term follow-up analysis of microsurgical clip ligation and endovascular coil embolization for dorsal wall blister aneurysms of the internal carotid artery.

PubMed

Brown, Mason A; Guandique, Cristian F; Parish, Jonathan; McMillan, Aubrey C; Lehnert, Stephen; Mansour, Nassir; Tu, Michael; Bohnstedt, Bradley N; Payner, Troy D; Leipzig, Thomas J; DeNardo, Andrew J; Scott, John A; Cohen-Gadol, Aaron A

2017-05-01

Blister aneurysms at non-branching sites of the dorsal internal carotid artery (dICA) are fragile, rare, and often difficult to treat. The purpose of this study is to address the demographics, treatment modalities, and long-term outcome of patients treated for dICA blister aneurysms. A retrospective review of medical records identified all consecutive patients who presented with a blister aneurysm from 2002 to 2011 at our institution. Eighteen patients (M=7, F=11; mean age: 48.4±15.1years; range: 15-65years) harbored a total of 43 aneurysms, 25 of which were dorsal wall blister aneurysms of the ICA. Eleven (61.1%) patients presented with aneurysmal subarachnoid hemorrhage (aSAH), and 10 (55.6%) patients had multiple aneurysms at admission. Twelve patients had 18 aneurysms that were treated microsurgically. Five (41.7%) of these patients had a single recurrence that was retreated with subsequent repeat clip ligation. Six patients had 7 blister aneurysms that were treated with endovascularly. One (16.7%) of these patients had a single recurrence that was retreated with subsequent coil embolization. Postoperative vasospasm occurred in 8 (44.4%) patients, one of whom suffered from a stroke. This is one of the largest single-institution dICA blister aneurysm studies to date. There was no detected significant difference between microsurgical clip ligation and endovascular coil embolization in terms of surgical outcome. These blister aneurysms demonstrate a propensity to be associated with multiple cerebral aneurysms. Strict clinical and angiographic long-term follow-up may be warranted. Blister aneurysms are focal wall defects covered by a thin layer of fibrous tissue and adventitia, lacking the usual collagenous layer. Due to their pathologically thin vessel wall, blister aneurysms are prone to rupture. The management of these rare and fragile aneurysms presents a number of challenges. Here, we address the long-term outcome of patients treated for blister aneurysms at non-branching sites of the dICA. The presented data and analysis is imperative to determine the necessary strict long-term clinical and angiographic follow-up. Copyright © 2017 Elsevier Ltd. All rights reserved.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

PubMed Central

Cho, Won-Sang; Park, Sukh Que; Ko, Jun Kyeung; Kim, Dae-Won; Park, Jung Cheol; Yeon, Je Young; Chung, Seung Young; Chung, Joonho; Joo, Sung-Pil; Hwang, Gyojun; Kim, Deog Young; Chang, Won Hyuk; Choi, Kyu-Sun; Lee, Sung Ho; Sheen, Seung Hun; Kang, Hyun-Seung; Kim, Byung Moon; Bae, Hee-Joon; Oh, Chang Wan; Park, Hyeon Seon

2018-01-01

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research. PMID:29526058

Risk Factors for the Rupture of Intracranial Aneurysms Using Computed Tomography Angiography.

PubMed

Wang, Guang-Xian; Wen, Li; Yang, Liu; Zhang, Qi-Chuang; Yin, Jin-Bo; Duan, Chun-Mei; Zhang, Dong

2018-02-01

To study the clinical and morphologic characteristics associated with risk factors for the rupture of intracranial aneurysms (IAs). A total of 1115 consecutive patients with 1282 IAs were reviewed from August 2011 to February 2016. The patients and IAs were divided into ruptured and unruptured groups. Based on the clinical and morphologic findings, the risk factors for IA rupture were assessed using statistical methods. Age, hypertension, diabetes mellitus, and cerebral atherosclerosis were associated with ruptured IAs. IAs located in the anterior cerebral artery, the anterior communicating artery, the posterior communicating artery, and the internal carotid artery were associated with ruptured IAs. Ruptures were also associated with arterial bifurcations, irregular aneurysm shapes, and all continuous data, except neck width. Binary logistic regression showed that IAs located at bifurcations (odds ratio [OR], 1.804), with irregular shapes (OR, 4.677), with high aspect ratios (ARs) (OR, 5.037) or with small mean diameters (MDs) (OR, 0.495) are more prone to rupture. Receiver operating characteristic analysis showed that the threshold values of the AR and MD were 1 and 3.70 mm, respectively. Morphologic characteristics, such as being located at bifurcations, being irregularly shaped, having a high AR (>1), and having a small MD (<3.70 mm), were better predictors of rupture. Copyright © 2017 Elsevier Inc. All rights reserved.

Microcephalic osteodysplastic primordial dwarfism type II (MOPD II) with multiple vascular complications misdiagnosed as Dubowitz syndrome.

PubMed

Dieks, Jana-Katharina; Baumer, Alessandra; Wilichowski, Ekkehard; Rauch, Anita; Sigler, Matthias

2014-09-01

To date, the genetic basis of Dubowitz syndrome (short stature, microcephaly, facial abnormalities, eczema) is unknown and vascular complications are not known to be associated with this syndrome. In microcephalic osteodysplastic primordial dwarfism type II (MOPD II; disproportionate short statue, microcephaly, facial abnormalities), however, cerebral aneurysms and other vascular abnormalities are frequent complications. MOPD II is a genetic disorder caused by mutations in the pericentrin (PCNT) gene (21q22). We report on a patient who came to our attention as a 22-year-old with subarachnoid bleeding due to a ruptured cranial aneurysm. Until then, the patient was thought and published to have Dubowitz syndrome; previously, he was treated with coronary bypass surgery for extensive coronary angiopathy. Consecutive genetic testing revealed MOPD II. After clinical stabilization, the patient was discharged to a specialized rehabilitation center where he died due to re-rupture of a cranial aneurysm. In patients with short stature-especially when clinical features are accompanied by vascular complications-MOPD II should be considered as a differential diagnosis leading to consecutive genetic testing. After detection of mutations in the PCNT gene, a full vascular status including cerebral imaging and cardiac evaluation needs to be determined in order to analyze vascular abnormalities and initiate prophylactic treatment.

Mechanical deterioration underlies malignant behavior of aneurysmal human ascending aorta.

PubMed

Koullias, George; Modak, Raj; Tranquilli, Maryann; Korkolis, Dimitris P; Barash, Paul; Elefteriades, John A

2005-09-01

The human ascending aorta becomes markedly prone to rupture and dissection at a diameter of 6 cm. The mechanical substrate for this malignant behavior is unknown. This investigation applied engineering analysis to human ascending aortic aneurysms and compared their structural characteristics with those of normal aortas. We measured the mechanical characteristics of the aorta by direct epiaortic echocardiography at the time of surgery in 33 patients with ascending aortic aneurysm undergoing aortic replacement and in 20 control patients with normal aortas undergoing coronary artery bypass grafting. Six parameters were measured in all patients: aortic diameter in systole and diastole, aortic wall thickness in systole and diastole, and blood pressure in systole and diastole. These were used to calculate mechanical characteristics of the aorta from standard equations. Aortic distensibility reflects the elastic qualities of the aorta. Aortic wall stress reflects the disrupting force experienced within the aortic wall. Incremental elastic modulus indicates loss of elasticity reserve. Aortic distensibility falls to extremely low levels as aortic dimension rises toward 6 cm (3.02 mm Hg(-1) for small aortas versus 1.45 mm Hg(-1) for aortas larger than 5 cm, P < .05). Aortic wall stress rises to 157.8 kPa for the aneurysmal aorta, compared with 92.5 kPa for normal aortas. For 6-cm aortas at pressures of 200 mm Hg or more, wall stress rises to 857 kPa, nearly exceeding the known maximal tensile strength of human aneurysmal aortic wall. Incremental elastic modulus deteriorates (1.93 +/- 0.88 MPa vs 1.18 +/- 0.21 MPa, P < .05) in aneurysmal aortas relative to that in normal aortas. The mechanical properties of the aneurysmal aorta deteriorate dramatically as the aorta enlarges, reaching critical levels associated with rupture by a diameter of 6 cm. This mechanical deterioration provides an explanation in engineering terms for the malignant clinical behavior (rupture and dissection) of the aorta at these dimensions. This work adds to our fundamental understanding of the biology of aortic aneurysms and promises to permit future application of engineering measurements to supplement aneurysm size in clinical decision making in aneurysmal disease.

Women undergoing aortic surgery are at higher risk for unplanned readmissions compared with men especially when discharged home.

PubMed

Flink, Benjamin J; Long, Chandler A; Duwayri, Yazan; Brewster, Luke P; Veeraswamy, Ravi; Gallagher, Katherine; Arya, Shipra

2016-06-01

Women undergoing vascular surgery have higher morbidity and mortality. Our study explores gender-based differences in patient-centered outcomes such as readmission, length of stay (LOS), and discharge destination (home vs nonhome facility) in aortic aneurysm surgery. Patients were identified from the American College of Surgeons National Surgical Quality Improvement Project database (2011-2013) undergoing abdominal, thoracic, and thoracoabdominal aortic aneurysms (N = 17,763), who were discharged and survived their index hospitalization. The primary outcome was unplanned readmission, and secondary outcomes were discharge to a nonhome facility, LOS, and reasons for unplanned readmission. Univariate, multivariate, and stratified analyses based on gender and discharge destination were used. Overall, 1541 patients (8.7%) experienced an unplanned readmission, with a significantly higher risk in women vs men (10.8% vs 8%; P < .001) overall (Procedure subtypes: abdominal aortic aneurysm [10.1% vs 7.7%; P < .001], thoracic aortic aneurysm [14.1% vs 13.5%; P = .8], and thoracoabdominal aortic aneurysm [14.8% vs 10%; P = .051]). The higher odds of readmission in women compared with men persisted in multivariate analysis after controlling for covariates (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.05-1.4). Similarly, the rate of discharge to a nonhome facility was nearly double in women compared with men (20.6% vs 10.7%; P < .001), but discharge to a nonhome facility was not a significant predictor of unplanned readmission. Upon stratification by discharge destination, the higher odds of readmissions in women compared with men occurred in patients who were discharged home (OR, 1.2; 95% CI, 1.02-1.4) but not in those who were discharged to a nonhome facility (OR, 1.06; 95% CI, 0.8-1.4). Significant differences in LOS were seen in patients who were discharged home. No gender differences were found in reasons for readmission with the three most common reasons being thromboembolic events, wound infections, and pneumonia. Gender disparity exists in the risk of unplanned readmission among aortic aneurysm surgery patients. Women who were discharged home have a higher likelihood of unplanned readmission despite longer LOS than men. These data suggest that further study into the discharge planning processes, social factors, and use of rehabilitation services is needed for women undergoing aortic procedures to decrease readmissions. Published by Elsevier Inc.

Intracranial vessel wall imaging for evaluation of steno-occlusive diseases and intracranial aneurysms.

PubMed

Brinjikji, Waleed; Mossa-Basha, Mahmud; Huston, John; Rabinstein, Alejandro A; Lanzino, Giuseppe; Lehman, Vance T

2017-03-01

Cerebrovascular diseases have traditionally been classified, diagnosed and managed based on their luminal characteristics. However, over the past several years, several advancements in MRI techniques have ushered in high-resolution vessel wall imaging (HR-VWI), enabling evaluation of intracranial vessel wall pathology. These advancements now allow us to differentiate diseases which have a common angiographic appearance but vastly different natural histories (i.e. moyamoya versus atherosclerosis, reversible cerebral vasoconstriction syndrome versus vasculitis, stable versus unstable intracranial aneurysms). In this review, we detail the anatomical, histopathological and imaging characteristics of various intracranial steno-occlusive diseases and types of intracranial aneurysms and describe the role that HR-VWI can play in diagnosis, risk stratification and treatment. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Tailored flow sequestration treatment using high-flow and low-flow bypass for partially thrombosed giant internal carotid artery aneurysm-a technical case report.

PubMed

Hasegawa, Hirotaka; Inoue, Tomohiro; Tamura, Akira; Saito, Isamu

2016-10-01

Direct clipping of giant partially thrombosed intracranial internal carotid artery (ICA) aneurysms is challenging, especially when important perforating arteries are involved. Proximal occlusion with bypass represents a possible alternative approach. An 80-year-old female presented with worsening visual acuity and severe headache caused by partially thrombosed giant (38 mm in diameter) aneurysms of the right ICA, suggestive of impending rupture. Direct clipping in conjunction with temporary occlusion of the lesion involving the anterior choroidal artery (AChA) was considered too risky. Thus, we sequestrated the ipsilateral ICA flow into a low-flow and a high-flow system using two external carotid artery (ECA)-ICA bypasses and one in situ bypass with cervical ICA ligation. As a result, the low-flow system by the superficial temporal artery-middle cerebral artery (MCA) bypass perfused mainly the proximal MCA lesions and aneurysm, whereas the high-flow system by ECA-radial artery-M2 bypass exclusively supplied the residual distal MCA area. This tailored flow sequestration successfully interrupted intra-aneurysmal flow and accelerated near-complete thrombosis of the aneurysm while preserving the AChA and avoiding any significant neurological deterioration. We conclude that this method is effective for the management of giant partially thrombosed aneurysms of the ICA, especially when direct clipping is difficult.

Crossing Y-stent technique with dual open-cell stents for coiling of wide-necked bifurcation aneurysms.

PubMed

Ko, Jun Kyeung; Han, In Ho; Cho, Won Ho; Choi, Byung Kwan; Cha, Seung Heon; Choi, Chang Hwa; Lee, Sang Weon; Lee, Tae Hong

2015-05-01

Double stenting in a Y-configuration is a promising therapeutic option for wide-necked cerebral aneurysms not amenable to reconstruction with a single stent. We retrospectively evaluated the efficacy and safety of the crossing Y-stent technique for coiling of wide-necked bifurcation aneurysms. By collecting clinical and radiological data we evaluated from January 2007 through December 2013, 20 wide-necked bifurcation aneurysms. Twelve unruptured and eight ruptured aneurysms in 20 patients were treated with crossing Y-stent-assisted coiling. Aneurysm size and neck size ranged from 3.2 to 28.2mm (mean 7.5mm) and from 1.9 to 9.1mm (mean 4.5mm). A Y-configuration was established successfully in all 20 patients. All aneurysms were treated with a pair of Neuroform stents. The immediate angiographic results were total occlusion in 17 aneurysms, residual neck in two, and residual sac in one. Peri-operative morbidity was only 5%. Fifteen of 18 surviving patients underwent follow-up conventional angiography (mean, 10.9 months). The result showed stable occlusion in all 15 aneurysms and asymptomatic in-stent occlusion in one branch artery. At the end of the observation period (mean, 33.5 months), all 12 patients without subarachnoid hemorrhage had excellent clinical outcomes (mRS 0), except one (mRS 2). Of eight patients with subarachnoid hemorrhage, four remained symptom free (mRS 0), while the other four had were dependent or dead (mRS score, 3-6). In this report on 20 patients, crossing Y-stent technique for coiling of wide-necked bifurcation aneurysms showed a good technical safety and favorable clinical and angiographic outcome. Copyright © 2015. Published by Elsevier B.V.

Curvature effect on hemodynamic conditions at the inner bend of the carotid siphon and its relation to aneurysm formation.

PubMed

Lauric, Alexandra; Hippelheuser, James; Safain, Mina G; Malek, Adel M

2014-09-22

Although high-impact hemodynamic forces are thought to lead to cerebral aneurysmal change, little is known about the aneurysm formation on the inner aspect of vascular bends such as the internal carotid artery (ICA) siphon where wall shear stress (WSS) is expected to be low. This study evaluates the effect of vessel curvature and hemodynamics on aneurysm formation along the inner carotid siphon. Catheter 3D-rotational angiographic volumes of 35 ICA (10 aneurysms, 25 controls) were evaluated in 3D for radius of curvature and peak curvature of the siphon bend, followed by univariate statistical analysis. Computational fluid dynamic (CFD) simulations were performed on patient-derived models after aneurysm removal and on synthetic variants of increasing curvature. Peak focal siphon curvature was significantly higher in aneurysm bearing ICAs (0.36 ± 0.045 vs. 0.30 ± 0.048 mm(-1), p=0.003), with no difference in global radius of curvature (p=0.36). In CFD simulations, increasing parametric curvature tightness (from 5 to 3mm radius) resulted in dramatic increase of WSS and WSS gradient magnitude (WSSG) on the inner wall of the bend. In patient-derived data, the location of aneurysms coincided with regions of low WSS (<4 Pa) flanked by high WSS and WSSG peaks. WSS peaks correlated with the aneurysm neck. In contrast, control siphon bends displayed low, almost constant, WSS and WSSG profiles with little spatial variation. High bend curvature induces dynamically fluctuating high proximal WSS and WSSG followed by regions of flow stasis and recirculation, leading to local conditions known to induce destructive vessel wall remodeling and aneurysmal initiation. Copyright © 2014 Elsevier Ltd. All rights reserved.

The Medina Embolic Device: early clinical experience from a single center

PubMed Central

Aguilar Perez, Marta; Bhogal, Pervinder; Martinez Moreno, Rosa; Bäzner, Hansjörg; Ganslandt, Oliver; Henkes, Hans

2017-01-01

Objective To report our initial experience with the Medina Embolic Device (MED) in unruptured intracranial aneurysms either as sole treatment or in conjunction with additional devices. Methods 15 consecutive patients (6 women, 9 men) with unruptured aneurysms were treated between September 2015 and April 2016. The aneurysm fundus measured at least 5 mm. We evaluated the angiographic appearances of treated aneurysms at the end of the procedure and at follow-up, the clinical status, complications, and requirement for adjunctive devices. Results The MED was successfully deployed in all but one case and adjunctive devices were required in 10 cases. Aneurysm locations were middle cerebral artery bifurcation (n=3), internal carotid artery (ICA) bifurcation (n=1), supraclinoid ICA (n=5), posterior communicating artery (n=1), anterior communicating artery (n=2), cavernous ICA (n=2), distal basilar sidewall (n=1), basilar tip (n=1). Three patients had complications although none could be attributed to the MED. Immediate angiographic results were modified Raymond-Roy classification (mRRC) I=1, mRRC II=5, mRRC IIIa=3, mRRC IIIb=5, and one patient showed contrast stasis within the fundus of the aneurysm. Follow-up angiography was available in 11 patients, with four showing complete aneurysm exclusion, six with stable remnants and one patient with an enlarging neck remnant. Conclusions The MED represents a major step forward in the treatment of intracranial aneurysms. It can result in rapid exclusion of an aneurysm from the circulation and has a good safety profile. We believe that the true value of the MED will be in combining its use with adjunctive devices such as endoluminal flow diverters that will result in rapid aneurysmal exclusion. PMID:27484746

Safety, efficacy, and cost of intraoperative indocyanine green angiography compared to intraoperative catheter angiography in cerebral aneurysm surgery.

PubMed

Hardesty, Douglas A; Thind, Harjot; Zabramski, Joseph M; Spetzler, Robert F; Nakaji, Peter

2014-08-01

Intraoperative angiography in cerebrovascular neurosurgery can drive the repositioning or addition of aneurysm clips. Our institution has switched from a strategy of intraoperative digital subtraction angiography (DSA) universally, to a strategy of indocyanine green (ICG) videoangiography with DSA on an as-needed basis. We retrospectively evaluated whether the rates of perioperative stroke, unexpected postoperative aneurysm residual, or parent vessel stenosis differed in 100 patients from each era (2002, "DSA era"; 2007, "ICG era"). The clip repositioning rate for neck residual or parent vessel stenosis did not differ significantly between the two eras. There were no differences in the rate of perioperative stroke or rate of false-negative studies. The per-patient cost of intraoperative imaging within the DSA era was significantly higher than in the ICG era. The replacement of routine intraoperative DSA with ICG videoangiography and selective intraoperative DSA in cerebrovascular aneurysm surgery is safe and effective. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

Octogenarians Undergoing Open Repair Have Higher Mortality Compared with Fenestrated Endovascular Repair of Intact Abdominal Aortic Aneurysms Involving the Visceral Vessels.

PubMed

Locham, Satinderjit; Faateh, Muhammad; Dakour-Aridi, Hanaa; Nejim, Besma; Malas, Mahmoud

2018-04-18

Prior studies have shown that octogenarians have a higher risk of mortality than nonoctogenarians undergoing open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Fenestrated endovascular aneurysm repair (F-EVAR) was approved by the Food and Drug Administration (FDA) in 2012 and has been used as a less invasive approach to treat patients with suboptimal neck anatomy with favorable outcomes compared with traditional OAR. The aim of the study is to compare 30-day outcomes of F-EVAR versus OAR in octogenarians undergoing repair of AAA involving the visceral vessels in the United States. All patients with postoperative diagnosis of nonruptured AAA repair were identified in the National Surgical Quality Improvement Program database (2006-2015). Univariate and multivariate analyses were implemented to examine 30-day morbidity and mortality adjusting for patient demographics and comorbidities. A total of 548 octogenarians underwent repair of nonruptured AAA involving the visceral vessels, of which 242 (44%) were F-EVARs, and 306 (56%) were OARs. Octogenarians undergoing F-EVAR were on average 1-year older (median age [interquartile range]: 83 [82, 86] versus 82 [81, 85], P = 0.004) and more likely to be male (82% vs. 64%, P < 0.001) compared with OAR. Prevalence of diabetes (13% vs. 6%, P = 0.005) and progressive renal failure (57% vs. 47%, P = 0.03) was also higher in patients undergoing F-EVAR compared with OAR. Thirty-day postoperative mortality was higher after OAR (8.5% vs. 4.1%, P = 0.04). Secondary outcomes including cardiopulmonary (27.1% vs. 5.8%, P < 0.001) and renal injury (10.8% vs. 2.1%, P < 0.001) were also significantly higher in OAR compared with F-EVAR. After adjusting for patients' demographics and comorbidities, OAR had almost 4-fold increased risk of 30-day postoperative mortality compared with F-EVAR (odds ratio [95% confidence interval]: 3.90 [1.48-10.31], P = 0.006). In this large national cohort of octogenarians undergoing repair for complex AAA's, we showed that F-EVAR is associated with significantly lower postoperative morbidity and mortality than open repair. One of the main limitations of the study is the lack of anatomical data. However, despite that, our findings support the shifting paradigm toward minimally invasive approach in this frail population for treatment of complex AAA's. Further studies are needed to evaluate the long-term benefit of any repair in octogenarians. Copyright © 2018 Elsevier Inc. All rights reserved.

Retrospective review of cerebral mycotic aneurysms in 26 patients: focus on treatment in strongly immunocompromised patients with a brief literature review.

PubMed

Allen, L M; Fowler, A M; Walker, C; Derdeyn, C P; Nguyen, B V; Hasso, A N; Ghodke, B V; Zipfel, G J; Cross, D T; Moran, C J

2013-04-01

Cerebral mycotic aneurysms are a rare and deadly type of aneurysm that have no definitive treatment guidelines. Our purpose was to retrospectively review known or suspected cases of CMA in order to identify patient populations that may be associated with higher morbidity and mortality. We hope that the identification of patients with these risk factors will lead to early stratification upon presentation, and more urgent treatment of their CMAs. We also hoped to identify any benefit or complication that was specific to either the endovascular or neurosurgical repair of CMAs. A retrospective multi-institutional study was performed examining cases of CMA during a 15-year period. Patients were considered strongly immunocompromised if there were long-term severely immunocompromised states: AIDS, chemotherapy, or steroid immunosuppression. Patients were excluded if angiographic findings suggested an alternative diagnosis or if an infectious etiology was unknown. Antibiotics were considered "noninvasive treatment." Endovascular and neurosurgical repair were considered "invasive treatment." Data were recorded by reviewing electronic medical records and imaging reports. Twenty-six patients with 40 CMAs were included. Three patients were considered strongly immunocompromised and presented with 4 CMAs, which demonstrated larger average size and more rapid growth; 3 of these patients' aneurysms were treated invasively in the acute period, with the one that was not ruptured causing death. Technical success (aneurysm occlusion without rupture or recanalization) and clinical success (no neurologic complication attributable to the intervention) were obtained equally endovascularly and neurosurgically. Clipping was aborted in favor of coiling for 1 patient. Anticoagulation needed reversal before 2 patients underwent craniotomy for clipping after valve replacement. For CMAs treated with antibiotics alone with angiographic follow-up (n=11), initial aneurysm size was unrelated to persistence and 64% completely regressed. We recommend initial invasive treatment for CMAs in strongly immunocompromised patients. Testing for underlying immunocompromised states is warranted in patients with CMAs. Endovascular treatment is favored over neurosurgical treatment in patients requiring acute cardiac valve repair due to delays with anticoagulation reversal.

Anaesthetic and ICU management of aneurysmal subarachnoid haemorrhage: a survey of European practice.

PubMed

Velly, Lionel J; Bilotta, Federico; Fàbregas, Neus; Soehle, Martin; Bruder, Nicolas J; Nathanson, Michael H

2015-03-01

Many aspects of the perioperative management of aneurysmal subarachnoid haemorrhage (SAH) remain controversial. It would be useful to assess differences in the treatment of SAH in Europe to identify areas for improvement. To determine the clinical practice of physicians treating SAH and to evaluate any discrepancy between practice and published evidence. An electronic survey. Physicians identified through each national society of neuroanaesthesiology and neurocritical care. A 31-item online questionnaire was distributed by the ENIG group. Questions were designed to investigate anaesthetic management of SAH and diagnostic and treatment approaches to cerebral vasospasm. The survey was available from early October to the end of November 2012. Completed surveys were received from 268 respondents, of whom 81% replied that aneurysm treatment was conducted early (within 24 h). Sixty-five percent of centres treated more than 60% of SAH by coiling, 19% had high-volume clipping (>60% of aneurysms clipped) and 16% used both methods equally. No clear threshold for arterial blood pressure target was identified during coiling, temporary clipping or in patients without vasospasm after the aneurysm had been secured. Almost all respondents used nimodipine (97%); 21% also used statins and 20% used magnesium for prevention of vasospasm. A quarter of respondents used intra-arterial vasodilators alone, 5% used cerebral angioplasty alone and 48% used both endovascular methods to treat symptomatic vasospasm. In high-volume clipping treatment centres, 58% of respondents used endovascular methods to manage vasospasm compared with 86% at high-volume coiling treatment centres (P < 0.001). The most commonly used intra-arterial vasodilator was nimodipine (82%), but milrinone was used by 23% and papaverine by 19%. More respondents (44%) selected 'triple-H' therapy over hypertension alone (30%) to treat vasospasm. We found striking variability in the practice patterns of European physicians involved in early treatment of SAH. Significant differences were noted among countries and between high and low-volume coiling centres.

Predicting symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage with an artificial neural network in a pediatric population.

PubMed

Skoch, Jesse; Tahir, Rizwan; Abruzzo, Todd; Taylor, John M; Zuccarello, Mario; Vadivelu, Sudhakar

2017-12-01

Artificial neural networks (ANN) are increasingly applied to complex medical problem solving algorithms because their outcome prediction performance is superior to existing multiple regression models. ANN can successfully identify symptomatic cerebral vasospasm (SCV) in adults presenting after aneurysmal subarachnoid hemorrhage (aSAH). Although SCV is unusual in children with aSAH, the clinical consequences are severe. Consequently, reliable tools to predict patients at greatest risk for SCV may have significant value. We applied ANN modeling to a consecutive cohort of pediatric aSAH cases to assess its ability to predict SCV. A retrospective chart review was conducted to identify patients < 21 years of age who presented with spontaneously ruptured, non-traumatic, non-mycotic, non-flow-related intracranial arterial aneurysms to our institution between January 2002 and January 2015. Demographics, clinical, radiographic, and outcome data were analyzed using an adapted ANN model using learned value nodes from the adult aneurysmal SAH dataset previously reported. The strength of the ANN prediction was measured between - 1 and 1 with - 1 representing no likelihood of SCV and 1 representing high likelihood of SCV. Sixteen patients met study inclusion criteria. The median age for aSAH patients was 15 years. Ten underwent surgical clipping and 6 underwent endovascular coiling for definitive treatment. One patient experienced SCV and 15 did not. The ANN applied here was able to accurately predict all 16 outcomes. The mean strength of prediction for those who did not exhibit SCV was - 0.86. The strength for the one patient who did exhibit SCV was 0.93. Adult-derived aneurysmal SAH value nodes can be applied to a simple AAN model to accurately predict SCV in children presenting with aSAH. Further work is needed to determine if ANN models can prospectively predict SCV in the pediatric aSAH population in toto; adapted to include mycotic, traumatic, and flow-related origins as well.

[Systemic complications of subarachnoid hemorrhage from spontaneous rupture of a cerebral aneurysm].

PubMed

Rama-Maceiras, P; Fàbregas Julià, N; Ingelmo Ingelmo, I; Hernández-Palazón, J

2010-12-01

Systemic complications secondary to subarachnoid hemorrhage from an aneurysm are common (40%) and the mortality attributable to them (23%) is comparable to mortality from the primary lesion, rebleeding, or vasospasm. Although nonneurologic medical complications are avoidable, they worsen the prognosis, lengthen the hospital stay, and generate additional costs. The prevention, early detection, and appropriate treatment of systemic complications will be essential for managing the individual patient's case. Treatment should cover major symptoms (headache, nausea, and dizziness) and ambient noise should be reduced, all with the aim of achieving excellence and improving the patient's perception of quality of care.

Haemodynamics of giant cerebral aneurysm: A comparison between the rigid-wall, one-way and two-way FSI models

NASA Astrophysics Data System (ADS)

Khe, A. K.; Cherevko, A. A.; Chupakhin, A. P.; Bobkova, M. S.; Krivoshapkin, A. L.; Orlov, K. Yu

2016-06-01

In this paper a computer simulation of a blood flow in cerebral vessels with a giant saccular aneurysm at the bifurcation of the basilar artery is performed. The modelling is based on patient-specific clinical data (both flow domain geometry and boundary conditions for the inlets and outlets). The hydrodynamic and mechanical parameters are calculated in the frameworks of three models: rigid-wall assumption, one-way FSI approach, and full (two-way) hydroelastic model. A comparison of the numerical solutions shows that mutual fluid- solid interaction can result in qualitative changes in the structure of the fluid flow. Other characteristics of the flow (pressure, stress, strain and displacement) qualitatively agree with each other in different approaches. However, the quantitative comparison shows that accounting for the flow-vessel interaction, in general, decreases the absolute values of these parameters. Solving of the hydroelasticity problem gives a more detailed solution at a cost of highly increased computational time.

The Factors Associated with Outcomes in Surgically Managed Ruptured Cerebral Aneurysm.

PubMed

Chee, Lai Chuang; Siregar, Johari Adnan; Ghani, Abdul Rahman Izani; Idris, Zamzuri; Rahman Mohd, Noor Azman A

2018-02-01

Ruptured cerebral aneurysm is a life-threatening condition that requires urgent medical attention. In Malaysia, a prospective study by the Umum Sarawak Hospital, Neurosurgical Center, in the year 2000-2002 revealed an average of two cases of intracranial aneurysms per month with an operative mortality of 20% and management mortality of 25%. Failure to diagnose, delay in admission to a neurosurgical centre, and lack of facilities could have led to the poor surgical outcome in these patients. The purpose of this study is to identify the factors that significantly predict the outcome of patients undergoing a surgical clipping of ruptured aneurysm in the local population. A single center retrospective study with a review of medical records was performed involving 105 patients, who were surgically treated for ruptured intracranial aneurysms in the Sultanah Aminah Hospital, in Johor Bahru, from July 2011 to January 2016. Information collected was the patient demographic data, Glasgow Coma Scale (GCS) prior to surgery, World Federation of Neurosurgical Societies Scale (WFNS), subarachnoid hemorrhage (SAH) grading system, and timing between SAH ictus and surgery. A good clinical grade was defined as WFNS grade I-III, whereas, WFNS grades IV and V were considered to be poor grades. The outcomes at discharge and six months post surgery were assessed using the modified Rankin's Scale (mRS). The mRS scores of 0 to 2 were grouped into the "favourable" category and mRS scores of 3 to 6 were grouped into the "unfavourable" category. Only cases of proven ruptured aneurysmal SAH involving anterior circulation that underwent surgical clipping were included in the study. The data collected was analysed using the Statistical Package for Social Sciences (SPSS). Univariate and multivariate analyses were performed and a P -value of < 0.05 was considered to be statistically significant. A total of 105 patients were included. The group was comprised of 42.9% male and 57.1% female patients. The mean GCS of the patients subjected to surgical clipping was 13, with the majority falling into the good clinical grade (78.1%). The mean timing of the surgery after SAH was 5.3 days and this was further categorised into early (day one to day three, 45.3%), intermediate (day four to day ten, 56.2%), and late (after day ten, 9.5%). The total favourable outcome achieved at discharge was 59.0% as compared to 41.0% of the unfavourable outcome, with an overall mortality rate of 10.5%. At the six-month post surgery review ( n = 94), the patients with a favourable outcome constituted 71.3% as compared to 28.7% with an unfavourable outcome. The mortality, six months post surgery was 3.2%. On a univariate analysis of early surgical clipping, patients with a better GCS and good clinical grade had a significantly better outcome at discharge. Based on the univariate study, six months post surgery, the timing of the surgery and the clinical grade remained significant predictors of the outcome. On the basis of the multivariate analysis, male patients of younger age, with a good clinical grade, were associated with favourable outcomes, both at discharge and six months post surgery. In this study, we concluded that younger male patients with a good clinical grade were associated with a favourable outcome both at discharge and six months post surgery. We did not find the timing of the surgery, size of the aneurysm or duration of surgery to be associated with a patient's surgical outcome. Increasing age was not associated with the surgical outcome in a longer term of patient's follow up.

Successful flow reduction surgery for a ruptured true posterior communicating artery aneurysm caused by the common carotid artery ligation for epistaxis.

PubMed

Yamao, Yukihiro; Takahashi, Jun C; Satow, Tetsu; Iihara, Koji; Miyamoto, Susumu

2014-01-01

Carotid artery occlusion can lead to the development of rare true posterior communicating artery (PCoA) aneurysms because of hemodynamic stress on the PCoA. Surgical treatment of these lesions is challenging. The authors report a case of a true PCoA aneurysm that developed and ruptured 37 years after ligation of the ipsilateral common carotid artery for epistaxis. The lesion was successfully treated with clipping of the distal M1 segment of the middle cerebral artery (MCA) after the occipital artery-radial artery free graft-MCA bypass, which led to extreme reduction in collateral flow through the PCoA. A cortical branch, located just proximal to the obliteration site, functioned as a sufficient flow outlet. The aneurysm shrank, and the patient has been doing well without any symptoms for 5 years after surgery. M1 obliteration combined with high-flow extra-intracranial bypass might be a promising option for a true PCoA aneurysm, and therapeutic design that leaves a sufficient flow outlet on the M1 is mandatory to avoid unexpected occlusion of the M1 and its perforators.

Successful flow reduction surgery for a ruptured true posterior communicating artery aneurysm caused by the common carotid artery ligation for epistaxis

PubMed Central

Yamao, Yukihiro; Takahashi, Jun C.; Satow, Tetsu; Iihara, Koji; Miyamoto, Susumu

2014-01-01

Background: Carotid artery occlusion can lead to the development of rare true posterior communicating artery (PCoA) aneurysms because of hemodynamic stress on the PCoA. Surgical treatment of these lesions is challenging. Case Description: The authors report a case of a true PCoA aneurysm that developed and ruptured 37 years after ligation of the ipsilateral common carotid artery for epistaxis. The lesion was successfully treated with clipping of the distal M1 segment of the middle cerebral artery (MCA) after the occipital artery-radial artery free graft-MCA bypass, which led to extreme reduction in collateral flow through the PCoA. A cortical branch, located just proximal to the obliteration site, functioned as a sufficient flow outlet. The aneurysm shrank, and the patient has been doing well without any symptoms for 5 years after surgery. Conclusions: M1 obliteration combined with high-flow extra-intracranial bypass might be a promising option for a true PCoA aneurysm, and therapeutic design that leaves a sufficient flow outlet on the M1 is mandatory to avoid unexpected occlusion of the M1 and its perforators. PMID:25525556

Association between an aplastic basilar artery, unaccompanied by a primitive carotid-vertebrobasilar anastomosis, and multiple aneurysms on the dominant posterior communicating artery.

PubMed

Behari, Sanjay; Krishna, Himanshu; Kumar, Marakani V Kiran; Sawlani, Vijay; Phadke, Rajendra V; Jain, Vijendra K

2004-05-01

Basilar artery (BA) aplasia when unaccompanied by a primitive carotid-vertebrobasilar anastomosis is exceedingly rare. The association of BA aplasia with two aneurysms on the dominant posterior communicating artery (PCoA) has not been previously reported. This 40-year-old man presented in a state of drowsiness and responded to simple commands only after being coaxed. He had complete left cranial third nerve palsy, right hemiparesis, and persisting signs of meningeal irritation. A computerized tomography (CT) scan revealed subarachnoid and intraventricular hemorrhage. An angiogram revealed BA aplasia. The right PCoA followed a sinuous course with multiple loops and provided the dominant supply to the posterior circulation. This vessel harbored two aneurysms, one at the origin of the PCoA from the internal carotid artery and the other at the looping segment just proximal to the brainstem. The left PCoA was extremely thin. The pterional transsylvian approach was used to clip the two aneurysms on the PCoA. The hemodynamic changes produced by the BA aplasia may have produced alterations in the cerebral vasculature leading to aneurysm formation and consequent subarachnoid hemorrhage.

Thrombosed Aneurysm of the Posterior Inferior Cerebellar Artery and Lateral Medullary Ischemia as the Initial Presentation of Polyarteritis Nodosa: Case Report and Literature Review.

PubMed

Boukobza, Monique; Dossier, Antoine; Laissy, Jean-Pierre

2018-03-27

A 27-year-old woman with a previously undiagnosed polyarteritis nodosa (PAN) developed lateral medullary stroke related to a thrombosed posterior inferior cerebellar artery (PICA)-origin aneurysm. A concurrent thrombosis of the PICA was identified on high-resolution 3-dimensional CUBE T1 magnetic resonance imaging sequence at 3 T. Body computed tomography angiography, magnetic resonance imaging-magnetic resonance angiography, and digital angiography revealed multiple tiny aneurysms of the visceral arteries and bilateral kidney infarcts. On the basis of these findings and of laboratory data, the patient was diagnosed as having PAN. Intracranial aneurysms (IAs) are extremely rare in PAN and usually manifest as subarachnoid or cerebral hemorrhage. Ischemic manifestation of small thrombosed IA is a rare occurrence. This case highlights (1) an uncommon complication in patients with PAN (16 other cases of IAs in patients with PAN found in the literature), (2) an unusual initial presentation of PAN, and (3) a thrombosed PICA-origin aneurysm responsible for an ischemic stroke and for secondary thrombosis of the parent vessel. Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

4D Magnetic Resonance Velocimetry in a 3D printed brain aneurysm

NASA Astrophysics Data System (ADS)

Amili, Omid; Schiavazzi, Daniele; Coletti, Filippo

2016-11-01

Cerebral aneurysms are of great clinical importance. It is believed that hemodynamics play a critical role in the development, growth, and rupture of brain arteries with such condition. The flow structure in the aneurysm sac is complex, unsteady, and three-dimensional. Therefore the time-resolved measurement of the three-dimensional three-component velocity field is crucial to predict the clinical outcome. In this study magnetic resonance velocimetry is used to assess the fluid dynamics inside a 3D printed model of a giant intracranial aneurysm. We reach sub-millimeter resolution while resolving sixteen instances within the cardiac cycle. The physiological flow waveform is imposed using an in-house built pump in a flow circuit where the cardiovascular impedance is matched. The flow evolution over time is reconstructed in detail. The complex flow structure is characterized by vortical and helical motions that reside in the aneurysm for most part of the cycle. The 4D pressured distribution is also reconstructed from the velocity field. The present case study was used in a previous CFD challenge, therefore these results may provide useful experimental comparison for simulations performed by other research groups.

Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies: proposal of a multidisciplinary research group.

PubMed

Vergouwen, Mervyn D I; Vermeulen, Marinus; van Gijn, Jan; Rinkel, Gabriel J E; Wijdicks, Eelco F; Muizelaar, J Paul; Mendelow, A David; Juvela, Seppo; Yonas, Howard; Terbrugge, Karel G; Macdonald, R Loch; Diringer, Michael N; Broderick, Joseph P; Dreier, Jens P; Roos, Yvo B W E M

2010-10-01

In clinical trials and observational studies there is considerable inconsistency in the use of definitions to describe delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage. A major cause for this inconsistency is the combining of radiographic evidence of vasospasm with clinical features of cerebral ischemia, although multiple factors may contribute to DCI. The second issue is the variability and overlap of terms used to describe each phenomenon. This makes comparisons among studies difficult. An international ad hoc panel of experts involved in subarachnoid hemorrhage research developed and proposed a definition of DCI to be used as an outcome measure in clinical trials and observational studies. We used a consensus-building approach. It is proposed that in observational studies and clinical trials aiming to investigate strategies to prevent DCI, the 2 main outcome measures should be: (1) cerebral infarction identified on CT or MRI or proven at autopsy, after exclusion of procedure-related infarctions; and (2) functional outcome. Secondary outcome measure should be clinical deterioration caused by DCI, after exclusion of other potential causes of clinical deterioration. Vasospasm on angiography or transcranial Doppler can also be used as an outcome measure to investigate proof of concept but should be interpreted in conjunction with DCI or functional outcome. The proposed measures reflect the most relevant morphological and clinical features of DCI without regard to pathogenesis to be used as an outcome measure in clinical trials and observational studies.

Patency of the posterior communicating artery following treatment with the Pipeline Embolization Device.

PubMed

Daou, Badih; Valle-Giler, Edison P; Chalouhi, Nohra; Starke, Robert M; Tjoumakaris, Stavropoula; Hasan, David; Rosenwasser, Robert H; Hebert, Ryan; Jabbour, Pascal

2017-02-01

OBJECTIVE The Pipeline Embolization Device (PED) has become an effective treatment strategy for some cerebral aneurysms. Concerns regarding the patency of branch arteries have been raised. The objective of this study was to assess the patency of the posterior communicating artery (PCoA) following treatment of PCoA aneurysms using the PED. METHODS All patients with PCoA aneurysms treated with the PED who had angiographic follow-up were retrospectively identified. The patency of the PCoA at follow-up was evaluated by 2 authors who were not involved in the intervention. Univariate and multivariate analyses were performed to identify factors associated with the following: 1) PCoA patency versus no or diminished flow, and 2) PCoA patency and diminished flow versus PCoA occlusion. RESULTS Thirty patients with an angiographic follow-up of 6 months were included. Aneurysm obliteration was achieved in 25 patients (83.3%). The PCoA was patent in 7 patients (23.3%), had diminished flow in 7 patients (23.3%), and was occluded in 16 patients (53.3%). In the univariate analysis of outcome, there was a trend for aneurysms with incomplete occlusion, aneurysms not previously treated, those with presence of a fetal PCoA, and those with an artery coming from the aneurysm to have higher odds of the PCoA remaining patent. In univariate and multivariate analyses of factors associated with outcome, fetal PCoA and presence of an artery coming from the aneurysm were associated with the PCoA remaining open with or without diminished flow. No patients had symptoms related to PCoA occlusion. CONCLUSIONS Occlusion and diminished flow through the PCoA is common following PED treatment of PCoA aneurysms. However, it is clinically insignificant in most cases.

The efficiency of the new Yasargil titanium fenestrated mini-clips for ideal clipping of a cerebral aneurysm

PubMed Central

Ota, Nakao; Tanikawa, Rokuya; Noda, Kosumo; Tsuboi, Toshiyuki; Kamiyama, Hiroyasu; Tokuda, Sadahisa

2015-01-01

Background: The fenestrated clip is sometimes useful in limited approach angle and narrow working space. However, before the development of the new Yasargil titanium fenestrated mini-clip, the only variations of fenestrated clips were those of larger sizes. And those larger clips have a problem of the triangle-shaped gap at the proximal end of the blade. The authors describe the efficiency, limitations and surgical technique of using the Yasargil titanium fenestrated mini-clip. Methods: Fifty-nine cases of aneurysms were treated using these mini-clips. Aneurysm location, size and dome neck ratio, mean follow-up period, neck remnant, and recurrence rate were also analyzed. Among these cases, we present eight characteristic cases, including a case with aneurysm recurrence, and we review the problems associated with the triangle-shaped gap at the proximal end of the clip. Results: The average size of the aneurysms was 5.57 mm, and the dome neck ratio was >2.0 in 1.69%, >1.5 in 11.8%, >1.2 in 35.6%, and <1.2 in 50.8% of cases. The mean follow-up period for the 59 cases was 5.5 months (range, 0.5–16 months). Angiographic recurrence of the treated portion occurred in 1 case (1.7%), including an aneurysm in the basilar artery tip aneurysm. Conclusion: The availability of the Yasargil titanium fenestrated mini-clip increases the options for clipping to minimize the remnant of the clipped aneurysm. However, there is still concern over the triangular space at the base of the blade, especially when treating an aneurysm with a thin vessel wall. Therefore, modification of the clipping technique is sometimes needed. PMID:26664871

Flat panel angiography images in the post-operative follow-up of surgically clipped intracranial aneurysms.

PubMed

Budai, Caterina; Cirillo, Luigi; Patruno, Francesco; Dall'olio, Massimo; Princiotta, Ciro; Leonardi, Marco

2014-04-01

Cerebral aneurysms must be monitored for varying periods after surgical and/or endovascular treatment and the duration of follow-up will depend on the type of therapy and the immediate post-operative outcome. Surgical clipping for intracranial aneurysms is a valid treatment but the metal clips generate artefacts so that follow-up monitoring still relies on catheter angiography. This study reports our preliminary experience with volumetric angiography using a Philips Allura Xper FD biplane system in the post-operative monitoring of aneurysm residues or major vascular changes following the surgical clipping of intracranial aneurysms. Volumetric angiography yields not only volume-rendered (VR) images, but a volume CT can also be reconstructed at high spatial and contrast resolution from a single acquisition, significantly enhancing the technique's diagnostic power. Between August 2012 and April 2013, we studied 19 patients with a total of 26 aneurysms treated by surgical clipping alone or in combination with endovascular treatment. All patients underwent standard post-operative angiographic follow-up including a rotational volumetric acquisition. Follow-up monitoring disclosed eight aneurysm residues whose assessment was optimal after surgical clipping both in patients with one metal clip and in those with two or more clips. In addition, small residues (1.3 mm) could be monitored together with any change in the calibre or course of vessels located adjacent to the clips. In conclusion, flat panel volume CT is much more reliable than the old 3D acquisitions that yielded only VR images. This is particularly true in patients with small aneurysm residues or lesions with multiple metal clips.

[Anesthetic management for cerebral aneurysm surgery in a patient with aortitis syndrome accompanied by lung edema].

PubMed

Maeda, Ryoko; Kohno, Yumiko; Hoshino, Hajime; Suzuki, Hideo; Hirabayashi, Yoshiyuki; Seo, Norimasa

2003-08-01

A 48-year-old woman with aortitis syndrome underwent clipping of dissecting aneurysm of the left posterior inferior cerebellar artery following subarachnoid hemorrhage. Preoperative echocardiography demonstrated moderate aortic regurgitation and pulmonary hypertension. Intravenous infusion (1900 ml.day-1) was performed to avoid cerebral vasospasm, but the patient developed lung edema. She received delayed surgical treatment after the improvement of lung symptoms. Anesthesia was induced with fentanyl (0.1 mg), propofol (90 mg) and vecuronium (6 mg). Radial arterial flow was judged to be insufficient for cannulation, and a cannulation was therefore performed on the dorsal pedis artery. During induction of anesthesia, there was a significant decrease in the arterial pressure, that required a total of 32 mg of intravenous ephedrine. Following tracheal intubation, a central venous catheter was inserted and dopamine was continuously administered. The patient was positioned in the park bench position. We thought that the placement of the introducer for Swan-Ganz catheter was difficult under the position and Swan-Ganz catheter was not inserted. Anesthesia was maintained with sevoflurane, air, and oxygen. We continuously monitored the central venous pressure as an indicator of fluid balance. In this case, we monitored dorsal pedis arterial pressure directly, which might not be sufficiently reliable to predict the decrease in cerebral blood flow.

Aneurysm outflow angle at MRA as discriminant for accurate diagnosis and differentiation between small sidewall cerebral aneurysms and infundibula.

PubMed

Sun, Ling-Jun; Li, Yong-Dong; Li, Ming-Hua; Wang, Wu; Gu, Bin-Xian

2017-06-01

To evaluate whether the aneurysm outflow angle (OA) at MR angiography (MRA) might serve as discriminant for accurate diagnosis of, and differentiation between, small sidewall cerebral aneurysms (SCAs) and infundibula. Between June 2007 and July 2015, 426 consecutive patients with SCAs completed both an MRA and DSA examination. Of these, 156 patients with small SCAs and 52 patients with infundibula were included in this study. A patient with an OA ≥90° was defined as having a SCA, while those with OA <90° were defined as having an infundibulum. DSA identified 172 SCAs in 156 patients and 55 infundibula in 52 patients. The average OA on MRA was 102.96°±13.36° (range 60°-151°) in 172 SCAs of 156 patients. An OA of ≥90° was seen for 159 (92.4%) small SCAs in 147 patients, while an OA of <90° was observed for 13 SCAs. The average OA on MRA was 69.05°±14.26° (range 35-107°) in 55 infundibula of 52 patients. An OA of ≥90° was seen in one patient with one infundibulum; while an OA of <90° was observed for 54 infundibula (98.2%) in 51 patients. The average OA in SCAs (n=172) was greater than the average OA in infundibula (n=55; 102.96° vs 69.05°, p<0.001). The OA at MRA could serve as discriminant for accurate diagnosis of, and differentiation between, small SCAs and infundibula. 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/.

Flow diverter effect of LVIS stent on cerebral aneurysm hemodynamics: a comparison with Enterprise stents and the Pipeline device.

PubMed

Wang, Chao; Tian, Zhongbin; Liu, Jian; Jing, Linkai; Paliwal, Nikhil; Wang, Shengzhang; Zhang, Ying; Xiang, Jianping; Siddiqui, Adnan H; Meng, Hui; Yang, Xinjian

2016-07-02

The aim of this study was to quantify the effect of the new Low-profile Visualized Intraluminal Support (LVIS®D) device and the difference of fluid diverting effect compared with the Pipeline device and the Enterprise stent using computational fluid dynamics (CFD). In this research, we simulated three aneurysms constructed from 3D digital subtraction angiography (DSA). The Enterprise, LVIS and the Pipeline device were virtually conformed to fit into the vessel lumen and placed across the aneurysm orifice. Computational fluid dynamics analysis was performed to compare the hemodynamic differences such as WSS, Velocity and Pressure among these stents. Control referred to the unstented model, the percentage of hemodynamic changes were all compared to Control. A single LVIS stent caused more wall shear stress reduction than double Enterprise stents (39.96 vs. 30.51 %) and velocity (23.13 vs. 18.64 %). Significant reduction in wall shear stress (63.88 %) and velocity (46.05 %) was observed in the double-LVIS stents. A single Pipeline showed less reduction in WSS (51.08 %) and velocity (37.87 %) compared with double-LVIS stent. The double-Pipeline stents resulted in the most reduction in WSS (72.37 %) and velocity (54.26 %). Moreover, the pressure increased with minuscule extent after stenting, compared with the unstented model. This is the first study analyzing flow modifications associated with LVIS stents. We found that the LVIS stent has certain hemodynamic effects on cerebral aneurysms: a single LVIS stent caused more flow reductions than the double-Enterprise stent but less than a Pipeline device. Nevertheless, the double-LVIS stent resulted in a better flow diverting effect than a Pipeline device.

Development and application of a volume penalization immersed boundary method for the computation of blood flow and shear stresses in cerebral vessels and aneurysms.

PubMed

Mikhal, Julia; Geurts, Bernard J

2013-12-01

A volume-penalizing immersed boundary method is presented for the simulation of laminar incompressible flow inside geometrically complex blood vessels in the human brain. We concentrate on cerebral aneurysms and compute flow in curved brain vessels with and without spherical aneurysm cavities attached. We approximate blood as an incompressible Newtonian fluid and simulate the flow with the use of a skew-symmetric finite-volume discretization and explicit time-stepping. A key element of the immersed boundary method is the so-called masking function. This is a binary function with which we identify at any location in the domain whether it is 'solid' or 'fluid', allowing to represent objects immersed in a Cartesian grid. We compare three definitions of the masking function for geometries that are non-aligned with the grid. In each case a 'staircase' representation is used in which a grid cell is either 'solid' or 'fluid'. Reliable findings are obtained with our immersed boundary method, even at fairly coarse meshes with about 16 grid cells across a velocity profile. The validation of the immersed boundary method is provided on the basis of classical Poiseuille flow in a cylindrical pipe. We obtain first order convergence for the velocity and the shear stress, reflecting the fact that in our approach the solid-fluid interface is localized with an accuracy on the order of a grid cell. Simulations for curved vessels and aneurysms are done for different flow regimes, characterized by different values of the Reynolds number (Re). The validation is performed for laminar flow at Re = 250, while the flow in more complex geometries is studied at Re = 100 and Re = 250, as suggested by physiological conditions pertaining to flow of blood in the circle of Willis.

Characterizing heterogeneous properties of cerebral aneurysms with unknown stress-free geometry: a precursor to in vivo identification.

PubMed

Zhao, Xuefeng; Raghavan, Madhavan L; Lu, Jia

2011-05-01

Knowledge of elastic properties of cerebral aneurysms is crucial for understanding the biomechanical behavior of the lesion. However, characterizing tissue properties using in vivo motion data presents a tremendous challenge. Aside from the limitation of data accuracy, a pressing issue is that the in vivo motion does not expose the stress-free geometry. This is compounded by the nonlinearity, anisotropy, and heterogeneity of the tissue behavior. This article introduces a method for identifying the heterogeneous properties of aneurysm wall tissue under unknown stress-free configuration. In the proposed approach, an accessible configuration is taken as the reference; the unknown stress-free configuration is represented locally by a metric tensor describing the prestrain from the stress-free configuration to the reference configuration. Material parameters are identified together with the metric tensor pointwisely. The paradigm is tested numerically using a forward-inverse analysis loop. An image-derived sac is considered. The aneurysm tissue is modeled as an eightply laminate whose constitutive behavior is described by an anisotropic hyperelastic strain-energy function containing four material parameters. The parameters are assumed to vary continuously in two assigned patterns to represent two types of material heterogeneity. Nine configurations between the diastolic and systolic pressures are generated by forward quasi-static finite element analyses. These configurations are fed to the inverse analysis to delineate the material parameters and the metric tensor. The recovered and the assigned distributions are in good agreement. A forward verification is conducted by comparing the displacement solutions obtained from the recovered and the assigned material parameters at a different pressure. The nodal displacements are found in excellent agreement.

The Weekend Effect in AAA Repair.

PubMed

O'Donnell, Thomas F X; Li, Chun; Swerdlow, Nicholas J; Liang, Patric; Pothof, Alexander B; Patel, Virendra I; Giles, Kristina A; Malas, Mahmoud B; Schermerhorn, Marc L

2018-04-18

Conflicting reports exist regarding whether patients undergoing surgery on the weekend or later in the week experience worse outcomes. We identified patients undergoing abdominal aortic aneurysm (AAA) repair in the Vascular Quality Initiative between 2009 and 2017 [n = 38,498; 30,537 endovascular aneurysm repair (EVAR) and 7961 open repair]. We utilized mixed effects logistic regression to compare adjusted rates of perioperative mortality based on the day of repair. Tuesday was the most common day for elective repair (22%), Friday for symptomatic repairs (20%), and ruptured aneurysms were evenly distributed. Patients with ruptured aneurysms experienced similar adjusted mortality whether they underwent repair during the week or on weekends. Transfers of ruptured AAA were more common over the weekend. However, patients transferred on the weekend experienced higher adjusted mortality than those transferred during the week (28% vs 21%, P = 0.02), despite the fact that during the week, transferred patients actually experienced lower adjusted mortality than patients treated at the index hospital (21% vs 31%, P < 0.01). Among symptomatic patients, adjusted mortality was higher for those undergoing repair over the weekend than those whose surgeries were delayed until a weekday (7.9% vs 3.1%, P = 0.02). Adjusted mortality in elective cases did not vary across the days of the week. Results were consistent between open and EVAR patients. We found no evidence of a weekend effect for ruptured or symptomatic AAA repair. However, patients with ruptured AAA transferred on the weekend experienced higher mortality than those transferred during the week, suggesting a need for improvement in weekend transfer processes.

Clinical values of intraoperative indocyanine green fluorescence video angiography with Flow 800 software in cerebrovascular surgery.

PubMed

Ye, Xun; Liu, Xing-Ju; Ma, Li; Liu, Ling-Tong; Wang, Wen-Lei; Wang, Shuo; Cao, Yong; Zhang, Dong; Wang, Rong; Zhao, Ji-Zong; Zhao, Yuan-Li

2013-11-01

Microscope-integrated near-infrared indocyanine green video angiography (ICG-VA) has been used in neurosurgery for a decade. This study aimed to assess the value of intraoperative indocyanine green (ICG) video angiography with Flow 800 software in cerebrovascular surgery and to discover its hemodynamic features and changes of cerebrovascular diseases during surgery. A total of 87 patients who received ICG-VA during various surgical procedures were enrolled in this study. Among them, 45 cases were cerebral aneurysms, 25 were cerebral arteriovenous malformations (AVMs), and 17 were moyamoya disease (MMD). A surgical microscope integrating an infrared fluorescence module was used to confirm the residual aneurysms and blocking of perforating arteries in aneurysms. Feeder arteries, draining veins, and normal cortical vessels were identified by the time delay color mode of Flow 800 software. Hemodynamic parameters were recorded. All data were analyzed by SPSS version 18.0 (SPSS Inc., USA). T-test was used to analyze the hemodynamic features of AVMs and MMDs, the influence on peripheral cortex after resection in AVMs, and superficial temporal artery to middle cerebral artery (STA-MCA) bypass in MMDs. The visual delay map obtained by Flow 800 software had more advantages than the traditional playback mode in identifying the feeder arteries, draining veins, and their relations to normal cortex vessels. The maximum fluorescence intensity (MFI) and the slope of ICG fluorescence curve of feeder arteries and draining veins were higher than normal peripheral vessels (MFI: 584.24±85.86 vs. 382.94 ± 91.50, slope: 144.95 ± 38.08 vs. 69.20 ± 13.08, P < 0.05). The arteriovenous transit time in AVM was significantly shorter than in normal cortical vessels ((0.60 ± 0.27) vs. (2.08 ± 1.42) seconds, P < 0.05). After resection of AVM, the slope of artery in the cortex increased, which reflected the increased cerebral flow. In patients with MMD, after STA-MCA bypass, cortex perfusion of corresponding branches region increased and local cycle time became shorter. Intraoperative ICG video angiography combined with hemodynamic parameter analysis obtained by Flow 800 software appears to be useful for intraoperative monitoring of regional cerebral blood flow in cerebrovascular disease.

Continuous intra-arterial nimodipine infusion in patients with severe refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a feasibility study and outcome results.

PubMed

Bele, Sylvia; Proescholdt, Martin A; Hochreiter, Andreas; Schuierer, Gerhard; Scheitzach, Judith; Wendl, Christina; Kieninger, Martin; Schneiker, Andre; Bründl, Elisabeth; Schödel, Petra; Schebesch, Karl-Michael; Brawanski, Alexander

2015-12-01

Severe cerebral vasospasm is a major cause of death and disability in patients with aneurysmal subarachnoid hemorrhage. No causative treatment is yet available and hypertensive hypervolemic therapy (HHT) is often insufficient to avoid delayed cerebral ischemia and neurological deficits. We compared patients receiving continuous intra-arterial infusion of the calcium-antagonist nimodipine with a historical group treated with HHT and oral nimodipine alone. Between 0.5 and 1.2 mg/h of nimodipine were continuously administered by intra-arterial infusion via microcatheters either into the internal carotid or vertebral artery or both, depending on the areas of vasospasm. The effect was controlled via multimodal neuromonitoring and transcranial Doppler sonography. Outcome was determined by means of the Glasgow Outcome Scale at discharge and 6 months after the hemorrhage and compared to a historical control group. Twenty-one patients received 28 intra-arterial nimodipine infusions. Six months after discharge, the occurrence of cerebral infarctions was significantly lower (42.6 %) in the nimodipine group than in the control group (75.0 %). This result was reflected by a significantly higher proportion (76.0 %) of patients with good outcome in the nimodipine-treated group, when compared to 10.0 % good outcome in the control group. Median GOS was 4 in the nimodipine group and 2 in the control group (p = 0.001). Continuous intra-arterial nimodipine infusion is an effective treatment for patients with severe cerebral vasospasm who fail to respond to HHT and oral nimodipine alone. Key to the effective administration of continuous intra-arterial nimodipine is multimodal neuromonitoring and the individual adaptation of dosage and time of infusion for each patient.

A review of the surgical management of right-sided aortic arch aneurysms

PubMed Central

Barr, James G.; Sepehripour, Amir H.; Jarral, Omar A.; Tsipas, Pantelis; Kokotsakis, John; Kourliouros, Antonios; Athanasiou, Thanos

2016-01-01

Aneurysms and dissections of the right-sided aortic arch are rare and published data are limited to a few case reports and small series. The optimal treatment strategy of this entity and the challenges associated with their management are not yet fully investigated and conclusive. We performed a systematic review of the literature to identify all patients who underwent surgical or endovascular intervention for right aortic arch aneurysms or dissections. The search was limited to the articles published only in English. We focused on presentation and critically assessed different management strategies and outcomes. We identified 74 studies that reported 99 patients undergoing surgical or endovascular intervention for a right aortic arch aneurysm or dissection. The median age was 61 years. The commonest presenting symptoms were chest or back pain and dysphagia. Eighty-eight patients had an aberrant left subclavian artery with only 11 patients having the mirror image variant of a right aortic arch. The commonest pathology was aneurysm arising from a Kommerell's diverticulum occurring in over 50% of the patients. Twenty-eight patients had dissections, 19 of these were Type B and 9 were Type A. Eighty-one patients had elective operations while 18 had emergency procedures. Sixty-seven patients underwent surgical treatment, 20 patients had hybrid surgical and endovascular procedures and 12 had totally endovascular procedure. There were 5 deaths, 4 of which were in patients undergoing emergency surgery and none in the endovascular repair group. Aneurysms and dissections of a right-sided aortic arch are rare. Advances in endovascular treatment and hybrid surgical and endovascular management are making this rare pathology amenable to these approaches and may confer improved outcomes compared with conventional extensive repair techniques. PMID:27001673

Characteristics of Intracranial Aneurysms in the Else Kröner-Fresenius Registry of Autosomal Dominant Polycystic Kidney Disease

PubMed Central

Neumann, Hartmut P.H.; Malinoc, Angelica; Bacher, Janina; Nabulsi, Zinaida; Ivanovas, Vera; Bruechle, Nadine Ortiz; Mader, Irina; Hoffmann, Michael M.; Riegler, Peter; Kraemer-Guth, Annette; Burchardi, Christian; Schaeffner, Elke; Martin, Rodolfo S.; Azurmendi, Pablo J.; Zerres, Klaus; Jilg, Cordula; Eng, Charis; Gläsker, Sven

2012-01-01

Background Patients who harbor intracranial aneurysms (IAs) run a risk for aneurysm rupture and subsequent subarachnoid hemorrhage which frequently results in permanent deficits or death. Prophylactic treatment of unruptured aneurysms is possible and recommended depending on the size and location of the aneurysm as well as patient age and condition. IAs are major manifestations of autosomal dominant polycystic kidney disease (ADPKD). Current guidelines do not suggest surveillance of IAs in ADPKD except in the setting of family history if IA was known in any relative with ADPKD. Management of IAs in ADPKD is problematic because limited data exist from large studies. Methods We established the Else Kröner-Fresenius Registry for ADPKD in Germany. Clinical data were assessed for age at diagnosis of IAs, stage of renal insufficiency, and number, location and size of IAs as well as family history of cerebral events. Patients with symptomatic or asymptomatic IAs were included. All patients with ADPKD-related IAs were offered mutation scanning of the susceptibility genes for ADPKD, the PKD1 and PKD2 genes. Results Of 463 eligible ADPKD patients from the population base of Germany, 32 (7%) were found to have IAs, diagnosed at the age of 2–71 years, 19 females and 13 males. Twenty (63%) of these 32 patients were symptomatic, whereas IAs were detected in an asymptomatic stage in 12 patients. IAs were multifocal in 12 and unifocal in 20 patients. In 26 patients (81%), IAs were diagnosed before end-stage renal failure. Twenty-five out of 27 unrelated index cases (93%) had no IAs or cerebral events documented in their relatives with ADPKD. In 16 unrelated index patients and 3 relatives, we detected germline mutations. The mutations were randomly distributed across the PKD1 gene in 14 and the PKD2 gene in 2 index cases. Questionnaires answered for 320/441 ADPKD patients without IAs revealed that only 45/320 (14%) had MR angiography. Conclusion In ADPKD, rupture of IAs occurs frequently before the start of dialysis, is only infrequently associated with a family history of IAs or subarachnoid hemorrhage, and is associated with mutations either of the PKD1 or the PKD2 gene of any type. Screening for IAs is widely insufficiently performed, should not be restricted to families with a history of cerebral events and should be started before end-stage renal failure. PMID:23139683

The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms.

PubMed

Reynolds, Matthew R; Buckley, Robert T; Indrakanti, Santoshi S; Turkmani, Ali H; Oh, Gerald; Crobeddu, Emanuela; Fargen, Kyle M; El Ahmadieh, Tarek Y; Naidech, Andrew M; Amin-Hanjani, Sepideh; Lanzino, Giuseppe; Hoh, Brian L; Bendok, Bernard R; Zipfel, Gregory J

2015-10-01

Vasopressor-induced hypertension (VIH) is an established treatment for patients with aneurysmal subarachnoid hemorrhage (SAH) who develop vasospasm and delayed cerebral ischemia (DCI). However, the safety of VIH in patients with coincident, unruptured, unprotected intracranial aneurysms is uncertain. This retrospective multiinstitutional study identified 1) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who required VIH therapy (VIH group), and 2) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who did not require VIH therapy (non-VIH group). All patients had previously undergone surgical or endovascular treatment for the presumed ruptured aneurysm. Comparisons between the VIH and non-VIH patients were made in terms of the patient characteristics, clinical and radiographic severity of SAH, total number of aneurysms, number of ruptured/unruptured aneurysms, aneurysm location/size, number of unruptured and unprotected aneurysms during VIH, severity of vasospasm, degree of hypervolemia, and degree and duration of VIH therapy. For the VIH group (n = 176), 484 aneurysms were diagnosed, 231 aneurysms were treated, and 253 unruptured aneurysms were left unprotected during 1293 total days of VIH therapy (5.12 total years of VIH therapy for unruptured, unprotected aneurysms). For the non-VIH group (n = 73), 207 aneurysms were diagnosed, 93 aneurysms were treated, and 114 unruptured aneurysms were left unprotected. For the VIH and non-VIH groups, the mean sizes of the ruptured (7.2 ± 0.3 vs 7.8 ± 0.6 mm, respectively; p = 0.27) and unruptured (3.4 ± 0.2 vs 3.2 ± 0.2 mm, respectively; p = 0.40) aneurysms did not differ. The authors observed 1 new SAH from a previously unruptured, unprotected aneurysm in each group (1 of 176 vs 1 of 73 patients; p = 0.50). Baseline patient characteristics and comorbidities were similar between groups. While the degree of hypervolemia was similar between the VIH and non-VIH patients (fluid balance over the first 10 days of therapy: 3146.2 ± 296.4 vs 2910.5 ± 450.7 ml, respectively; p = 0.67), VIH resulted in a significant increase in mean arterial pressure (mean increase over the first 10 days of therapy relative to baseline: 125.1% ± 1.0% vs 98.2% ± 1.2%, respectively; p < 0.01) and systolic blood pressure (125.6% ± 1.1% vs. 104.1% ± 5.2%, respectively; p < 0.01). For small, unruptured, unprotected intracranial aneurysms in SAH patients, the frequency of aneurysm rupture during VIH therapy is rare. The authors do not recommend withholding VIH therapy from these patients.

Comparison of endovascular repair with branched stent graft and open repair for aortic arch aneurysm.

PubMed

Kawatou, Masahide; Minakata, Kenji; Sakamoto, Kazuhisa; Nakatsu, Taro; Tazaki, Junichi; Higami, Hirooki; Uehara, Kyokun; Yamazaki, Kazuhiro; Inoue, Kanji; Kimura, Takeshi; Sakata, Ryuzo

2017-08-01

Although conventional open repair is our preference for patients with aortic arch aneurysms, we have often chosen thoracic endovascular aneurysm repair (TEVAR) with a handmade branched stent graft (bTEVAR) in high-risk patients. The aim of this study was to compare the midterm clinical outcomes of our bTEVAR technique to those of the open repair. Between January 2007 and December 2014, we treated 129 patients with aortic arch aneurysm by means of either conventional open repair (OPEN, n = 61) or bTEVAR (n = 68) at our institution. The mean ages were 70.5 ± 12.7 years in the OPEN group and 72.7 ± 12.5 years in the bTEVAR group (P = 0.32). The aetiologies included true aneurysm in 101 patients (78.3%) and chronic dissection in 26 (20.1%). There were 2 (3.3%) in-hospital deaths in the OPEN group and 3 (4.4%) in the bTEVAR group. The mean follow-up duration was 3.0 ± 2.1 years (2.4 ± 1.9 years in the OPEN group and 3.6 ± 2.3 years in the bTEVAR group). There was no difference in 5-year aneurysm-related mortality between groups (10.7% in OPEN vs 12.8% in bTEVAR, P = 0.50). In terms of late additional procedures, however, none were required in the OPEN group, whereas 10 (15.4%) additional endovascular repairs and 4 (6.2%) open repairs were required in the bTEVAR group. Our bTEVAR could be performed with low early mortality, and it yielded similar midterm aneurysm-related mortality to that of conventional open repair. However, these patients undergoing this technique required more late additional procedures than those undergoing conventional open repair. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Treatment of Wide-Neck Bifurcation Aneurysm Using "WEB Device Waffle Cone Technique".

PubMed

Mihalea, Cristian; Caroff, Jildaz; Rouchaud, Aymeric; Pescariu, Sorin; Moret, Jacques; Spelle, Laurent

2018-05-01

The endovascular treatment of wide-neck bifurcation aneurysms can be challenging and often requires the use of adjunctive techniques and devices. We report our first experience of using a waffle-cone technique adapted to the Woven Endoluminal Bridge (WEB) device in a large-neck basilar tip aneurysm, suitable in cases where the use of Y stenting or other techniques is limited due to anatomic restrictions. The procedure was complete, and angiographic occlusion of the aneurysm was achieved 24 hours post treatment, as confirmed by digital subtraction angiography. No complications occurred. The case reported here was not suitable for Y stenting or deployment of the WEB device alone, due to the small caliber of both posterior cerebral arteries and their origin at the neck level. The main advantage of this technique is that both devices have a controlled detachment system and are fully independent. To our knowledge, this technique has not been reported previously and this modality of treatment has never been described in the literature. Copyright © 2018 Elsevier Inc. All rights reserved.

Principles of neuroanesthesia in aneurysmal subarachnoid hemorrhage: The Helsinki experience.

PubMed

Randell, Tarja; Niemelä, Mika; Kyttä, Juha; Tanskanen, Päivi; Määttänen, Markku; Karatas, Ayse; Ishii, Keisuke; Dashti, Reza; Shen, Hu; Hernesniemi, Juha

2006-10-01

Aneurysmal subarachnoid hemorrhage is a devastating disease that is followed by a marked stress response affecting other organs besides the brain. The aim in the management of patients with aSAH is not only to prevent rebleedings by treating the aneurysm by either microneurosurgery or endovascular surgery, but also to evacuate acute space-occupying hematomas and to treat hydrocephalus. This review is based on the experience of the authors in the management of more than 7500 patients with aSAH treated in the Department of Neurosurgery at Helsinki University Central Hospital, Finland. The role of the neuroanesthesiologist together with the neurosurgeon may begin in the emergency department to assess and stabilize the general medical and neurologic status of the patients. Early preoperative management of patients in the NICU, prevention of rebleeding, and providing a slack brain during microneurosurgical procedures are further steps. Postoperative management, prevention, and treatment of possible medical complications and cerebrovascular spasm are as necessary as high-quality microsurgery. Multidisciplinary and professional teamwork is essential in the management of patients with cerebral aneurysms.

Hemodynamics of a Patient-Specific Aneurysm Model with Proper Orthogonal Decomposition

NASA Astrophysics Data System (ADS)

Han, Suyue; Chang, Gary Han; Modarres-Sadeghi, Yahya

2017-11-01

Wall shear stress (WSS) and oscillatory shear index (OSI) are two of the most-widely studied hemodynamic quantities in cardiovascular systems that have been shown to have the ability to elicit biological responses of the arterial wall, which could be used to predict the aneurysm development and rupture. In this study, a reduced-order model (ROM) of the hemodynamics of a patient-specific cerebral aneurysm is studied. The snapshot Proper Orthogonal Decomposition (POD) is utilized to construct the reduced-order bases of the flow using a CFD training set with known inflow parameters. It was shown that the area of low WSS and high OSI is correlated to higher POD modes. The resulting ROM can reproduce both WSS and OSI computationally for future parametric studies with significantly less computational cost. Agreement was observed between the WSS and OSI values obtained using direct CFD results and ROM results.

Wall Shear Stress Distribution in a Patient-Specific Cerebral Aneurysm Model using Reduced Order Modeling

NASA Astrophysics Data System (ADS)

Han, Suyue; Chang, Gary Han; Schirmer, Clemens; Modarres-Sadeghi, Yahya

2016-11-01

We construct a reduced-order model (ROM) to study the Wall Shear Stress (WSS) distributions in image-based patient-specific aneurysms models. The magnitude of WSS has been shown to be a critical factor in growth and rupture of human aneurysms. We start the process by running a training case using Computational Fluid Dynamics (CFD) simulation with time-varying flow parameters, such that these parameters cover the range of parameters of interest. The method of snapshot Proper Orthogonal Decomposition (POD) is utilized to construct the reduced-order bases using the training CFD simulation. The resulting ROM enables us to study the flow patterns and the WSS distributions over a range of system parameters computationally very efficiently with a relatively small number of modes. This enables comprehensive analysis of the model system across a range of physiological conditions without the need to re-compute the simulation for small changes in the system parameters.

Split-brain phenomena in anterior communicating artery aneurysm rupture: A case report.

PubMed

Korsakova, Natalya; Liebson, Elizabeth; Moskovich, Lena

2017-06-01

In 1976, a patient with an anterior communicating artery aneurysm (ACoAA) rupture (diagnosed on angiography) and sub-arachnoid hemorrhage (SAH) underwent serial neuropsychological testing revealing a classical anterior cerebral artery (ACA) spasm picture with severe anterograde amnesia of Korsakoff's type and dysexecutive syndrome. In addition, the patient demonstrated impaired hemispheric interaction with alien hand syndrome, dyscopia-dysgraphia, complete left ear neglect, and other, more complex, split-brain phenomena. He was evaluated by A. R. Luria in 1976. Following surgery the patient demonstrated gradual improvement. © 2017 The Institute of Psychology, Chinese Academy of Sciences and John Wiley & Sons Australia, Ltd.

Combined open proximal and stent-graft distal repair for distal arch aneurysms: an alternative to total debranching.

PubMed

Zierer, Andreas; Sanchez, Luis A; Moon, Marc R

2009-07-01

We present herein a novel, combined, simultaneous open proximal and stent-graft distal repair for complex distal aortic arch aneurysms involving the descending aorta. In the first surgical step, the transverse arch is opened during selective antegrade cerebral perfusion, and a Dacron graft (DuPont, Wilmington, DE) is positioned down the descending aorta in an elephant trunk-like fashion with its proximal free margin sutured circumferentially to the aorta just distal to the left subclavian or left common carotid artery. With the graft serving as the new proximal landing zone, subsequent endovascular repair is performed antegrade during rewarming through the ascending aorta.

Haptoglobin phenotype predicts cerebral vasospasm and clinical deterioration after aneurysmal subarachnoid hemorrhage.

PubMed

Ohnishi, Hiroyuki; Iihara, Koji; Kaku, Yasuyuki; Yamauchi, Keita; Fukuda, Kenji; Nishimura, Kunihiro; Nakai, Michikazu; Satow, Tetsu; Nakajima, Norio; Ikegawa, Masaya

2013-05-01

Vasospasm (VS) and delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) are thought to greatly affect prognosis. Haptoglobin (Hp) is a hemoglobin-binding protein expressed by a genetic polymorphism (1-1, 2-1, and 2-2). Our objects were to investigate whether the Hp phenotype could predict the incidence of cerebral infarction, favorable outcome, clinical deterioration by DCI, and angiographical VS after aneurysmal SAH. Ninety-five consecutive patients who underwent clipping or coil embolization were studied. Favorable functional outcome was defined as a modified Rankin Scale score of 0-2 at 3 months. Angiographical VS was diagnosed based on cerebral angiography findings performed between days 7 and 10 after SAH. The Hp 2-2 group had a significantly greater risk of angiographical VS than that of Hp 2-1 and 1-1 groups combined on univariate (odds ratio [OR]: 3.60, confidence interval [CI]: 1.49-8.67, P = .003) and multivariate logistic regression analyses after being adjusted for age, sex, Fisher groups, and other risk factors (OR: 3.75, CI: 1.54-9.16, P = .004). The Hp 2-2 group also showed the tendency of a greater risk of clinical deterioration by DCI with marginal significance on univariate and age- and sex-adjusted analyses (univariate OR: 2.46, CI: .90-6.74, P = .080; age- and sex-adjusted OR: 2.46, CI: .89-6.82, P = .080) but not after being adjusted for other multiple risk factors. The Hp 2-2 group was not associated with the favorable 3-month outcome and cerebral infarction (univariate: P = .867, P = .209; multivariate: P = .905, P = .292). The Hp phenotype seems to be associated with a higher rate of angiographical VS and clinical deterioration by DCI but does not affect the incidence of cerebral infarction and favorable outcome. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Utilization of Pipeline embolization device for treatment of ruptured intracranial aneurysms: US multicenter experience.

PubMed

Lin, Ning; Brouillard, Adam M; Keigher, Kiffon M; Lopes, Demetrius K; Binning, Mandy J; Liebman, Kenneth M; Veznedaroglu, Erol; Magarik, Jordan A; Mocco, J; Duckworth, Edward A; Arthur, Adam S; Ringer, Andrew J; Snyder, Kenneth V; Levy, Elad I; Siddiqui, Adnan H

2015-11-01

Utilization of the Pipeline embolization device (PED) in complex ruptured aneurysms has not been well studied. We evaluated the safety and effectiveness data from five participating US centers. Records of patients with ruptured cerebral aneurysms who underwent PED treatment between 2011 and 2013 were retrospectively reviewed. 26 patients with ruptured aneurysms underwent PED treatment (mean age 51.4 ± 13.2 years;16 women). At presentation, 8 patients (30.8%) had a Hunt-Hess grade of IV or above; 11 required extraventricular drain placement. Aneurysm morphologies were: 8 dissecting, 8 blister-like, 6 fusiform, and 4 saccular. There were 22 anterior circulation and 4 posterior circulation aneurysms. PED deployment was successful in all patients, with adjunctive coiling utilized in 12. Periprocedural complications occurred in 5 (19.2%), including 3 inhospital deaths. 23 patients (88.5%) had postoperative angiography at a mean of 5.9 months: 18 aneurysms (78.3%) were completely occluded, 3 (13.0%) had residual neck filling, and 2 (8.7%) had residual dome filling. All blister-type aneurysms were completely occluded at follow-up. Clinical follow-up was available for an average of 10.1 months (range 2-21 months), with one asymptomatic in-stent stenosis and one asymptomatic thromboembolic stroke noted. Good outcome (modified Rankin Scale (mRS) score of 0-2) was achieved in 20 patients (76.9%), fair (mRS 3-4) in 3 (11.5%), and 3 died (11.5%). The PED can be utilized for ruptured aneurysms and is a good option for blister-type aneurysms. However, due to periprocedural complications, it should be reserved for lesions that are difficult to treat by conventional clipping or coiling. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Decision-making and neurosurgeons' agreement in the management of aneurysmal subarachnoid haemorrhage based on computed tomography angiography.

PubMed

Maldaner, Nicolai; Burkhardt, Jan-Karl; Stienen, Martin Nikolaus; Goldberg, Johannes; Bervini, David; Bijlenga, Philippe; Croci, Davide; Zumofen, Daniel; D'Alonzo, Donato; Marbacher, Serge; Maduri, Rodolfo; Daniel, Roy Thomas; Serra, Carlo; Esposito, Giuseppe; Neidert, Marian C; Bozinov, Oliver; Regli, Luca

2018-02-01

To determine the neurosurgeon's agreement in aneurysmal subarachnoid haemorrhage (aSAH) management with special emphasis on the rater's level of experience. A secondary aim was to analyse potential aneurysm variables associated with the therapeutic recommendation. Basic clinical information and admission computed tomography angiography (CTA) images of 30 consecutive aSAH patients were provided. Twelve neurosurgeons independently evaluated aneurysm characteristics and gave recommendations regarding the emergency management and aneurysm occlusion therapy. Inter-rater variability and predictors of treatment recommendation were evaluated. There was an overall moderate agreement in treatment decision [κ = 0.43; 95% confidence interval ((CI), 0.387-0.474] with moderate agreement for surgical (κ = 0.43; 95% CI, 0.386-0.479) and endovascular treatment recommendation (κ = 0.45; 95% CI, 0.398-0.49). Agreement on detailed treatment recommendations including clip, coil, bypass, stent, flow diverter and ventriculostomy was low to moderate. Inter-rater agreement did not significantly differ between residents and consultants. Middle cerebral artery (MCA) aneurysm location was a positive predictor of surgical treatment [odds ratio (OR), 49.57; 95% CI, 10.416-235.865; p < 0.001], while patients aged >65 years (OR, 0.12; 95% CI, 0.03-0.0434; p = 0.001), fusiform aneurysm type (OR, 0.18; 95% CI, 0.044-0.747; p = 0.018) and intracerebral haematoma (ICA) aneurysm location (OR, 0.24; 95% CI, 0.088-0.643; p = 0.005) were associated with a recommendation for endovascular treatment. Agreement on aSAH management varies considerably across neurosurgeons, while therapeutic decision-making is challenging on an individual patient level. However, patients aged >65 years, fusiform aneurysm shape and ICA location were associated with endovascular treatment recommendation, while MCA aneurysm location remains a surgical domain in the opinion of neurosurgeons without formal endovascular training.

Reversible cerebral vasoconstriction syndrome with involvement of external carotid artery branches.

PubMed

Shaik, S; Chhetri, S K; Roberts, G; Wuppalapati, S; Emsley, H C A

2014-07-01

A 44-year-old woman presented with recurrent episodes of thunderclap headache. Neurological examination and computed tomography brain imaging were unremarkable. Cerebrospinal fluid findings were consistent with subarachnoid hemorrhage. Computed tomography angiography of the circle of Willis showed multiple areas of segmental vasoconstriction. This finding was confirmed on cerebral catheter angiography, with segmental vasoconstriction involving bilateral internal carotid, posterior cerebral, and external carotid branches. No aneurysm or other vascular abnormality was identified. She received treatment with nimodipine. A selective serotonin reuptake inhibitor, started 4 weeks earlier, was discontinued. Follow-up angiography after 3 months demonstrated complete resolution of the segmental vasoconstriction, confirming the diagnosis of reversible cerebral vasoconstriction syndrome (RCVS). She remained headache free at follow-up. To our knowledge, external carotid artery branch involvement in RCVS has been described only in one previous occasion.

Comparison of eye-lens doses imparted during interventional and non-interventional neuroimaging techniques for assessment of intracranial aneurysms.

PubMed

Guberina, N; Dietrich, U; Forsting, M; Ringelstein, A

2018-02-01

A neurointerventional examination of intracranial aneurysms often involves the eye lens in the primary beam of radiation. To assess and compare eye-lens doses imparted during interventional and non-interventional imaging techniques for the examination of intracranial aneurysms. We performed a phantom study on an anthropomorphic phantom (ATOM dosimetry phantom 702-D; CIRS, Norfolk, Virginia, USA) and assessed eye-lens doses with thermoluminescent dosimeters (TLDs) type 100 (LiF:Mg, Ti) during (1) interventional (depiction of all cerebral arteries with triple 3D-rotational angiography and twice 2-plane DSA anteroposterior and lateral projections) and (2) non-interventional (CT angiography (CTA)) diagnosis of intracranial aneurysms. Eye-lens doses were calculated following recommendations of the ICRP 103. Image quality was analysed in retrospective by two experienced radiologists on the basis of non-interventional and interventional pan-angiography examinations of patients with incidental aneurysms (n=50) on a five-point Likert scale. The following eye-lens doses were assessed: (1) interventional setting (triple 3D-rotational angiography and twice 2-plane DSA anteroposterior and lateral projections) 12 mGy; (2) non-interventional setting (CTA) 4.1 mGy. Image quality for depiction of intracranial aneurysms (>3 mm) was evaluated as good by both readers for both imaging techniques. Eye-lens doses are markedly higher during the interventional than during the non-interventional diagnosis of intracranial aneurysms. For the eye-lens dose, CTA offers considerable radiation dose savings in the diagnosis of intracranial aneurysms. 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/.

Procedure-related haemorrhage in embolisation of intracranial aneurysms with Guglielmi detachable coils.

PubMed

Kwon, B J; Han, M H; Oh, C W; Kim, K H; Chang, K H

2003-08-01

We reviewed the haemorrhagic complications of the endovascular treatment of intracranial aneurysms, in terms of frequency, pre-embolisation clinical status, clinical and radiological manifestations, management and prognosis. In 275 patients treated for 303 aneurysms over 7 years we had seven (one man and six women--2.3%) with haemorrhage during or immediately after endovascular treatment. All procedures were performed with a standardised protocol of heparinisation and anaesthesia. Four had ruptured aneurysms, two at the tip of the basilar artery, and one ach on the internal carotid and posterior cerebral artery, treated after 12, 5, 14, and 2 days, respectively, three were in Hunt and Hess grade 2 and one in grade 1. Bleeding occurred during coiling in three, after placement of at least four coils, and during manipulation of the guidewire to enter the aneurysm in the fourth. Haemorrhage was manifest as extravasation of contrast medium, with a sudden rise in systolic blood pressure in three patients. The other three patients had unruptured aneurysms; they had stable blood pressure and angiographic findings during the procedure, but one, under sedation, had seizures immediately after insertion of four coils, and the other two had seizures, headache and vomiting on the day following the procedure. Heparin reversal with protamine sulphate was started promptly started when bleeding was detected in four patients, and the embolisation was completed with additional coils in three. Emergency ventricular drainage was performed in the two patients with ruptured aneurysm and one with an unruptured aneurysm who had abnormal neurological responses or hydrocephalus. The bleeding caused a third nerve palsy in one patient, which might have been due to ischaemia and progressively improved.

CT angiography for one-year follow-up of intracranial aneurysms treated with the WEB device: Utility in evaluating aneurysm occlusion and WEB compression at one year.

PubMed

Raoult, Hélène; Eugène, François; Le Bras, Anthony; Mineur, Géraldine; Carsin-Nicol, Béatrice; Ferré, Jean-Christophe; Gauvrit, Jean-Yves

2018-03-07

The WEB is an innovative flow disruption device for cerebral aneurysm embolization with rapidly expanding indications. Our purpose was to evaluate the diagnostic performance of computed tomography angiography (CTA) at 1-year follow-up of aneurysms treated with the WEB. Between April 2014 and May 2016, the study prospectively included patients treated with the WEB at our institution, and followed up within 24hours by CTA and at 1year by CTA, time-of-flight magnetic resonance angiography (TOF MRA) and digital subtraction angiography (DSA). The diagnostic quality of imaging data was assessed based on the confidence index, artifacts, and WEB shape depiction. The imaging diagnostic performance was assessed using 3 criteria at 1year: aneurysm occlusion status and worsening, and WEB shape compression. Interobserver and intermodality agreement was determined by calculating κ values. The study ultimately included 16 patients (9 women, mean age 53±7.6years). CTA quality confidence was scored as 2/2, artifacts 0.4/2 and WEB shape depiction 1.9/2, superior to TOF MRA for the latter two criteria. Aneurysm occlusion was adequate in 93.7% of patients, with CTA showing excellent interobserver reproducibility and agreement with DSA on a 4-grade scale (κ=1.00), while TOF MRA yielded good reproducibility (κ=0.76) and agreement with DSA (κ=0.69). CTA also identified aneurysm occlusion worsening (43.7%) and WEB compression (81.2%) in excellent agreement with DSA (κ=0.85 and 1.00). CTA is a reproducible and reliable technique for the follow-up of aneurysms treated with the WEB device. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Retrograde suction decompression of a large internal carotid aneurysm using a balloon guide catheter combined with a blood-returning circuit and STA-MCA bypass: a technical note.

PubMed

Matano, Fumihiro; Mizunari, Takayuki; Kominami, Shushi; Suzuki, Masanori; Fujiki, Yu; Kubota, Asami; Kobayashi, Shiro; Murai, Yasuo; Morita, Akio

2017-04-01

It is difficult to treat large internal carotid aneurysms with simple surgical clipping. Here, we present a retrograde suction decompression (RSD) procedure for large internal carotid aneurysms using a balloon guide catheter combined with a blood-returning circuit and a superficial temporal artery to middle cerebral artery (STA-MCA) bypass.All patients underwent an STA-MCA bypass before the temporary occlusion of the internal carotid artery (ICA). A 6-French sheath was inserted into the common carotid artery (CCA), and a 6-French Patrive balloon catheter was placed into the ICA 5 cm past the bifurcation. Aneurysm exposure was obtained; temporary clips were placed on the proximal M1, A1, and posterior communicating (Pcom) segments; and an extension tube was then connected to the balloon catheter. A three-way stopcock was placed, and aspiration was performed through the device to collapse the aneurysm. The aspirated blood was returned to a venous line with an added heparin to prevent anemia after aspiration. During the decompression, the blood flow to the cortical area was supplied through the STA-MCA bypass. After the aneurysm collapse, the surgeon carefully dissected the perforating artery from the aneurysm dome or neck, and permanent clips were then placed on the aneurysm neck. Our procedure has several advantages, such as STA-MCA bypass without external carotid artery occlusion for preventing ischemic complications of the cortical area, anemia may be avoided because of the return of the aspirated blood, and a hybrid operation room is not required to perform this method.

Identification of two novel critical mutations in PCNT gene resulting in microcephalic osteodysplastic primordial dwarfism type II associated with multiple intracranial aneurysms.

PubMed

Li, Fei-Feng; Wang, Xu-Dong; Zhu, Min-Wei; Lou, Zhi-Hong; Zhang, Qiong; Zhu, Chun-Yu; Feng, Hong-Lin; Lin, Zhi-Guo; Liu, Shu-Lin

2015-12-01

Microcephalic osteodysplastic primordial dwarfism type II (MOPD II) is a highly detrimental human autosomal inherited recessive disorder. The hallmark characteristics of this disease are intrauterine and postnatal growth restrictions, with some patients also having cerebrovascular problems such as cerebral aneurysms. The genomic basis behind most clinical features of MOPD II remains largely unclear. The aim of this work was to identify the genetic defects in a Chinese family with MOPD II associated with multiple intracranial aneurysms. The patient had typical MOPD II syndrome, with subarachnoid hemorrhage and multiple intracranial aneurysms. We identified three novel mutations in the PCNT gene, including one single base alteration (9842A>C in exon 45) and two deletions (Del-C in exon 30 and Del-16 in exon 41). The deletions were co-segregated with the affected individual in the family and were not present in the control population. Computer modeling demonstrated that the deletions may cause drastic changes on the secondary and tertiary structures, affecting the hydrophilicity and hydrophobicity of the mutant proteins. In conclusion, we identified two novel mutations in the PCNT gene associated with MOPD II and intracranial aneurysms, and the mutations were expected to alter the stability and functioning of the protein by computer modeling.

Hyperperfusion syndrome after trapping with high-flow bypass for a giant paraclinoid internal carotid artery aneurysm.

PubMed

Mohri, Masanao; Ichinose, Toshiya; Uchiyama, Naoyuki; Misaki, Kouichi; Nambu, Iku; Takabatake, Yasushi; Nakada, Mitsutoshi

2018-04-21

Hyperperfusion syndrome associated with aneurysm surgery is rare. The occurrence of the syndrome after trapping with high-flow bypass has not been described previously. Herein, we present a case of the syndrome occurring after trapping with high-flow bypass of an unruptured giant paraclinoid internal carotid artery (ICA) aneurysm. The patient was a 68-year-old woman with progressive loss of vision in her left eye. After a diagnosis of a left giant ICA aneurysm, she underwent successful trapping with high-flow bypass. No new neurological deficits were observed after surgery. Computed tomography (CT) on the same day and magnetic resonance imaging (MRI) on the next day revealed no hemorrhage or infarction. The patient had a headache and transit motor aphasia on postoperative day (POD) 8. Arterial spin-labeling magnetic resonance perfusion image on the same day and single photon emission CT scan on POD 10 demonstrated hyperperfusion in the left cerebral cortex. The symptoms gradually improved over a week and she had no new neurological deficits when discharged from hospital. This report suggests that, although rare, hyperperfusion syndrome after trapping with high-flow bypass should be considered in giant aneurysmal patients if they present with headache and neurological deficits in a delayed period. Copyright © 2018. Published by Elsevier Inc.

Study of Cognitive Impairments Following Clipping of Ruptured Anterior Circulation Aneurysms.

PubMed

Mohanty, Manju; Dhandapani, Sivashanmugam; Gupta, Sunil Kumar; Shahid, Adnan Hussain; Patra, Debi Prasad; Sharma, Anchal; Mathuriya, Suresh Narayan

2018-06-16

The cognitive impairments following treatment of ruptured aneurysms have often been underestimated. This study was to assess their prevalence and analyze various associated factors. Patients who were operated for ruptured anterior circulation aneurysms and discharged in Glasgow outcome scale 4-5 were studied at 3 months for various cognitive impairments. Continuous scales of memory (recent, remote, verbal, visual and overall memory), verbal fluency (phonemic and category fluency) and others were studied in relation to various factors. Univariate and multivariate analyses were performed using SPSS21. There were a total of 87 patients included in our study. Phonemic fluency was the most affected noted in 66% of patients. While 56% had some memory related impairments, 13 (15%) and 6 (7%) had moderate and severe deficits in recent memory, and 19 (22%) and 12 (14%) had moderate and severe deficits in remote memory respectively. Patients operated for anterior cerebral artery (ACA) aneurysms have significantly greater impairments in recent (34% vs 8%) and remote memory (43% vs 28%) compared to the rest, both in univariate (P values 0.01 & 0.002 respectively) and multivariate analyses (P values 0.01 & 0.03 respectively). ACA related aneurysms also had significantly greater independent impairments in phonemic fluency (P-value 0.04), compared to others. The clinical grade had a significant independent impact only on remote memory (P-value 0.01). Cognitive impairments are frequent following treatment of ruptured anterior circulation aneurysms. Impairments in recent memory, remote memory, and phonemic fluency are significantly greater following treatment of ACA related aneurysms, compared to others, independent of other factors. Copyright © 2018. Published by Elsevier Inc.

An examination of aneurysm rerupture rates with epsilon aminocaproic acid.

PubMed

Schuette, Albert J; Hui, Ferdinand K; Obuchowski, Nancy A; Walkup, Raymond R; Cawley, Charles M; Barrow, Daniel L; Samuels, Owen B

2013-08-01

Epsilon aminocaproic acid (EACA) has been used in the past to prevent cerebral aneurysm rerupture. Recent studies have indicated that short-term treatment with EACA can lower rebleeding rates without significantly increasing ischemic or thrombotic complications or permanent shunt rates. The goal of this study is to determine the efficacy of EACA in the prevention of aneurysm rerupture at a high volume subarachnoid hemorrhage center. We conducted a retrospective study of 355 consecutive subarachnoid hemorrhage patients over a 2-year period under our current protocol for EACA use. Patients were divided by presentation time to our institution and whether the patient received EACA. The primary endpoints of the study were rebleeding rates, ischemic complications, thrombotic complications, vasospasm, shunt rates, and outcomes. Rerupture rates were reduced by half in the entire pool of patients on EACA after controlling for Hunt and Hess Scores and Fisher Scores. In patients who received early aneurysm treatment, this effect persisted but was non-statistically significant due to the small numbers of reruptures. In addition, there was no evidence to suggest that EACA increased ischemic or thrombotic complications, vasospasm, or VPS rates. In patients presenting earlier than 24 h to our institution, there was a non-significant trend toward worse outcomes after EACA use. This trend was reversed in patients arriving after 24 h. There is evidence to suggest that EACA is protective from aneurysm rerupture without significant ischemic or thrombotic complications when used for less than 72 h. However, if the aneurysm is treated, this effect is modest indicating that early aneurysm treatment remains the gold standard for rerupture prevention.

Novel device and technique for minimally invasive intracerebral hematoma evacuation in the same setting of a ruptured intracranial aneurysm: combined treatment in the neurointerventional angiography suite.

PubMed

Turner, Raymond D; Vargas, Jan; Turk, Aquilla S; Chaudry, M Imran; Spiotta, Alejandro M

2015-03-01

The presence of intracerebral hematoma from aneurysm rupture is an indication for craniotomy for clot evacuation and aneurysm clipping. Some centers have begun securing aneurysms with coil embolization followed by clot evacuation in the operating room. This approach requires transporting a patient from the angiography suite to the operating room, which can take valuable time and resources. To report our experience with 3 cases in which a novel technique for minimally invasive evacuation of intracerebral hematomas after endovascular treatment of ruptured intracranial aneurysms was used. The Penumbra Apollo system can be used in the angiography suite in conjunction with neuroendovascular techniques to simultaneously address a symptomatic hematoma associated with a ruptured aneurysm. Standard preoperative computed tomography angiography was performed on arrival to the emergency department. The patients underwent diagnostic cerebral angiography followed by balloon-assisted coil embolization and then remained in the neurointerventional suite for intracerebral hematoma evacuation with the Apollo system. All patients tolerated coil embolization and hematoma evacuation well. The combined procedures lasted <3 hours in both cases. Two patients were eventually discharged to acute rehabilitation facilities less than a month after their initial insult, and 1 has been cleared to return to work. The other patient was transferred to hospice care. The Apollo aspiration system appears to be a safe and effective minimally invasive option for intracerebral hematoma evacuation, particularly when coupled with endovascular embolization of ruptured intracranial aneurysms. Future work will address which patient population is most likely to benefit from this promising technique.

[Acute brain expansion during emergency neck clipping surgery for cerebral aneurysms in a patient with dilated cardiomyopathy].

PubMed

Nakao, M; Kawaguchi, R; Nakatani, K; Niinai, H; Takezaki, T; Hanaki, C

1996-06-01

A 61-year-old male with coma and undiagnosed dilated cardiomyopathy received emergency cerebral aneurysm surgery. Anesthesia was induced with thiamylal, fentanyl and vecuronium and maintained with 66% N2O and 1.0% isoflurane. Five hundred ml of 20% mannitol was infused in 30 min. At the end of the infusion, hypotension occurred. Immediately after the injection of ephedrine, acute brain swelling was observed. The operation was switched to external decompression. Post-operative echocardiography revealed the presence of dilated cardiomyopathy (DCM). The ejection fraction was 34%. Two weeks later, the second operation was scheduled. The anesthesia was induced with fentanyl, midazolam and vecuronium and maintained with N2O and 0.7% isoflurane. Nitroglycerine, lidocaine, PGE1, dopamine and dobutamine were infused throughout the operation. Five hundred ml of 20% mannitol was infused in 60 min. There were no considerable hemodynamic changes and no episode of brain expansion during operation. We conclude that the rapid infusion of mannitol can trigger acute cardiac failure and brain edema in patients with DCM.

Traumatic occlusion of the anterior cerebral artery--case report.

PubMed

Ishibashi, A; Kubota, Y; Yokokura, Y; Soejima, Y; Hiratsuka, T

1995-12-01

A 71-year-old female presented with posttraumatic occlusion of the anterior cerebral artery (ACA) after a road accident in which she was hit in the mid-frontal region. Initial computed tomography (CT) demonstrated frontal skull fractures and pneumocephalus. High density areas were also identified in the right basal cisterns, suggesting traumatic subarachnoid hemorrhage. She was alert on admission, but with attendant shock due to crush wounds. Her condition rapidly deteriorated and an emergency amputation of her left leg was performed. After aggressive treatment with transfusion and infusion, her systolic pressure increased to 120 mmHg. Her consciousness remained disturbed. Serial CT disclosed hemorrhagic infarction in the entire medial side of the right frontal lobe. Magnetic resonance angiography demonstrated decreased flow voids in the bilateral A1 segments and right ACA, and a basilar artery aneurysm, which was unruptured clinically. Three weeks after the injury, she regained consciousness. Six months later, she had motor aphasia and left upper extremity weakness. The clinicopathological mechanism causing the traumatic occlusion of the ACA in the present case was probably dissecting aneurysm.

Foreign Body Emboli following Cerebrovascular Interventions: Clinical, Radiographic, and Histopathologic Features.

PubMed

Shapiro, M; Ollenschleger, M D; Baccin, C; Becske, T; Spiegel, G R; Wang, Y; Song, X; Raz, E; Zumofen, D; Potts, M B; Nelson, P K

2015-11-01

Foreign material emboli following cerebral, cardiac, and peripheral catheterizations have been reported since the mid-1990s. Catheter coatings have been frequently implicated. The most recent surge of interest in this phenomenon within the neurointerventional community is associated with procedures using flow-diversion devices for the treatment of cerebral aneurysms. Following coil-supported Pipeline embolization in 4 cases and stent-supported coiling in 1, 5 patients developed multiple subcentimeter enhancing lesions, usually with surrounding edema and variable magnetic susceptibility in the vascular territories of the treated aneurysms. Conventional angiography findings were unrevealing. Laboratory work-up showed mild CSF protein elevation with no leukocytosis. Brain biopsy in 2 cases revealed granulomatous angiitis encasing foreign material, identical in stain appearance to a polyvinylpyrrolidone catheter coating. Corticosteroid administration typically produced clinical improvement. A heterogeneous radiographic and clinical course was noted, with rise and fall in the number of enhancing lesions in 2 patients and persistence in others. The etiology may be related to widespread adoption of increasingly sophisticated catheterization techniques. © 2015 by American Journal of Neuroradiology.

Magnetic Resonance Imaging Susceptibility-Weighted Imaging Lesion and Contrast Enhancement May Represent Infectious Intracranial Aneurysm in Infective Endocarditis.

PubMed

Cho, Sung-Min; Rice, Cory; Marquardt, Robert J; Zhang, Lucy Q; Khoury, Jean; Thatikunta, Prateek; Buletko, Andrew B; Hardman, Julian; Uchino, Ken; Wisco, Dolora

2017-01-01

Infectious intracranial aneurysm (IIA) can complicate infective endocarditis (IE). We aimed to describe the magnetic resonance imaging (MRI) characteristics of IIA. We reviewed IIAs among 116 consecutive patients with active IE by conducting a neurological evaluation at a single tertiary referral center from January 2015 to July 2016. MRIs and digital cerebral angiograms (DSA) were reviewed to identify MRI characteristics of IIAs. MRI susceptibility weighted imaging (SWI) was performed to collect data on cerebral microbleeds (CMBs) and sulcal SWI lesions. Out of 116 persons, 74 (63.8%) underwent DSA. IIAs were identified in 13 (17.6% of DSA, 11.2% of entire cohort) and 10 patients with aneurysms underwent MRI with SWI sequence. Nine (90%) out of 10 persons with IIAs had CMB >5 mm or sulcal lesions in SWI (9 in sulci, 6 in parenchyma, and 5 in both). Five out of 8 persons who underwent MRI brain with contrast had enhancement within the SWI lesions. In a multivariate logistic regression analysis, both sulcal SWI lesions (p < 0.001, OR 69, 95% CI 7.8-610) and contrast enhancement (p = 0.007, OR 16.5, 95% CI 2.3-121) were found to be significant predictors of the presence of IIAs. In the individuals with IE who underwent DSA and MRI, we found that neuroimaging characteristics, such as sulcal SWI lesion with or without contrast enhancement, are associated with the presence of IIA. © 2017 S. Karger AG, Basel.

Cerebral Aneurysm Clipping Surgery Simulation Using Patient-Specific 3D Printing and Silicone Casting.

PubMed

Ryan, Justin R; Almefty, Kaith K; Nakaji, Peter; Frakes, David H

2016-04-01

Neurosurgery simulator development is growing as practitioners recognize the need for improved instructional and rehearsal platforms to improve procedural skills and patient care. In addition, changes in practice patterns have decreased the volume of specific cases, such as aneurysm clippings, which reduces the opportunity for operating room experience. The authors developed a hands-on, dimensionally accurate model for aneurysm clipping using patient-derived anatomic data and three-dimensional (3D) printing. Design of the model focused on reproducibility as well as adaptability to new patient geometry. A modular, reproducible, and patient-derived medical simulacrum was developed for medical learners to practice aneurysmal clipping procedures. Various forms of 3D printing were used to develop a geometrically accurate cranium and vascular tree featuring 9 patient-derived aneurysms. 3D printing in conjunction with elastomeric casting was leveraged to achieve a patient-derived brain model with tactile properties not yet available from commercial 3D printing technology. An educational pilot study was performed to gauge simulation efficacy. Through the novel manufacturing process, a patient-derived simulacrum was developed for neurovascular surgical simulation. A follow-up qualitative study suggests potential to enhance current educational programs; assessments support the efficacy of the simulacrum. The proposed aneurysm clipping simulator has the potential to improve learning experiences in surgical environment. 3D printing and elastomeric casting can produce patient-derived models for a dynamic learning environment that add value to surgical training and preparation. Copyright © 2016 Elsevier Inc. All rights reserved.

Suture retraction technique to prevent parent vessel obstruction following aneurysm tandem clipping.

PubMed

Rayan, Tarek; Amin-Hanjani, Sepideh

2015-08-01

With large or giant aneurysms, the use of multiple tandem clips can be essential for complete obliteration of the aneurysm. One potential disadvantage, however, is the considerable cumulative weight of these clips, which may lead to kinking of the underlying parent vessels and obstruction of flow. The authors describe a simple technique to address this problem, guided by intraoperative blood flow measurements, in a patient with a ruptured near-giant 2.2 × 1.7-cm middle cerebral artery bifurcation aneurysm that was treated with the tandem clipping technique. A total of 11 clips were applied in a vertical stacked fashion. The cumulative weight of the clips caused kinking of the temporal M2 branch of the bifurcation with reduction of flow. A 4-0 Nurolon suture tie was applied to the hub of one of the clips and was tethered to the dura of the sphenoid ridge by a small mini-clip and reinforced by application of tissue sealant. The patient underwent intraoperative indocyanine green videoangiography as well as catheter angiography, which demonstrated complete aneurysmal obliteration and preservation of vessel branches. Postoperative angiography confirmed patency of the bifurcation vessels with mild vasospasm. The patient had a full recovery with no postoperative complications and was neurologically intact at her 6-month follow-up. The suture retraction technique allows a simple solution to parent vessel obstruction following aneurysm tandem clipping, in conjunction with the essential guidance provided by intraoperative flow measurements.

Hemodynamics in a giant intracranial aneurysm characterized by in vitro 4D flow MRI

PubMed Central

Schiavazzi, Daniele; Moen, Sean; Jagadeesan, Bharathi; Van de Moortele, Pierre-François; Coletti, Filippo

2018-01-01

Experimental and computational data suggest that hemodynamics play a critical role in the development, growth, and rupture of cerebral aneurysms. The flow structure, especially in aneurysms with a large sac, is highly complex and three-dimensional. Therefore, volumetric and time-resolved measurements of the flow properties are crucial to fully characterize the hemodynamics. In this study, phase-contrast Magnetic Resonance Imaging is used to assess the fluid dynamics inside a 3D-printed replica of a giant intracranial aneurysm, whose hemodynamics was previously simulated by multiple research groups. The physiological inflow waveform is imposed in a flow circuit with realistic cardiovascular impedance. Measurements are acquired with sub-millimeter spatial resolution for 16 time steps over a cardiac cycle, allowing for the detailed reconstruction of the flow evolution. Moreover, the three-dimensional and time-resolved pressure distribution is calculated from the velocity field by integrating the fluid dynamics equations, and is validated against differential pressure measurements using precision transducers. The flow structure is characterized by vortical motions that persist within the aneurysm sac for most of the cardiac cycle. All the main flow statistics including velocity, vorticity, pressure, and wall shear stress suggest that the flow pattern is dictated by the aneurysm morphology and is largely independent of the pulsatility of the inflow, at least for the flow regimes investigated here. Comparisons are carried out with previous computational simulations that used the same geometry and inflow conditions, both in terms of cycle-averaged and systolic quantities. PMID:29300738

Effect of nitrous oxide use on long-term neurologic and neuropsychological outcome in patients who received temporary proximal artery occlusion during cerebral aneurysm clipping surgery.

PubMed

Pasternak, Jeffrey J; McGregor, Diana G; Lanier, William L; Schroeder, Darrell R; Rusy, Deborah A; Hindman, Bradley; Clarke, William; Torner, James; Todd, Michael M

2009-03-01

The authors explored the relationship between nitrous oxide use and neurologic and neuropsychological outcome in a population of patients likely to experience intraoperative cerebral ischemia: those who had temporary cerebral arterial occlusion during aneurysm clipping surgery. A post hoc analysis of a subset of the data from the Intraoperative Hypothermia for Aneurysm Surgery Trial was conducted. Only subjects who had temporary arterial occlusion during surgery were included in the analysis. Metrics of short-term and long-term (i.e., 3 months after surgery) outcome were evaluated via both univariate and multivariate logistic regression analysis. An odds ratio (OR) greater than 1.0 denotes a worse outcome in patients receiving nitrous oxide. The authors evaluated 441 patients, of which 199 received nitrous oxide. Patients receiving nitrous oxide had a greater risk of delayed ischemic neurologic deficits (i.e., the clinical manifestation of vasospasm) (OR, 1.78, 95% confidence interval [CI], 1.08-2.95; P = 0.025). However, at 3 months after surgery, there was no difference in any metric of gross neurologic outcome: Glasgow Outcome Score (OR, 0.67; CI, 0.44-1.03; P = 0.065), Rankin Score (OR, 0.74; CI, 0.47-1.16; P = 0.192), National Institutes of Health Stroke Scale (OR, 1.02; CI, 0.66-1.56; P = 0.937), or Barthel Index (OR, 0.69; CI, 0.38-1.25; P = 0.22). The risk of impairment on at least one test of neuropsychological function was reduced in those who received nitrous oxide (OR, 0.56; CI, 0.36-0.89; P = 0.013). In this patient population, use of nitrous oxide was associated with an increased risk for the development of delayed ischemic neurologic deficits; however, there was no evidence of detriment to long-term gross neurologic or neuropsychological outcome.

[Clinical application of retrograde cerebral perfusion for brain protection during the surgery of ascending aortic aneurysm: 50 cases report].

PubMed

Dong, Pei-qing; Guan, Yu-long; He, Mei-ling; Yang, Jing; Wan, Cai-hong; Du, Shun-ping

2003-02-01

To assess retrospectively the effects of different protective methods on brain in ascending aortic aneurysm surgery. In 65 patients, aneurysm was dissected to the aortic arch or right arch. To protect brain, deep hypothermic circulatory arrest (DHCA) combined with retrograde cerebral perfusion (RCP) through the superior vena cava (n = 50) and simple DHCA (n = 15) were used during the procedure. Blood samples for lactic acid level from the jugular vein were compared in both groups at different phase, and perfusion blood distribution and oxygen content difference between the perfused and returned blood were measured in some RCP patients. The DHCA time was 35.9 +/- 18.8 min (10.0 - 63.0 min) and DHCA + RCP time was 45.5 +/- 17.2 min (16.0 - 81.0 min). The resuscitation time was 7.1 +/- 1.6 h (4.4 - 9.4 h) in DHCA patients and 5.4 +/- 2.2 h (2.0 - 9.0 h) in RCP patients. Operation death was 3/15 in the DHCA group and 1/50 in the RCP patients. Central nervous complication existed in 3/12 of DHCA patients and 1/49 of RCP patients (P < 0.01). The overall survival rate was 96% (RCP) vs 67% (DHCA), central nervous system dysfunction was 20% in DHCA vs 2% in RCP (P < 0.01). The blood lactic acid level increased significantly after reperfusion in DHCA than in RCP. The blood distribution measurement approximated to 20% of the perfused blood returned from arch vessels. Oxygen content between perfused and returned blood showed that oxygen uptake was adequate in the RCP group. The application of RCP could prolong the safety duration of circulation arrest. Cerebral perfusion may reep the brain cool and flush out particulate and air embolism. Open anastomosis of the aortic arch to the prosthesis can be safely performed. RCP is acceptable for brain protection in clinical practice.

The outcome of a surgical protocol based on ischemia overprotection in large and giant aneurysms of the anterior cerebral circulation.

PubMed

Imai, Hideaki; Watanabe, Katsushige; Miyagishima, Takaaki; Yoshimoto, Yuhei; Kin, Taichi; Nakatomi, Hirofumi; Saito, Nobuhito

2016-07-01

Aiming to define the optimal treatment of large and giant aneurysms (LGAs) in the anterior circulation, we present our surgical protocol and patient outcome. A series of 42 patients with intracavernous LGAs (n = 16), paraclinoid (C2) LGAs (n = 17), and peripheral (middle cerebral artery-MCA or anterior cerebral artery-ACA) LGAs (n = 9) were treated after bypass under motor evoked potential (MEP) monitoring. Preoperatively, three categories of ischemic tolerance during internal carotid artery (ICA) occlusion were defined on conventional angiography: optimal, suboptimal, and insufficient collaterals. Accordingly, three types of bypass: low flow (LFB), middle flow (MFB) and high flow (HFB) were applied for the cases with optimal, suboptimal, and insufficient collaterals, respectively. Outcome was evaluated by the Glasgow Outcome Scale (GOS). All patients had excellent GOS score except one, who suffered a major ischemic stroke immediately after surgery for a paraclinoid lesion. Forty-one patients were followed up for 87.1 ± 40.1 months (range 13-144 months). Intracavernous LGAs were all treated by proximal occlusion with bypass surgery. Of paraclinoid LGA patients, 15 patients had direct clipping under suction decompression and other 2 patients with recurrent aneurysms had ICA (C2) proximal clipping with HFB. MEP monitoring guided for temporary clipping time and clip repositioning, observing significant MEP changes for up to 6 min duration. Of 9 peripheral LGAs patients 7 MCA LGAs had reconstructive clipping (n = 4) or trapping (n = 3) with bypass including LFB in 3 cases, MFB in 1 and HFB in 1. Two ACA LGAs had clipping (n = 1) or trapping (n = 1) with A3-A3 bypass. The applied protocol provided excellent results in intracavernous, paraclinoid, and peripheral thrombosed LGAs of the anterior circulation.

Fat and neurosurgery: does obesity affect outcome after intracranial surgery?

PubMed

Schultheiss, Kim E; Jang, Yeon Gyoe; Yanowitch, Rachel N; Tolentino, Jocelyn; Curry, Daniel J; Lüders, Jürgen; Asgarzadie-Gadim, Farbod; Macdonald, R Loch

2009-02-01

Obesity has been linked to increased morbidity and mortality after some surgical procedures. The purpose of this study was to determine whether obesity affects outcome after general neurosurgery and subarachnoid hemorrhage (SAH). Three data sets were analyzed, including a retrospective review of 404 patients undergoing cranial and spinal neurosurgical procedures, a prospective collection of 100 patients with aneurysmal SAH, and data from 3567 patients with aneurysmal SAH who were entered into randomized clinical trials of tirilazad. For each data set, outcome was assessed by mortality, postoperative morbidity, and Glasgow Outcome Scale score. Prognostic factors, including body weight and body mass index, were tested for their effect on these outcomes using multivariable logistic regression. For patients undergoing general cranial and spinal neurosurgery, independent predictors of morbidity and mortality were age, American Society of Anesthesia class, disseminated malignancy, emergency surgery, and increased duration of surgery. For patients with SAH, score on the Glasgow Outcome Scale was associated with age and admission Glasgow Coma Scale score. In the tirilazad data set, multiple factors were associated with score on the Glasgow Outcome Scale, but, as with the other 2 data sets, body weight had no relationship to outcome. Obesity may have less effect on the outcome of patients with mainly cranial neurosurgical disease and aneurysmal SAH than it does on patients undergoing other types of surgery.

How to Perfuse: Concepts of Cerebral Protection during Arch Replacement

PubMed Central

Habertheuer, Andreas; Wiedemann, Dominik; Kocher, Alfred; Laufer, Guenther; Vallabhajosyula, Prashanth

2015-01-01

Arch surgery remains undoubtedly among the most technically and strategically challenging endeavors in cardiovascular surgery. Surgical interventions of thoracic aneurysms involving the aortic arch require complete circulatory arrest in deep hypothermia (DHCA) or elaborate cerebral perfusion strategies with varying degrees of hypothermia to achieve satisfactory protection of the brain from ischemic insults, that is, unilateral/bilateral antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP). Despite sophisticated and increasingly individualized surgical approaches for complex aortic pathologies, there remains a lack of consensus regarding the optimal method of cerebral protection and circulatory management during the time of arch exclusion. Many recent studies argue in favor of ACP with various degrees of hypothermic arrest during arch reconstruction and its advantages have been widely demonstrated. In fact ACP with more moderate degrees of hypothermia represents a paradigm shift in the cardiac surgery community and is widely adopted as an emergent strategy; however, many centers continue to report good results using other perfusion strategies. Amidst this important discussion we review currently available surgical strategies of cerebral protection management and compare the results of recent European multicenter and single-center data. PMID:26713319

Enteral nutrition increases interstitial brain glucose levels in poor-grade subarachnoid hemorrhage patients.

PubMed

Kofler, Mario; Schiefecker, Alois J; Beer, Ronny; Gaasch, Maxime; Rhomberg, Paul; Stover, John; Pfausler, Bettina; Thomé, Claudius; Schmutzhard, Erich; Helbok, Raimund

2018-03-01

Low brain tissue glucose levels after acute brain injury are associated with poor outcome. Whether enteral nutrition (EN) reliably increases cerebral glucose levels remains unclear. In this retrospective analysis of prospectively collected observational data, we investigate the effect of EN on brain metabolism in 17 poor-grade subarachnoid hemorrhage (SAH) patients undergoing cerebral microdialysis (CMD) monitoring. CMD-values were obtained hourly. A nutritional intervention was defined as the clinical routine administration of EN without supplemental parenteral nutrition. Sixty-three interventions were analyzed. The mean amount of EN per intervention was 472.4 ± 10.7 kcal. CMD-glucose levels significantly increased from 1.59 ± 0.13 mmol/l at baseline to a maximum of 2.03 ± 0.2 mmol/l after 5 h (p < 0.001), independently of insulin-treatment, baseline serum glucose, baseline brain metabolic distress (CMD-lactate-to-pyruvate-ratio (LPR) > 40) and the microdialysis probe location. The increase in CMD-glucose was directly dependent on the magnitude of increase of serum glucose levels (p = 0.007). No change in CMD-lactate, CMD-pyruvate, CMD-LPR, or CMD-glutamate (p > 0.4) was observed. Routine EN also increased CMD-glucose even if baseline concentrations were critically low ( < 0.7 mmol/l, neuroglucopenia; p < 0.001). These results may have treatment implications regarding glucose management of poor-grade aneurysmal SAH patients.

Use of the Ascent balloon for a 2-in-1 remodeling technique: feasibility and initial experience: case report.

PubMed

Clarençon, Frédéric; Pérot, Guillaume; Biondi, Alessandra; Di Maria, Federico; Szatmary, Zoltan; Chiras, Jacques; Sourour, Nader

2012-03-01

To present the feasibility of using the Ascent balloon, a new double-lumen remodeling balloon, for a new 2-in-1 technique allowing coiling through the lumen of the balloon without the use of an additional coiling microcatheter. Remodeling technique had enlarged the indications for endovascular treatment of intracranial aneurysm. Nevertheless, one of the limitations of this technique is that it requires using 2 devices in the same parent artery. A 55-year-old woman presented with a 7.7 × 4.5-mm incidental anterior communicating artery aneurysm. Only 1 A1 segment (left side) was patent on the cerebral angiogram. A 6F Fargo Max guiding catheter was positioned in the left petrous internal carotid artery. The Ascent balloon was placed in front of the neck of the aneurysm after navigation on a Traxcess 0.014-in guidewire. Coiling of the aneurysm sac was performed via 1 lumen of the device under iterative inflations of the balloon through the second lumen. This new 2-in-1 technique using a sole remodeling balloon without an additional coiling microcatheter is very promising, especially in cases of a small-caliber parent artery.

Effect of short-term ε-aminocaproic acid treatment on patients undergoing endovascular coil embolization following aneurysmal subarachnoid hemorrhage.

PubMed

Malekpour, Mahdi; Kulwin, Charles; Bohnstedt, Bradley N; Radmand, Golnar; Sethia, Rishabh; Mendenhall, Stephen K; Weyhenmeyer, Jonathan; Hendricks, Benjamin K; Leipzig, Thomas; Payner, Troy D; Shah, Mitesh V; Scott, John; DeNardo, Andrew; Sahlein, Daniel; Cohen-Gadol, Aaron A

2017-05-01

OBJECTIVE Aneurysmal rebleeding before definitive obliteration of the aneurysm is a cause of mortality and morbidity. There are limited data on the role of short-term antifibrinolytic therapy among patients undergoing endovascular intervention. METHODS All consecutive patients receiving endovascular therapy for their ruptured saccular aneurysm at the authors' institution between 2000 and 2011 were included in this study. These patients underwent endovascular coiling of their aneurysm within 72 hours of admission. In patients receiving ε-aminocaproic acid (EACA), the EACA administration was continued until the time of the endovascular procedure. Complications and clinical outcomes of endovascular treatment after aneurysmal subarachnoid hemorrhage (aSAH) were compared between EACA-treated and untreated patients. RESULTS During the 12-year study period, 341 patients underwent endovascular coiling. Short-term EACA treatment was administered in 146 patients and was withheld in the other 195 patients. EACA treatment did not change the risk of preinterventional rebleeding in this study (OR 0.782, 95% CI 0.176-3.480; p = 0.747). Moreover, EACA treatment did not increase the rate of thromboembolic events. On the other hand, patients who received EACA treatment had a significantly longer duration of hospital stay compared with their counterparts who were not treated with EACA (median 19 days, interquartile range [IQR] 12.5-30 days vs median 14 days, IQR 10-23 days; p < 0.001). EACA treatment was associated with increased odds of shunt requirement (OR 2.047, 95% CI 1.043-4.018; p = 0.037) and decreased odds of developing cardiac complications (OR 0.138, 95% CI 0.031-0.604; p = 0.009) and respiratory insufficiency (OR 0.471, 95% CI 0.239-0.926; p = 0.029). Short-term EACA treatment did not affect the Glasgow Outcome Scale score at discharge, 6 months, or 1 year following discharge. CONCLUSIONS In this study, short-term EACA treatment in patients who suffered from aSAH and received endovascular aneurysm repair did not decrease the risk of preinterventional rebleeding or increase the risk of thrombotic events. EACA did not affect outcome. Randomized clinical trials are required to provide robust clinical recommendation on short-term use of EACA.

[Use of "the Middlesex Elderly Assessment of Mental State" scale in the assessment of cognitive functioning in patients with aneurysmal subarachnoid haemorrhage].

PubMed

Chyza, Karolina Julia; Polityńska, Barbara; Kochanowicz, Jan; Lewko, Janusz

2007-03-01

It is now well established that cognitive deficits are a frequent consequence of aneurysmal subarachnoid haemorrhage (SAH). The cognitive status in the acute phase of the illness may provide valuable prognostic information in relation to the effects of the proposed treatment and long-term functioning of the patient. A prerequisite for this task is the identification of instruments that might prove useful in the diagnosis of neuropsychological deficits in patients with SAH. For these purposes we used The Middlesex Elderly Assessment of Mental State (MEAMS) in order to assess the cognitive deficits consequent upon SAH. To assess the cognitive functioning of patients undergoing treatment for SAH of aneurysmal origin in the acute stage of the illness, using a modified form of the MEAMS. 49 patients participated in the study, none of whom had a previous history of neurological or psychiatric illness. The age of the patients ranged between 23-70 years. 35 (71%) patients received surgical treatment (clipping of the aneurysm neck) and in 14 (29%) the aneurysm was embolised. The patients were assessed on two occasions: the first on admission to the Neurosurgery department following the SAH, and on the second, following treatment to secure the aneurysm. A modified version of the MEAMS in two parallel versions was used in the assessment. The results obtained were evaluated with reference to a control group. A range of cognitive impairments was identified with the aid of the MEAMS in patients undergoing treatment for aneurysmal SAH. These included deficits in visual and auditory memory, executive, perceptual and visuo-spatial functions together with the tendency to perseverate. In those patients who underwent surgery, deficits were observed in the following areas: disorientation in relation to self, time and place; perceptual, memory and visuo-spatial impairments. The results obtained indicate that the Middlesex Elderly Assessment of Mental State, in the form used in the present study appears to be a sensitive and useful instrument for the screening of cognitive impairments in patients following SAH, in the acute stages of the illness.

Onyx HD-500 embolization of intracranial aneurysms: modified technique using continuous balloon inflation under conscious sedation.

PubMed

Rahme, Ralph; Grande, Andrew; Jimenez, Lincoln; Abruzzo, Todd A; Ringer, Andrew J

2014-08-01

The conventional technique of intracranial aneurysm embolization using Onyx HD-500 (ev3 Neurovascular, Irvine, CA, USA) involves repetitive balloon inflation-deflation cycles under general anesthesia. By limiting parent artery occlusion to 5 minutes, this cyclic technique is thought to minimize cerebral ischemia. However, intermittent balloon deflation may lengthen procedure time and allow balloon migration, resulting in intimal injury or Onyx leakage. We report our experience using a modified technique of uninterrupted Onyx injection with continuous balloon occlusion under conscious sedation. All Onyx embolization procedures for unruptured aneurysms performed by the senior author (A.J.R.) between September 2008 and April 2010 were retrospectively reviewed. Demographic, clinical, angiographic, and procedural data were recorded. Twenty-four embolization procedures were performed in 21 patients with 23 aneurysms, including four recurrences. Twenty aneurysms (87%) involved the paraclinoid or proximal supraclinoid internal carotid artery. Size ranged from 2.5 to 24mm and neck diameter from 2 to 8mm. The modified technique was employed in 19 cases. All but one patient (94.4%) tolerated continuous balloon inflation. Complete occlusion was achieved in 20 aneurysms (83.3%) and subtotal occlusion in three (12.5%). Stable angiographic results were seen in 85%, 94%, 94%, and 100% of patients at 6, 12, 24, and 36months, respectively. There were no deaths. Permanent non-disabling neurological morbidity occurred in one patient (4.2%). Minor, transient, and/or angiographic complications were seen in three patients (12.5%), none related to the technique itself. Onyx embolization of unruptured intracranial aneurysms can be safely and effectively performed using continuous balloon inflation under conscious sedation. Copyright © 2014 Elsevier Ltd. All rights reserved.

The use of electrophysiological monitoring in the intraoperative management of intracranial aneurysms

PubMed Central

Lopez, J.; Chang, S.; Steinberg, G.

1999-01-01

OBJECTIVES—Somatosensory evoked potentials (SSEPs) and brainstem auditory evoked potentials (BAEPs) have been increasingly utilised during surgery for intracranial aneurysms to identify cerebral ischaemia. Between July 1994 and April 1996, we surgically treated 70 aneurysms in 49 consecutive patients (58 operations) with the aid of intraoperative evoked potential monitoring. This study sought to evaluate the usefulness of SSEP and BAEP monitoring during intracranial aneurysm surgery.
METHODS—Mean patient age was 51.9 (range 18-79) years. The sizes of the aneurysms were 3-4 mm (15), 5-9 mm (26), 10-14 mm (11), 15-19 mm (seven), 20-24 mm (six), and >25 mm (five). SSEPs were monitored in 58 procedures (100%) and BAEPs in 15 (26%). The neurological status of the patients was evaluated before and after surgery.
RESULTS—Thirteen of the 58 procedures (22%) monitored with SSEPs had SSEP changes (12 transient, one persistent); 45 (78%) had no SSEP changes. Three of 15 patients (20%) monitored with BAEPs had changes (two transient, one persistent); 12 (80%) had no BAEP changes. Of the 14 patients with transient SSEP or BAEP changes, these changes resolved with adjustment or removal of aneurysm clips (nine), elevating MAP (four), or retractor adjustment (one). Mean time from precipitating event to electrophysiological change was 8.9 minutes (range 3-32), and the mean time for recovery of potentials in patients with transient changes was 20.2 minutes (range 3-60). Clinical outcome was excellent in 39 patients, good in five, and poor in three (two patients died), and was largely related to pretreatment grade.
CONCLUSIONS—SSEPs and BAEPs are useful in preventing clinical neurological injury during surgery for intracranial aneurysms and in predicting which patients will have unfavourable outcomes.

 PMID:10071098

3D digital subtraction angiography of intracranial aneurysms: comparison of flat panel detector with conventional image intensifier TV system using a vascular phantom.

PubMed

Kakeda, S; Korogi, Y; Ohnari, N; Hatakeyama, Y; Moriya, J; Oda, N; Nishino, K; Miyamoto, W

2007-05-01

Compared with the image intensifier (I.I.)-TV system, the flat panel detector (FPD) system of direct conversion type has several theoretic advantages, such as higher spatial resolution, wide dynamic range, and no image distortion. The purpose of this study was to compare the image quality of 3D digital subtraction angiography (DSA) in the FPD and conventional I.I.-TV systems using a vascular phantom. An anthropomorphic vascular phantom was designed to simulate the various intracranial aneurysms with aneurysmal bleb. The tubes of this vascular phantom were filled with 2 concentrations of contrast material (300 and 150 mg I/mL), and we obtained 3D DSA using the FPD and I.I.-TV systems. First, 2 blinded radiologists compared the volume-rendering images for 3D DSA on the FPD and I.I.-TV systems, looking for pseudostenosis artifacts. Then, 2 other radiologists independently evaluated both systems for the depiction of the simulated aneurysm and aneurysmal bleb using a 5-point scale. For the degree of the pseudostenosis artifacts at the M1 segment of the middle cerebral artery at 300 mg I/mL, 3D DSA with FPD system showed mild stenoses, whereas severe stenoses were observed at 3D DSA with I.I.-TV system. At both concentrations, the FPD system was significantly superior to I.I.-TV system regarding the depiction of aneurysm and aneurysmal bleb. Compared with the I.I.-TV system, the FPD system could create high-resolution 3D DSA combined with a reduction of the pseudostenosis artifacts.

Formation and Rupture of the Internal Carotid Artery Aneurysm after Multiple Courses of Intensity-Modulated Radiation Therapy for Management of the Skull Base Ewing Sarcoma/PNET: Case Report.

PubMed

Tamura, Manabu; Kogo, Kasei; Masuo, Osamu; Oura, Yoshinori; Matsumoto, Hiroyuki; Fujita, Koji; Nakao, Naoyuki; Uematsu, Yuji; Itakura, Toru; Chernov, Mikhail; Hayashi, Motohiro; Muragaki, Yoshihiro; Iseki, Hiroshi

2013-12-01

Background Aneurysm formation after stereotactic irradiation of skull base tumors is rare. The formation and rupture of an internal carotid artery (ICA) aneurysm in a patient with skull base Ewing sarcoma/primitive neuroectodermal tumor (PNET), who underwent surgery followed by multiple courses of intensity-modulated radiation therapy (IMRT) and chemotherapy, is described. Case Description A 25-year-old man presented with a sinonasal tumor with intraorbital and intracranial growth. At that time cerebral angiography did not reveal any vascular abnormalities. The lesion was resected subtotally. Histopathologic diagnosis was Ewing sarcoma/PNET. The patient underwent multiple courses of chemotherapy and three courses of IMRT at 3, 28, and 42 months after initial surgery. The total biologically effective dose delivered to the right ICA was 220.2 Gy. Seven months after the third IMRT, the patient experienced profound nasal bleeding that resulted in hypovolemic shock. Angiography revealed a ruptured right C4-C5 aneurysm and irregular stenotic changes of the ICA. Lifesaving endovascular trapping of the right ICA was done. The patient recovered well after surgery but died due to tumor recurrence 6 months later. Conclusion Excessive irradiation of the ICA may occasionally result in aneurysm formation, which should be borne in mind during stereotactic irradiation of malignant skull base tumors.

Relationship between endothelial nitric oxide synthase (eNOS) and natural history of intracranial aneurysms: meta-analysis.

PubMed

Paschoal, Eric Homero Albuquerque; Yamaki, Vitor Nagai; Teixeira, Renan Kleber Costa; Paschoal Junior, Fernando Mendes; Jong-A-Liem, Glaucia Suzanna; Teixeira, Manoel Jacobsen; Yamada, Elizabeth Sumi; Ribeiro-Dos-Santos, Ândrea; Bor-Seng-Shu, Edson

2018-01-01

The aneurysmal subarachnoid hemorrhage is a major public health problem described as a sudden drastic event with no warning symptoms and high morbidity and mortality rates. The role of the endothelial isoform of nitric oxide synthase gene polymorphism in intracranial aneurysms (IAs) is still a matter of controversy with divergent findings among European, American, and Asian populations. Our study purposed to test the association between intracranial aneurysms formation and nitric oxide gene polymorphisms through a systematic review and meta-analysis. Systematic search on Medline, Lilacs, and EMBASE was performed. The primary search resulted in 139 papers, out of which 9 met our inclusion criteria after a full text analysis. The dominant T786C model found a significant association with IA (OR 1.22, 95 % CI 1.04-1.44, p = 0.01), so did studies of the recessive T786C model (OR 0.37, 95 % CI 0.30-0.45, p < 0.0001) but with opposite effect. Our findings support the presence of the T786C polymorphism as a predictor for the development of intracranial aneurysm in the cerebral vascular system. More studies are necessary in order to elucidate the pathways of the endothelial nitric oxide synthase (eNOS) in cerebrovascular diseases and in defining how different allelic combinations of the eNOS gene single-nucleotide polymorphism (SNP) could favor this pathological process.

Fluid-structure Interaction Modeling of Aneurysmal Conditions with High and Normal Blood Pressures

NASA Astrophysics Data System (ADS)

Torii, Ryo; Oshima, Marie; Kobayashi, Toshio; Takagi, Kiyoshi; Tezduyar, Tayfun E.

2006-09-01

Hemodynamic factors like the wall shear stress play an important role in cardiovascular diseases. To investigate the influence of hemodynamic factors in blood vessels, the authors have developed a numerical fluid-structure interaction (FSI) analysis technique. The objective is to use numerical simulation as an effective tool to predict phenomena in a living human body. We applied the technique to a patient-specific arterial model, and with that we showed the effect of wall deformation on the WSS distribution. In this paper, we compute the interaction between the blood flow and the arterial wall for a patient-specific cerebral aneurysm with various hemodynamic conditions, such as hypertension. We particularly focus on the effects of hypertensive blood pressure on the interaction and the WSS, because hypertension is reported to be a risk factor in rupture of aneurysms. We also aim to show the possibility of FSI computations with hemodynamic conditions representing those risk factors in cardiovascular disease. The simulations show that the transient behavior of the interaction under hypertensive blood pressure is significantly different from the interaction under normal blood pressure. The transient behavior of the blood-flow velocity, and the resulting WSS and the mechanical stress in the aneurysmal wall, are significantly affected by hypertension. The results imply that hypertension affects the growth of an aneurysm and the damage in arterial tissues.

Efficacy of Flow-Diverting Devices for Cerebral Aneurysms: A Systematic Review and Meta-analysis.

PubMed

Zhou, Geng; Su, Ming; Zhu, Yue-Qi; Li, Ming-Hua

2016-01-01

To evaluate the efficacy of flow-diverting devices (FDDs) used in the treatment for intracranial aneurysms (IAs), we performed a meta-analysis of published literature on FDDs. A systematic electronic database search was conducted using MEDLINE, PubMed, Springer, and EBSCO for all accessible articles on FDDs published until December 2014. Abstracts, full-text manuscripts, and the reference lists of retrieved articles were analyzed. Random effects meta-analysis was used to pool the occlusion rate outcomes across studies. Fifty-nine studies containing efficacy data on 2263 patients with more than 2493 treated aneurysms were included in the analysis. The overall complete occlusion rate was 82.5% (95% CI, 78.8%-86%) across studies. The success rate of FDD implantation was 97.4% (95% CI, 95.4%-99.4%). The occlusion rate for anterior circulation aneurysms was 83.3% (95% CI, 71.2%-95.4%); with regard to complete occlusion, the odds ratio for anterior circulation aneurysms was significantly higher than that of posterior circulation IAs (odds ratio, 1.93; 95% CI, 1.00-3.73). FDDs have high technical success rates in the management of IAs. Additional studies on well-designed, multicenter, randomized controlled trials will be required to validate the findings of the present study and to identify the best therapeutic strategy for IAs depending on their size, location, and characteristics. Copyright © 2016 Elsevier Inc. All rights reserved.

Use of the Hardman index in predicting mortality in endovascular repair of ruptured abdominal aortic aneurysms.

PubMed

Conroy, Daniel M; Altaf, Nishath; Goode, Steve D; Braithwaite, Bruce D; MacSweeney, Shane T; Richards, Toby

2011-12-01

The Hardman index is a predictor of 30-day mortality after open ruptured abdominal aneurysm repair through the use of preoperative patient factors. The aim of this study was to assess the Hardman index in patients undergoing endovascular repair of ruptured aortic aneurysms. A retrospective analysis of 95 patients undergoing emergency endovascular repairs of computed tomography-confirmed ruptured aneurysms from 1994 to 2008 in a university hospital was performed. All relevant patient variables, calculations of the Hardman index, and the incidence of 30-day mortality were collected in these patients. Correlation of the relationship between each variable and the overall score with the incidence of 30-day mortality was undertaken. The 24-hour mortality was 16% and 30-day mortality 36%. Increasing scores on the Hardman index showed an increasing mortality rate. Thirty-day mortality in patients with a score of 0 to 2 was 30.5%, and in those with a score of ≥3 was 69.2% (P = .01, risk ratio = 2.26, 95% confidence interval = 0.98 to 5.17). This is lower than predicted in both patient groups based on Hardman index score. Loss of consciousness was the only statistically significant independent predictor of 30-day mortality with a risk ratio of 3.16 (95% confidence interval = 2.00-4.97, P < .001). These data suggest that the Hardman index can predict an increased risk of 30-day mortality from endovascular repairs of ruptured aortic aneurysms. However, mortality from endovascular repair is much lower than would be predicted in open repair and it therefore cannot be used clinically as a tool for exclusion from intervention.

Moderate hyperventilation during intravenous anesthesia increases net cerebral lactate efflux.

PubMed

Grüne, Frank; Kazmaier, Stephan; Sonntag, Hans; Stolker, Robert Jan; Weyland, Andreas

2014-02-01

Hyperventilation is known to decrease cerebral blood flow (CBF) and to impair cerebral metabolism, but the threshold in patients undergoing intravenous anesthesia is unknown. The authors hypothesized that reduced CBF associated with moderate hyperventilation might impair cerebral aerobic metabolism in patients undergoing intravenous anesthesia. Thirty male patients scheduled for coronary surgery were included in a prospective, controlled crossover trial. Measurements were performed under fentanyl-midazolam anesthesia in a randomized sequence aiming at partial pressures of carbon dioxide of 30 and 50 mmHg. Endpoints were CBF, blood flow velocity in the middle cerebral artery, and cerebral metabolic rates for oxygen, glucose, and lactate. Global CBF was measured using a modified Kety-Schmidt technique with argon as inert gas tracer. CBF velocity of the middle cerebral artery was recorded by transcranial Doppler sonography. Data were presented as mean (SD). Two-sided paired t tests and one-way ANOVA for repeated measures were used for statistical analysis. Moderate hyperventilation significantly decreased CBF by 60%, blood flow velocity by 41%, cerebral oxygen delivery by 58%, and partial pressure of oxygen of the jugular venous bulb by 45%. Cerebral metabolic rates for oxygen and glucose remained unchanged; however, net cerebral lactate efflux significantly increased from -0.38 (2.18) to -2.41(2.43) µmol min 100 g. Moderate hyperventilation, when compared with moderate hypoventilation, in patients with cardiovascular disease undergoing intravenous anesthesia increased net cerebral lactate efflux and markedly reduced CBF and partial pressure of oxygen of the jugular venous bulb, suggesting partial impairment of cerebral aerobic metabolism at clinically relevant levels of hypocapnia.

Loss of function mutations in EPHB4 are responsible for vein of Galen aneurysmal malformation.

PubMed

Vivanti, Alexandre; Ozanne, Augustin; Grondin, Cynthia; Saliou, Guillaume; Quevarec, Loic; Maurey, Helène; Aubourg, Patrick; Benachi, Alexandra; Gut, Marta; Gut, Ivo; Martinovic, Jelena; Sénat, Marie Victoire; Tawk, Marcel; Melki, Judith

2018-04-01

See Meschia (doi:10.1093/brain/awy066) for a scientific commentary on this article.Vein of Galen aneurysmal malformation is a congenital anomaly of the cerebral vasculature representing 30% of all paediatric vascular malformations. We conducted whole exome sequencing in 19 unrelated patients presenting this malformation and subsequently screened candidate genes in a cohort of 32 additional patients using either targeted exome or Sanger sequencing. In a cohort of 51 patients, we found five affected individuals with heterozygous mutations in EPHB4 including de novo frameshift (p.His191Alafs*32) or inherited deleterious splice or missense mutations predicted to be pathogenic by in silico tools. Knockdown of ephb4 in zebrafish embryos leads to specific anomalies of dorsal cranial vessels including the dorsal longitudinal vein, which is the orthologue of the median prosencephalic vein and the embryonic precursor of the vein of Galen. This model allowed us to investigate EPHB4 loss-of-function mutations in this disease by the ability to rescue the brain vascular defect in knockdown zebrafish co-injected with wild-type, but not truncated EPHB4, mimicking the p.His191Alafs mutation. Our data showed that in both species, loss of function mutations of EPHB4 result in specific and similar brain vascular development anomalies. Recently, EPHB4 germline mutations have been reported in non-immune hydrops fetalis and in cutaneous capillary malformation-arteriovenous malformation. Here, we show that EPHB4 mutations are also responsible for vein of Galen aneurysmal malformation, indicating that heterozygous germline mutations of EPHB4 result in a large clinical spectrum. The identification of EPHB4 pathogenic mutations in patients presenting capillary malformation or vein of Galen aneurysmal malformation should lead to careful follow-up of pregnancy of carriers for early detection of anomaly of the cerebral vasculature in order to propose optimal neonatal care. Endovascular embolization indeed greatly improved the prognosis of patients.

Benefit of cerebrospinal fluid spectrophotometry in the assessment of CT scan negative suspected subarachnoid haemorrhage: a diagnostic accuracy study.

PubMed

Hann, Angus; Chu, Kevin; Greenslade, Jaimi; Williams, Julian; Brown, Anthony

2015-01-01

This study aimed to determine if performing cerebrospinal fluid spectrophotometry in addition to visual inspection detects more ruptured cerebral aneurysms than performing cerebrospinal fluid visual inspection alone in patients with a normal head CT scan but suspected of suffering an aneurysmal subarachnoid haemorrhage (SAH). We performed a single-centre retrospective study of patients presenting to the emergency department of a tertiary hospital who underwent both head CT scan and lumbar puncture to exclude SAH. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of an approach utilising both spectrophotometry and visual inspection (combined approach) was compared to visual inspection alone. A total of 409 patients (mean age 37.8 years, 56.2% female) were recruited and six (1.5%) had a cerebral aneurysm on angiography. The sensitivity of visual inspection was 50% (95% confidence interval [CI]: 12.4-82.6%), specificity was 99% (95% CI: 97.5-99.7%), PPV was 42.9% (95% CI: 10.4-81.3%) and NPV was 99.2% (95% CI: 97.8-99.8%). The combined approach had a sensitivity of 100% (95% CI: 54.1-100%), specificity of 79.7% (95% CI: 75.4-83.5%), PPV of 6.8% (95% CI: 2.6-14.3%) and a NPV of 100% (95% CI: 98.8-100%). The sensitivity of the combined approach was not significantly different to that of visual inspection alone (p=0.25). Visual inspection had a significantly higher specificity than the combined approach (p<0.01). The combined approach detected more cases of aneurysmal SAH than visual inspection alone, however the difference in sensitivity was not statistically significant. Visual xanthochromia should prompt angiography because of a superior specificity and PPV. Due to its reduced sensitivity, caution should be applied when using only visual inspection of the supernatant. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

Combined Direct and Indirect Cerebral Revascularization Using Local and Flow-Through Flaps.

PubMed

Azadgoli, Beina; Leland, Hyuma A; Wolfswinkel, Erik M; Bakhsheshian, Joshua; Russin, Jonathan J; Carey, Joseph N

2018-02-01

 Extracranial-intracranial bypass is indicated in ischemic disease such as moyamoya, certain intracranial aneurysms, and other complex neurovascular diseases. In this article, we present our series of local and flow-through flaps for cerebral revascularization as an additional tool to provide direct and indirect revascularization and/or soft tissue coverage.  A retrospective review of a prospectively maintained database was performed identifying nine patients. Ten direct arterial bypass procedures with nine indirect revascularization and/or soft tissue reconstruction were performed.  Indications for arterial bypass included intracranial aneurysm ( n  = 2) and moyamoya disease ( n  = 8). Indications for soft tissue transfer included infected cranioplasty (one) and indirect cerebral revascularization (eight). Four flow-through flaps and five pedicled flaps were used including a flow-through radial forearm fasciocutaneous flap (one), flow-through radial forearm fascial flaps (three), and pedicled temporoparietal fascial (TPF) flaps with distal end anastomosis (five). The superficial temporal vessels (seven) and facial vessels (two) were used as the vascular inflow. Arterial bypass was established into the middle cerebral artery (six) and anterior communicating artery (three). There were no intraoperative complications. All flaps survived with no donor-site complications. In one case of flow-through TPF flap, the direct graft failed, but the indirect flap remained vascularized.  Local and flow-through flaps can improve combined direct and indirect revascularization and provide soft tissue reconstruction. Minimal morbidity has been encountered in early outcomes though long-term results remain under investigation for these combined neurosurgery and plastic surgery procedures.  The level of evidence is IV. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Development of three-dimensional hollow elastic model for cerebral aneurysm clipping simulation enabling rapid and low cost prototyping.

PubMed

Mashiko, Toshihiro; Otani, Keisuke; Kawano, Ryutaro; Konno, Takehiko; Kaneko, Naoki; Ito, Yumiko; Watanabe, Eiju

2015-03-01

We developed a method for fabricating a three-dimensional hollow and elastic aneurysm model useful for surgical simulation and surgical training. In this article, we explain the hollow elastic model prototyping method and report on the effects of applying it to presurgical simulation and surgical training. A three-dimensional printer using acrylonitrile-butadiene-styrene as a modeling material was used to produce a vessel model. The prototype was then coated with liquid silicone. After the silicone had hardened, the acrylonitrile-butadiene-styrene was melted with xylene and removed, leaving an outer layer as a hollow elastic model. Simulations using the hollow elastic model were performed in 12 patients. In all patients, the clipping proceeded as scheduled. The surgeon's postoperative assessment was favorable in all cases. This method enables easy fabrication at low cost. Simulation using the hollow elastic model is thought to be useful for understanding of three-dimensional aneurysm structure. Copyright © 2015 Elsevier Inc. All rights reserved.

Comparison of 3D TOF-MRA and 3D CE-MRA at 3T for imaging of intracranial aneurysms.

PubMed

Cirillo, Mario; Scomazzoni, Francesco; Cirillo, Luigi; Cadioli, Marcello; Simionato, Franco; Iadanza, Antonella; Kirchin, Miles; Righi, Claudio; Anzalone, Nicoletta

2013-12-01

To compare 3T elliptical-centric CE MRA with 3T TOF MRA for the detection and characterization of unruptured intracranial aneurysms (UIAs), by using digital subtracted angiography (DSA) as reference. Twenty-nine patients (12 male, 17 female; mean age: 62 years) with 41 aneurysms (34 saccular, 7 fusiform; mean diameter: 8.85 mm [range 2.0-26.4mm]) were evaluated with MRA at 3T each underwent 3D TOF-MRA examination without contrast and then a 3D contrast-enhanced (CE-MRA) examination with 0.1mmol/kg bodyweight gadobenate dimeglumine and k-space elliptic mapping (Contrast ENhanced Timing Robust Angiography [CENTRA]). Both TOF and CE-MRA images were used to evaluate morphologic features that impact the risk of rupture and the selection of a treatment. Almost half (20/41) of UIAs were located in the internal carotid artery, 7 in the anterior communicating artery, 9 in the middle cerebral artery and 4 in the vertebro-basilar arterial system. All patients also underwent DSA before or after the MR examination. The CE-MRA results were in all cases consistent with the DSA dataset. No differences were noted between 3D TOF-MRA and CE-MRA concerning the detection and location of the 41 aneurysms or visualization of the parental artery. Differences were apparent concerning the visualization of morphologic features, especially for large aneurysms (>13 mm). An irregular sac shape was demonstrated for 21 aneurysms on CE-MRA but only 13/21 aneurysms on 3D TOF-MRA. Likewise, CE-MRA permitted visualization of an aneurismal neck and calculation of the sac/neck ratio for all 34 aneurysms with a neck demonstrated at DSA. Conversely, a neck was visible for only 24/34 aneurysms at 3D TOF-MRA. 3D CE-MRA detected 15 aneurysms with branches originating from the sac and/or neck, whereas branches were recognized in only 12/15 aneurysms at 3D TOF-MRA. For evaluation of intracranial aneurysms at 3T, 3D CE-MRA is superior to 3D TOF-MRA for assessment of sac shape, detection of aneurysmal neck, and visualization of branches originating from the sac or neck itself, if the size of the aneurysm is greater than 13 mm. 3T 3D CE-MRA is as accurate and effective as DSA for the evaluation of UIAs. Copyright © 2013. Published by Elsevier Ireland Ltd.