Double-barrel STA-MCA bypass and partial trapping of a ruptured mycotic MCA aneurysm with flash fluorescence technique

Mycotic brain aneurysms are rare and unusual cerebrovascular lesions arising from septic emboli that degrade the elastic lamina and vessel wall of intracranial arteries, which results in pathologic dilatation. Mycotic aneurysms are nonsaccular lesions that are not often suitable for clipping and instead require bypass, trapping, and flow reversal. This case demonstrates the use of indocyanine green “flash fluorescence” to identify the cortical distribution supplied by an aneurysm’s outflow, facilitating safe treatment with a double-barrel extracranial-intracranial bypass and partial trapping and conversion of a deep bypass to a superficial one. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21163

The utility of dual-energy computed tomography angiography for the evaluation of brain aneurysms after endovascular coiling: a prospective study

Background Non-invasive alternatives to digital subtraction angiography (DSA) for follow-up of patients with coiled aneurysms are sought. Purpose To compare a novel method of dual-energy computed tomography angiography (DE-CTA) for postoperative assessment of coiled brain aneurysms to detect aneurysm recanalization and patency of adjacent blood vessels, with DSA. Material and Methods Patients who underwent endovascular cerebral aneurysm coiling were prospectively evaluated postoperatively by both DE-CTA and conventional DSA. CTA was performed using a novel dual-energy method with single-source and fast kilovoltage switching. DSA was performed using biplanar cerebral angiography. An experienced neuroradiologist and neurosurgeon, both blinded to the original radiological results, reviewed the images. Results A total of 54 patients (16 men, 38 women; mean age=47.6 + 9 years) with 55 coiled aneurysms were enrolled in our study between July 2014 and June 2015: 29 patients had suffered a subarachnoid hemorrhage and 26 patients had an incidentally found cerebral aneurysm. All patients had at least one DSA and DE-CTA performed at most one week apart. DE-CTA showed a 100% sensitivity and specificity in detection of complete aneurysm occlusion and 80% sensitivity and specificity for detection of residual necks and domes. DE-CTA successfully detected all vascular diameter changes as comparable to DSA with minimal interfering artifact. Conclusion DE-CTA is a promising non-invasive alternative to conventional catheter-based angiography for identification of aneurysm recurrence and assessment of adjacent arteries after endovascular coiling. It allows for far more rapid image acquisition than DSA, is non-invasive, and is widely available at clinical centers.

Intrasaccular flow disruption for brain aneurysms: a systematic review of long-term outcomes

OBJECTIVE The long-term safety and efficacy of intrasaccular flow disruption (IFD) for the treatment of brain aneurysms remain unclear. With accumulating experience and increasing use of IFD devices, recent studies have provided additional data regarding their outcomes. This review summarizes the long-term outcomes of IFD-treated brain aneurysms. METHODS A systematic literature review was performed on May 23, 2021, in PubMed, Web of Science, and Ovid MEDLINE for aneurysm treatment outcomes with IFD devices. Procedural details, including use of adjunctive devices and complications, were collected. The quality of studies was assessed using the Downs and Black checklist. Angiographic outcomes were classified as complete occlusion, residual neck, and residual aneurysm. Other outcomes included need for retreatment, permanent neurological deficit, and mortality. Pooled analyses were performed. RESULTS The final analysis comprised 1217 patients with 1249 aneurysms from 22 studies. The mean aneurysm diameter and neck width were 6.9 and 4.5 mm, respectively, and 27.6% of aneurysms were ruptured. The complete occlusion rates at 12 months and final follow-up (pooled mean duration 15.7 months) were 50.1% and 58.2%, respectively. Adjunctive devices were used in 6.4% of cases. The rates of hemorrhage, symptomatic infarction, permanent neurological deficit, and mortality were 1.2%, 2.8%, 1.0%, and 2.6%, respectively. CONCLUSIONS IFD is a very safe treatment for appropriately selected brain aneurysms with low complication and neurological deterioration rates. However, complete occlusion is achieved in only half of IFD-treated aneurysms at 1 year with a modest increase beyond this time point. As the majority of the studies were single arm, the pooled data are subject to selection and reporting biases. Future device developments, increased operator experience, and direct comparisons with alternative endovascular strategies and surgical clipping may clarify the role of IFD in aneurysm management.

Cotinine Levels Influence the Risk of Rupture of Brain Aneurysms

The relationship between nicotine levels in smokers and brain aneurysm has never been determined. To assess the levels of cotinine in smoker patients with ruptured and unruptured brain aneurysm and the risk of aneurysm rupture we quantified cotinine levels in smoker patients with ruptured or unruptured brain aneurysms. We identified a control group of smokers and nonsmokers without brain aneurysm. Out of 182 participants cerebral aneurysms were statistically significantly associated with smoking (P<0.001) and female sex (P=0.006). Cotinine levels were significantly correlated with both the presence (P=0.009) and the rupture (P=0.002) of brain aneurysms. Compared with nonsmokers, smokers had a 5-fold higher risk of having a brain aneurysm (OR, 5.72; 95% CI, 2.96–11.07; P<0.001). The risk of rupture of brain aneurysms increased by 50% with each cotinine unit and was 4-fold higher with cotinine levels between 4 and 6 (OR, 3.75; 95% CI, 1.48–9.53; P=0.005). With increasing age, the cotinine level decreased (P <0.001, rho= –0.28), declining by 2% with each year of age. In the whole population, the probability of a ruptured aneurysm in patients with cotinine levels between 4 and 6 was higher than in those with levels between 0 and 3 (OR, 5.55; 95% CI, 1.08–28.5; P=0.040). Our results suggest that high cotinine levels in smokers with brain aneurysm, rather than size, are significantly associated with high rupture risk. Cotinine levels decrease with age, possibly reducing the risk of formation and rupture of a brain aneurysm.

The incidence and localization of arterial Fenestrations of the human brain and their Association to brain aneurysms

The aim of the study was to determine the frequency of occurrence and the most common locations of the fenestration of the cerebral arteries, i.e. developmental anomalies consisting of segmental vessel splitting and also the correlation between their presence and the formation of intracranial aneurysms. 6,545 patients in Independent Public Teaching Hospital No. 4 in Lublin in years 2009-2019 who have undergone the angio-CT examination of the head were retrospectively analyzed. The incidence of vascular fenestration was 0.75%, of which 75% were women and 25% men. Reported vascular anomalies most often occurred in the anterior parts of the circle of Willis – ACA (30.61%), AComA (22.45%) and also in BA (30.61%). It has been shown that the occurrence of different types of fenestrations was similar in the group of men and women. There have been diagnosed 11 cases of intracranial aneurysms among patients with observed fenestration (22.45%). For comparison, the incidence of cerebral aneurysms in Western Europe and the US ranges from 2% to 6%. It leads to the conclusion that among patients with fenestration, this type of vascular anomaly occurs much more often, hence they require more frequent control.

Cerebral Bypass for Aneurysms in the Era of Flow Diversion: Single-Surgeon Case Series

BACKGROUND With recent advances in endovascular treatments of brain aneurysms such as flow diverters, the role of cerebral revascularization needs to be re-evaluated. OBJECTIVE To evaluate the contemporary indications and outcomes of cerebral revascularization for brain aneurysms. METHODS A retrospective evaluation of a prospectively maintained database was performed to review clinical and imaging data of all the patients who underwent cerebral revascularization for brain aneurysms over the past 10 yr. RESULTS Among 174 cerebral revascularizations, 40 (in 36 patients) were done for the treatment of aneurysms. In total, 9 patients underwent combined endovascular treatment and surgical revascularization. Immediate aneurysm occlusion was achieved in 30 patients (83.3%). Immediate postoperative bypass patency was confirmed in 33 patients (92%). Postoperative neurological deficit was observed in 4 patients (11.1%). There were 2 mortalities in the postoperative period. Aneurysm total occlusion rate was 91% at 1 yr. Thirty patients had 1 yr clinical and radiological follow-up. Clinical evaluations showed modified Rankin Scale 2 or less in 25 patients at 1 yr. Bypass patency was confirmed in 27 (90%). Patients with fair/poor outcome were all in the subarachnoid hemorrhage group. Twenty-one patients had follow-up studies for 3 yr or beyond with no evidence of stroke or aneurysm recurrence. CONCLUSION Our results support that cerebral revascularization can be regarded as a viable and durable treatment option for these challenging aneurysms with acceptable morbidity. Cerebral bypass should be offered in selected cases where standard endovascular or surgical treatment is not efficacious or curative.