Association between hemodynamics, morphology, and rupture risk of intracranial aneurysms: a computational fluid modeling study

The rupture risk of intracranial saccular aneurysm: a case-control study based on a three-dimensional computed tomography angiography model

Background

Assessing the risk of rupture in intracranial aneurysms is crucial. Advancements in medical imaging now allow for three-dimensional (3D) assessments of aneurysms, providing a more detailed understanding of their morphology and associated risks. This study aimed to compare the 3D morphological parameters of ruptured and unruptured intracranial saccular aneurysms (ISAs) using computed tomography angiography (CTA) and to analyze risk factors linked to ISA rupture.

Methods

This retrospective case-control study included patients diagnosed with ISAs via CTA, for which data were sourced from both the Emergency Department and Inpatient Unit in The First Affiliated Hospital of Jinan University. The patients were categorized into rupture and unrupture groups. We used 3D-Slicer (version 5.2.2, Slicer Community) to construct morphological models of the ISAs and their parent arteries. These models facilitated assessments of intracranial aneurysmal volume (IAV), aneurysmal surface area (ASA), and maximum sectional area (MSA). Differences in 3D morphological parameters between ruptured and unruptured ISAs were then analyzed. For statistical analysis, we first performed single factor analysis on the data, constructed a receiver operating characteristic (ROC) curve one by one with statistically significant parameters, and screened out ROC curves that met the sample requirements. Second, we performed multiparameter logistic regression analysis to construct a ROC curve model and analyzed its predictive performance.

Results

The analysis encompassed 97 patients comprising 97 ISAs diagnosed from March 2016 to March 2022. Significant differences in morphological parameters were observed between the rupture and unrupture groups (P<0.05), including IAV, ASA, MSA, IAV/diameter (IAV/D), IAV/neck width (IAV/N), MSA/diameter (MSA/D), MSA/neck width (MSA/N), ASA/neck width (ASA/N), and ASA/MSA. It was found that the IAV, ASA, and MSA values of the rupture group were larger than those of the unrupture group. Meanwhile, the IAV/D, IAV/N, MSA/D, MSA/N, and ASA/N values were larger in the rupture group, while ASA/MSA and ASA/IAV were smaller.

Conclusions

This study underscores the significance of specific morphological indicators, such as ASA/N and ASA/MSA, in predicting the rupture risk of ISAs. The IAV, MSA, and ASA parameters, especially in relation to diameter and neck width, provide crucial insights into the rupture potential of ISAs.

Balloon neck-plasty to create a wide-necked aneurysm in the elastase-induced rabbit model

PURPOSE

The elastase-induced aneurysm (EIA) model in rabbits has been proposed for translational research; however, the adjustment of aneurysm neck size remains challenging. In this study, the technical feasibility and safety of balloon neck-plasty to create a wide-necked aneurysm in rabbit EIA model were investigated.

METHODS

Male New Zealand White rabbits (N = 15) were randomly assigned to three groups: group A, EIA creation without neck-plasty; group B, neck-plasty immediately after EIA creation; group C, neck-plasty 4 weeks after EIA creation. The diameter of balloon used for neck-plasty was determined 1 mm larger than origin carotid artery diameter. All rabbits were euthanized 4 weeks after their final surgery. Aneurysm neck, height, dome-to-neck (D/N) ratio, and histologic parameters were compared among the groups.

RESULTS

Aneurysm creation was technically successful in 14 out of 15 rabbits (93.3%), with one rabbit experiencing mortality due to an adverse anesthetic event during the surgery. Saccular and wide-necked aneurysms were successfully created in all rabbits. Aneurysm neck was significantly greater in groups B and C compared to group A (all P < .05). D/N ratio was significantly lower in groups B and C compared to group A (all P < .05). Additionally, tunica media thickness, vessel area, and luminal area were significantly greater in groups B and C compared to group A (all P < .05). These variables were found to be significantly greater in group B compared to group C (all P < .05).

CONCLUSION

The creation of a wide-necked aneurysm using balloon neck-plasty after elastase induction in rabbits has been determined to be technically feasible and safe.

A predictive model for the recurrence of intracranial aneurysms following coil embolization

Objective

This study aimed to identify risk factors for intracranial aneurysms (IAs) recurrence and establish a predictive model to aid evaluation.

Methods

A total of 302 patients with 312 IAs undergoing coil embolization between September 2017 and October 2022 were divided into two groups based on digital subtraction angiography follow-up. Clinical characteristics, operation-related factors, and morphologies were measured. Cox proportional hazard regression was used to identify the risk factors. Hazard ratios (HRs) were used to score points, and a predictive model was established. The test cohorts consisted of 51 IAs. Receiver operating characteristic curves were generated to determine the cutoff values and area under the curves (AUCs). A Delong test was performed to compare the AUCs.

Results

Diameter maximum (D max) (p < 0.001, HR = 1.221), Raymond-Roy occlusion classification (RROC) II or III (p = 0.004, HR = 2.852), and ruptured status (p < 0.001, HR = 7.782) were independent risk factors for the recurrence of IAs. A predictive model was established: D max + 2 * RROC (II or III; yes = 1, no = 0) + 6 * ruptured status (yes = 1; no = 0). The AUC of the predictive model (0.818) was significantly higher than those of D max (0.704), RROC (II or III) (0.645), and rupture status (0.683), respectively (Delong test, p < 0.05). The cutoff values of the predictive model and D max were 9.75 points and 6.65 mm, respectively.

Conclusion

The D max, RROC (II or III), and ruptured status could independently predict the recurrence of IAs after coil embolization. Our model could aid in practical evaluations.

Correlation between the rate of morphological changes and rupture of intracranial aneurysms during one cardiac cycle analyzed by 4D-CTA

Objective

This study aimed to analyze the relationship between the rate of morphological changes and intracranial aneurysm rupture during the cardiac cycle.

Methods

Eighty-four patients with intracranial aneurysms were retrospectively analyzed and divided into the rupture (42 cases) and unruptured (42 cases) groups. Four-dimensional computed tomography angiography (4D-CTA) was performed to collect quantitative parameters of aneurysm morphology and calculate the morphological change rate. The potential factors associated with aneurysm rupture were determined by comparing the general clinical data and rate of change in the location and morphology of the aneurysm between the two groups.

Results

Each morphological change rate in the rupture group was generally higher than that of the unruptured group. The rate of dome height change and aneurysm volume change were independent factors associated with aneurysm rupture. ROC curve analysis revealed that the diagnostic accuracy of the aneurysm volume change rate was higher. When the volume change rate was 12.33%, the sensitivity and specificity of rupture were 90.5 and 55.8%, respectively.

Conclusion

The rate of change in dome height and volume of intracranial aneurysms during one cardiac cycle were independent factors associated with aneurysm rupture.

Unilateral cerebral arterial tortuosity: Associated with aneurysm occurrence, but potentially inversely associated with aneurysm rupture

PURPOSE

To investigate the association of tortuosity of the main cerebral arteries with intracranial aneurysm (IA) occurrence and rupture. To investigate the relationship between arterial tortuosity and aneurysm morphology as well as conventional risk factors of vascular diseases.

METHODS

Three subject groups were analyzed in this study: Patients with ruptured IAs, patients with unruptured IAs, and healthy subjects. The groups were matched by sex and age using tendency score matching. Their intracranial magnetic resonance angiography (MRA) images were collected retrospectively. The intracranial arterial structures were segmented from the MRA images. Arterial tortuosity was measured and statistically compared between the different subject groups and different vessels. Correlation analysis was conducted between arterial tortuosity and clinical risk factors as well as aneurysm morphology.

RESULTS

120 patients were included in the study (average age: 67.5 years; 60% female), 40 for each group after matching. The tortuosity of the aneurysm-bearing artery was significantly greater than that of the contralateral artery in both the ruptured and unruptured IA groups (p < 0.001). There was no significant association between clinical risk factors (history of hypertension, hyperlipidemia, diabetes, smoking, and alcohol use) and arterial tortuosity. There were significant negative correlations between aneurysm-bearing artery tortuosity and aneurysm morphological features such as maximal diameter (p = 0.0011), neck diameter (p < 0.0001), maximum height (p = 0.0024), and size ratio (p = 0.0269).

CONCLUSION

The occurrence of cerebral aneurysms correlates to increased unilateral arterial tortuosity, but the risk of aneurysm enlargement/rupturing decreases with greater arterial tortuosity. Abnormal tortuosity may be congenital as tortuosity has no clear connection with acquired common risk factors of vascular diseases.

Endovascular treatment of multiple intracranial aneurysms in patients with subarachnoid hemorrhage: one or multiple sessions?

Objective

This study aimed to compare the safety and efficacy of single- and multiple-stage endovascular treatment in aneurysmal subarachnoid hemorrhage (SAH) patients with multiple intracranial aneurysms.

Methods

We retrospectively analyzed the clinical and imaging data of 61 patients who harbored multiple aneurysms and presented to our institution with aneurysmal subarachnoid hemorrhage. Patients were grouped according to endovascular treatment strategy: one-stage or multiple-stage.

Result

The 61 study patients harbored 136 aneurysms. One aneurysm in each patient had ruptured. In the one-stage treatment group, all 66 aneurysms in 31 patients were treated in one session. The mean follow-up was 25.8 months (range, 12-47). At the last follow-up, the modified Rankin scale was ≤2 in 27 patients. In total, 10 complications occurred (cerebral vasospasm, six patients; cerebral hemorrhage, two patients; and thromboembolism, two patients). In the multiple-stage treatment group, only the ruptured aneurysm (30 in total) was treated at the time of presentation, and the remaining aneurysms (40 in total) were treated later. The mean follow-up was 26.3 months (range, 7-49). At the last follow-up, the modified Rankin scale score was ≤2 in 28 patients. In total, five complications occurred (cerebral vasospasm, four patients; and subarachnoid hemorrhage, one patient). During the follow-up period, there was one recurrence of aneurysm with subarachnoid hemorrhage in the single-stage treatment group and four recurrences in the multiple-stage treatment group.

Conclusion

Both single- and multiple-stage endovascular treatment is safe and effective in aneurysmal subarachnoid hemorrhage patients who harbor multiple aneurysms. However, multiple-stage treatment is associated with a lower rate of hemorrhagic and ischemic complications.

A predictive hemodynamic model based on risk factors for ruptured mirror aneurysms

Objectives

To identify hemodynamic risk factors for intracranial aneurysm rupture and establish a predictive model to aid evaluation.

Methods

We analyzed the hemodynamic parameters of 91 pairs of ruptured mirror aneurysms. A conditional univariate analysis was used for the continuous variables. A conditional multivariate logistic regression analysis was performed to identify the independent risk factors. Differences where p < 0.05 were statistically significant. A predictive model was established based on independent risk factors. Odds ratios (ORs) were used to score points. The validation cohort consisted of 189 aneurysms. Receiver operating characteristic curves were generated to determine the cutoff values and area under the curves (AUCs) of the predictive model and independent risk factors.

Results

The conditional multivariate logistic analysis showed that the low shear area (LSA) (OR = 70.322, p = 0.044, CI = 1.112–4,445.256), mean combined hemodynamic parameter (CHP) (>0.087) (OR = 3.171, p = 0.034, CI = 1.089–9.236), and wall shear stress gradient (WSSG) ratio (>893.180) (OR = 5.740, p = 0.003, CI = 1.950–16.898) were independent risk factors. A prediction model was established: 23^*LSA + 1^*CHP mean (>0.087: yes = 1, no = 0) + 2 ^* WSSG ratio (>893.180: yes = 1, no = 0). The AUC values of the predictive model, LSA, mean CHP (>0.087), and WSSG ratio (>893.180) were 0.748, 0.700, 0.654, and 0.703, respectively. The predictive model and LSA cutoff values were 1.283 and 0.016, respectively. In the validation cohort, the predictive model, LSA, CHP (>0.087), and WSSG ratio (>893.180) were 0.736, 0.702, 0.689, and 0.706, respectively.

Conclusions

LSA, CHP (>0.087), and WSSG ratio (>893.180) were independent risk factors for aneurysm rupture. Our predictive model could aid practical evaluation.

Effect of hemodynamic changes on the risk of intracranial aneurysm rupture: a systematic review and meta-analysis

OBJECTIVE

In this study, the hemodynamic parameters of ruptured intracranial aneurysms (IAs) in various studies were summarized and analyzed to provide predictive parameters for IA rupture in clinical work.

METHODS

We searched PubMed, Web of science, Embase, and Cochrane databases for articles published before December 2021 to collect data on hemodynamic parameters associated with IA rupture. Differences in wall shear stress (WSS), oscillatory shear index (OSI), and low wall shear stress area (LSA) between ruptured and unruptured IAs in the literature were summarized and analyzed, and the standardized mean difference (SMD) of 95% CI was calculated by Review Manager 5.3.

RESULTS

By searching and screening the literature, this meta-analysis included 17 studies comprising 1,373 IA patients. In the ruptured aneurysm group, the level of WSS decreased significantly, while OSI and LSA increased obviously.

CONCLUSION

Low WSS, high OSI, and high LSA are closely related to the rupture of IAs, indicating the role of WSS, OSI, and LSA as important hemodynamic parameters for predicting the rupture of IAs in clinical work.

Aneurysmal wall enhancement and hemodynamics: pixel-level correlation between spatial distribution

BACKGROUND

Inflammation and hemodynamics are interrelated risk factors for intracranial aneurysm rupture. This study aimed to identify the relationship between these risk factors from an individual-patient perspective using biomarkers of aneurysm wall enhancement (AWE) derived from high-resolution magnetic resonance imaging (HR-MRI) and hemodynamic parameters by four-dimensional flow MRI (4D-flow MRI).

METHODS

A total of 29 patients with 29 unruptured intracranial aneurysms larger than 4 mm were included in this prospective cross-sectional study. A total of 24 aneurysms had AWE and 5 did not have AWE. A three-dimensional (3D) vessel model of each individual aneurysm was generated with 3D time-of-flight magnetic resonance angiography (3D TOF-MRA). Quantification of AWE was sampled with HR-MRI. Time-averaged wall shear stress (WSS) and oscillatory shear index (OSI) were calculated from the 4D-flow MRI. The correlation between spatial distribution of AWE and hemodynamic parameters measured at pixel-level was evaluated for each aneurysm.

RESULTS

In aneurysms with AWE, the spatial distribution of WSS was negatively correlated with AWE in 100% (24/24) of aneurysms, though 2 had an absolute value of the correlation coefficient <0.1. The OSI was positively correlated with AWE in 91.7% (22/24) of aneurysms; the other 2 aneurysms showed a negative correlation with AWE. In aneurysms with no AWE, there was no correlation between WSS (100%, 5/5), OSI (80%, 4/5), and wall inflammation.

CONCLUSIONS

The spatial distribution of WSS was negatively correlated with AWE in aneurysms with AWE, and OSI was positively correlated with AWE in most aneurysms with AWE. While aneurysms that did not contain AWE showed no correlation between hemodynamics and wall inflammation.

Vertigo: Could this Symptom Indicate the Existence of an Unruptured Intracranial Aneurysm?

Background:Unruptured intracranial aneurysms (UIAs) can be presented with various symptoms, including atypical headaches and cranial nerve deficits. Vertigo is often referred in the literature as a coexisting symptom. Our aim was to investigate the importance of vertigo in the UIA symptomatology and present a possible explanation for its existence. Methods:We conducted a retrospective observational multicenter study concerning patients with surgically treated intracranial aneurysms. During a period of 10 years, 1 085 patients with cerebral aneurysms underwent surgery. There were 812 patients with ruptured intracranial aneurysms (RIA) and 273 with UIA. The medical records for each of the 273 patients were analyzed. Results: After the implementation of exclusion criteria, 89 (32.6%) of UIA patients were selected in the study, from which 71 (79.8%) were females and 18 (20.2%) males. The mean age was 56.9 (± 12.876) years old. Vertigo existed in 72 (80.9%), headache in 41 (46.1%) and visual symptoms in 21 (23.6%) patients. No significant correlation (p >0.05) was demonstrated between gender, age or aneurysm location in correlation with vertigo, headache or visual symptoms, apart from a negative significant correlation between age and vertigo (p=0.031). Conclusion:Vertigo is an alarming symptom that could indicate the existence of an UIA. The pathophysiological mechanism could be explained by the formation of an aneurysmal vortex that projects into the parent artery, leading to disturbances in the laminar flow and formation of an irregular/turbulent flow, which potentially affects the cerebral autoregulation and by consequence, the central processing of movement.

Rebleeding of Ruptured Intracranial Aneurysm After Admission: A Multidimensional Nomogram Model to Risk Assessment

Objective

Rebleeding is recognized as the main cause of mortality after intracranial aneurysm rupture. Though timely intervention can prevent poor prognosis, there is no agreement on the surgical priority and choosing medical treatment for a short period after rupture. The aim of this study was to investigate the risk factors related to the rebleeding after admission and establish predicting models for better clinical decision-making.

Methods

The patients with ruptured intracranial aneurysms (RIAs) between January 2018 and September 2020 were reviewed. All patients fell to the primary and the validation cohort by January 2020. The hemodynamic parameters were determined through the computational fluid dynamics simulation. Cox regression analysis was conducted to identify the risk factors of rebleeding. Based on the independent risk factors, nomogram models were built, and their predicting accuracy was assessed by using the area under the curves (AUCs).

Result

A total of 577 patients with RIAs were enrolled in this present study, 86 patients of them were identified as undergoing rebleeding after admission. Thirteen parameters were identified as significantly different between stable and rebleeding aneurysms in the primary cohort. Cox regression analysis demonstrated that six parameters, including hypertension [hazard ratio (HR), 2.54; P = 0.044], bifurcation site (HR, 1.95; P = 0.013), irregular shape (HR, 4.22; P = 0.002), aspect ratio (HR, 12.91; P < 0.001), normalized wall shear stress average (HR, 0.16; P = 0.002), and oscillatory stress index (HR, 1.14; P < 0.001) were independent risk factors related to the rebleeding after admission. Two nomograms were established, the nomogram including clinical, morphological, and hemodynamic features (CMH nomogram) had the highest predicting accuracy (AUC, 0.92), followed by the nomogram including clinical and morphological features (CM nomogram; AUC, 0.83), ELAPSS score (AUC, 0.61), and PHASES score (AUC, 0.54). The calibration curve for the probability of rebleeding showed good agreement between prediction by nomograms and actual observation. In the validation cohort, the discrimination of the CMH nomogram was superior to the other models (AUC, 0.93 vs. 0.86, 0.71 and 0.48).

Conclusion

We presented two nomogram models, named CMH nomogram and CM nomogram, which could assist in identifying the RIAs with high risk of rebleeding.

Impact of aneurysm morphology on aneurysmal subarachnoid hemorrhage severity, cerebral infarction and functional outcome

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity. The objective was to evaluate, whether specific morphological aneurysm characteristics could serve as predictive values for aSAH severity, disease-related complications and clinical outcome.

METHODS

A total of 453 aSAH patients (mean age: 54.9 ± 13.8 years, mean aneurysm size: 7.5 ± 3.6 mm) treated at a single center were retrospectively included. A morphometric analysis was performed based on angiographic image sets, determining aneurysm location, aneurysm size, neck width, aneurysm size ratios, aneurysm morphology and vessel size. The following outcome measures were defined: World Federation of Neurosurgical Societies (WFNS) grade 4 and 5, Fisher grade 4, vasospasm, cerebral infarction and unfavorable functional outcome.

RESULTS

Regarding morphology parameters, aneurysm neck width was an independent predictor for Fisher 4 hemorrhage (OR: 1.1, 95%CI: 1.0-1.3, p = 0.048), while dome width (OR: 0.92, 95%CI: 0.86-0.97, p = 0.005) and internal carotid artery location (OR: 2.1, 95%CI: 1.1-4.2, p = 0.028) predicted vasospasm. None of the analyzed morphological characteristics prognosticated functional outcome. Patient age (OR: 0.95, 95%CI: 0.93-0.96, p < 0.001), WFNS score (OR: 4.8, 95%CI: 2.9-8.0, p < 0.001), Fisher score (OR: 2.3, 95%CI: 1.4-3.7, p < 0.001) and cerebral infarction (OR: 4.5, 95%CI: 2.7-7.8, p < 0.001) were independently associated with unfavorable outcome.

CONCLUSIONS

The findings indicate a correlation between aneurysm morphology, Fisher grade and vasospasm. Further studies will be required to reveal an independent association of aneurysm morphology with cerebral infarction and functional outcome.

Multidimensional predicting model of intracranial aneurysm stability with backpropagation neural network: a preliminary study

OBJECTIVES

The stability of intracranial aneurysms (IAs) may involve in multidimensional factors. Backpropagation (BP) neural network could be adopted to support clinical work. This preliminary study aimed to delve into the feasibility of BP neural network in assessing the risk of IA rupture/growth and to prove the advantage of multidimensional model over single/double-dimensional model.

METHODS

Thirty-six IA patients were recruited from a prospective registration study (ChiCTR1900024547). All patients were followed up until aneurysm ruptured/grew or 36 months after being diagnosed with the IAs. The multidimensional data regarding clinical, morphological, and hemodynamic characteristics were acquired. Hemodynamic analyses were conducted with patient-specific models. Based on these characteristics, seven models were built with BP neural network (the ratio of training set to validation set as 8:1). The area under curves (AUC) was calculated for subsequent comparison.

RESULTS

Forty-five characteristics were determined from 36 patients with 37 IAs. In the models based on the single dimension of IA characteristics, only morphological characteristics exhibited high performance in assessing 3-year IA stability (AUC = 0.703, P = 0.035). Among the models integrating two dimensions of IA characteristics, clinical-morphological (AUC = 0.731, P = 0.016), clinical-hemodynamic (AUC = 0.702, P = 0.036), and morphological-hemodynamic (AUC = 0.785, P = 0.003) models were capable of assessing the risk of 3-year IA rupture/growth. Moreover, the models including all three dimensions exhibited the maximum predicting significance (AUC = 0.811, P = 0.001).

CONCLUSION

The present preliminary study reported that BP neural network might support assessing the 3-year stability of IAs. Models based on multidimensional characteristics could improve the assessment accuracy for IA rupture/growth.

Cerebral aneurysm rupture status classification using statistical and machine learning methods

Morphological characterization and fluid dynamics simulations were carried out to classify the rupture status of 71 (36 unruptured, 35 ruptured) patient specific cerebral aneurysms using a machine learning approach together with statistical techniques. Eleven morphological and six hemodynamic parameters were evaluated individually and collectively for significance as rupture status predictors. The performance of each parameter was inspected using hypothesis testing, accuracy, confusion matrix, and the area under the receiver operating characteristic curve. Overall, the size ratio exhibited the best performance, followed by the diastolic wall shear stress, and systolic wall shear stress. The prediction capability of all 17 parameters together was evaluated using eight different machine learning algorithms. The logistic regression achieved the highest accuracy (0.75), whereas the random forest had the highest area under curve value among all the classifiers (0.82), surpassing the performance exhibited by the size ratio. Hence, we propose the random forest model as a tool that can help improve the rupture status prediction of cerebral aneurysms.

Morphological variables associated with ruptured basilar tip aneurysms

Morphological factors of intracranial aneurysms and the surrounding vasculature could affect aneurysm rupture risk in a location specific manner. Our goal was to identify image-based morphological parameters that correlated with ruptured basilar tip aneurysms. Three-dimensional morphological parameters obtained from CT-angiography (CTA) or digital subtraction angiography (DSA) from 200 patients with basilar tip aneurysms diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016 were evaluated. We examined aneurysm wall irregularity, the presence of daughter domes, hypoplastic, aplastic or fetal PCoAs, vertebral dominance, maximum height, perpendicular height, width, neck diameter, 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 statistical significance. In multivariable analysis, presence of a daughter dome, aspect ratio, and larger flow angle were significantly associated with rupture status. We also introduced two new variables, diameter size ratio and parent-daughter angle ratio, which were both significantly inversely associated with ruptured basilar tip aneurysms. Notably, multivariable analyses also showed that larger diameter size ratio was associated with higher Hunt-Hess score while smaller flow angle was associated with higher Fisher grade. These easily measurable parameters, including a new parameter that is unlikely to be affected by the formation of the aneurysm, could aid in screening strategies in high-risk patients with basilar tip aneurysms. One should note, however, that the changes in parameters related to aneurysm morphology may be secondary to aneurysm rupture rather than causal.

Pipeline Embolization device for intracranial aneurysms in a large Chinese cohort: factors related to aneurysm occlusion

Background and Purpose:

The Pipeline Embolization Device (PED, Covidien/Medtronic) is widely used to treat intracranial aneurysms. This PED in China post-market multi-center registry study (PLUS) investigated safety and effectiveness of the PED for intracranial aneurysms in the Chinese population.

Methods:

This was a panoramic, consecutive, real-world cohort registry study. Patients treated with PED with or without coils between November 2014 and October 2019 at 14 centers in China were included, and those treated by parent vessel occlusion or other stents were excluded. Study outcomes included angiographic evaluation of aneurysm occlusion, complications, in-stent stenosis, and predictors of aneurysm occlusion. A central committee reviewed all imaging and endpoint events.

Results:

In total, 1171 patients with 1322 intracranial aneurysms were included. The total occlusion rate was 81.4% (787/967) at mean follow-up of 8.96 ± 7.50 months, with 77.1% (380/493) occlusion in the PED alone and 85.9% (407/474) in the PED plus coiling group. On multi-variate analysis, female sex, hyperlipidemia, vertebral aneurysms, PED plus coiling, and blood flow detained to venous phase were significant predictors of aneurysm occlusion. In posterior circulation cohort, there was no variable associated with aneurysm occlusion. In-stent stenosis predictors included current smoking and cerebral sclerosis/stenosis.

Conclusion:

In the largest series on PED of multi-center date of China, data suggest that treatment with the flow-diverting PED in intracranial aneurysms was efficacious. The treatment of PED combined coiling and blood flow detained to venous phase after PED implant were associated with aneurysmal occlusion. The occlusion rate of vertebral aneurysms was higher than other location aneurysms.

Clinical Trial Registration:

ClinicalTrials.gov identifier: NCT03831672.

In Vitro Assessment of Flow Variability in an Intracranial Aneurysm Model Using 4D Flow MRI and Tomographic PIV

Aneurysm rupture has been suggested to be related to aneurysm geometry, morphology, and complex flow activity; therefore, understanding aneurysm-specific hemodynamics is crucial. 4D Flow MRI has been shown to be a feasible tool for assessing hemodynamics in intracranial aneurysms with high spatial resolution. However, it requires averaging over multiple heartbeats and cannot account for cycle-to-cycle hemodynamics variations. This study aimed to assess cycle-to-cycle flow dynamics variations in a patient-specific intracranial aneurysm model using tomographic particle image velocimetry (tomo-PIV) at a high image rate under pulsatile flow conditions. Time-resolved and time-averaged velocity flow fields within the aneurysm sac and estimations of wall shear stress (WSS) were compared with those from 4D Flow MRI. A one-way ANOVA showed a significant difference between cardiac cycles (p value < 0.0001); however, differences were not significant after PIV temporal and spatial resolution was matched to that of MRI (p value 0.9727). This comparison showed the spatial resolution to be the main contributor to assess cycle-to-cycle variability. Furthermore, the comparison with 4D Flow MRI between velocity components, streamlines, and estimated WSS showed good qualitative and quantitative agreement. This study showed the feasibility of patient-specific in-vitro experiments using tomo-PIV to assess 4D Flow MRI with high repeatability in the measurements.

Role of Morphological and Hemodynamic Factors in Predicting Intracranial Aneurysm Rupture: A Review

Intracranial aneurysms (IAs) carry the risk of rupture, which will lead to subarachnoid hemorrhage, which has a high mortality and morbidity risk. However, the treatment of IA's carries mortality and morbidity risks too. There are well-known risk factors for the rupture of IAs like age, size, and site. However, choosing patients with unruptured IAs for treatment is still a big challenge. This review article aimed to find out the relationship between morphological and hemodynamic characters of IAs with their rupture and incorporate these factors with well-known factors to yield an accurate module for predicting the rupture of IAs and decision-making in the treatment of unruptured IAs.

We searched in PubMed and Medline databases by using the following keywords: IAs, subarachnoid hemorrhage, and risk of rupture, morphology, and hemodynamic “mesh.” A total of 19 studies with 7269 patients and 9167 IAs, of which 1701 had ruptured, were reviewed thoroughly. Some modules like population, hypertension, age, size, earlier subarachnoid hemorrhage, and site (PHASES) score that involve well-known risk factors can be used to assess the risk of rupture of IAs. However, decision making for treating unruptured IA needs more detailed and more accurate modules. Studying morphological and hemodynamic factors and incorporation of them with well-known risk factors to yield a more comprehensive module will be very helpful in treating unruptured IA. Among morphological factors, aspect ratio (AR), size ratio (SR), aneurysm height, and bottle-neck factor showed significant effects on the growth and rupture of IA. Besides, wall shear stress (WSS), oscillatory shear index (OSI), and low wall shear stress area (LSA) as hemodynamic factors could have a substantial impact on the formation, shape, growth, and rupture of unruptured IA.

Computational fluid dynamics simulations of cerebral aneurysm using Newtonian, power-law and quasi-mechanistic blood viscosity models

Cerebral aneurysm is a fatal neurovascular disorder. Computational fluid dynamics simulation of aneurysm haemodynamics is one of the most important research tools which provide increasing potential for clinical applications. However, computational fluid dynamics modelling of such delicate neurovascular disorder involves physical complexities that cannot be easily simplified. Recently, it was shown that the Newtonian simplification used to close the shear stress tensor of the Navier-Stokes equation is not sufficient to explore aneurysm haemodynamics. This article explores the differences between the latter simplification, non-Newtonian power-law model and a newly proposed quasi-mechanistic model. The modified Krieger model, which treats blood as a suspension of plasma and particles, was implemented in computational fluid dynamics context here for the first time and is made available to the readers in a C# code in the supplementary material of this article. Two middle-cerebral artery and two anterior-communicating artery aneurysms, all ruptured, were utilized here as case studies. It was shown that the modified Krieger model had higher sensitivity for wall shear stress calculations in comparison with the other two models. The modified Krieger model yielded lower wall shear stress values consistently in comparison with the other two models. Moreover, the modified Krieger model has generally predicted higher pressure in the aneurysm models. Based on published aneurysm rupture studies, it is believed that ruptured aneurysms are usually correlated with lower wall shear stress values than unruptured ones. Therefore, this work concludes that the modified Krieger model is a potential candidate for providing better clinical relevance to aneurysm computational fluid dynamics simulations.

Computational Hemodynamic Modeling of Arterial Aneurysms: A Mini-Review

Arterial aneurysms are pathological dilations of blood vessels, which can be of clinical concern due to thrombosis, dissection, or rupture. Aneurysms can form throughout the arterial system, including intracranial, thoracic, abdominal, visceral, peripheral, or coronary arteries. Currently, aneurysm diameter and expansion rates are the most commonly used metrics to assess rupture risk. Surgical or endovascular interventions are clinical treatment options, but are invasive and associated with risk for the patient. For aneurysms in locations where thrombosis is the primary concern, diameter is also used to determine the level of therapeutic anticoagulation, a treatment that increases the possibility of internal bleeding. Since simple diameter is often insufficient to reliably determine rupture and thrombosis risk, computational hemodynamic simulations are being developed to help assess when an intervention is warranted. Created from subject-specific data, computational models have the potential to be used to predict growth, dissection, rupture, and thrombus-formation risk based on hemodynamic parameters, including wall shear stress, oscillatory shear index, residence time, and anomalous blood flow patterns. Generally, endothelial damage and flow stagnation within aneurysms can lead to coagulation, inflammation, and the release of proteases, which alter extracellular matrix composition, increasing risk of rupture. In this review, we highlight recent work that investigates aneurysm geometry, model parameter assumptions, and other specific considerations that influence computational aneurysm simulations. By highlighting modeling validation and verification approaches, we hope to inspire future computational efforts aimed at improving our understanding of aneurysm pathology and treatment risk stratification.

Focal irregularities in 7-Tesla MRI of unruptured intracranial aneurysms as an indicator for areas of altered blood-flow parameters

OBJECTIVE

In the last several decades, various factors have been studied for a better evaluation of the risk of rupture in incidentally discovered intracranial aneurysms (IAs). With advanced MRI, attempts were made to delineate the wall of IAs to identify weak areas prone to rupture. However, the field strength of the MRI investigations was insufficient for reasonable image resolution in many of these studies. Therefore, the aim of this study was to analyze findings of IAs in ultra-high field MRI at 7 Tesla (7 T).

METHODS

Patients with incidentally found IAs of at least 5 mm in diameter were included in this study and underwent MRI investigations at 7 T. At this field strength a hyperintense intravascular signal can be observed on nonenhanced images with a brighter "rim effect" along the vessel wall. Properties of this rim effect were evaluated and compared with computational fluid dynamics (CFD) analyses.

RESULTS

Overall, 23 aneurysms showed sufficient image quality for further evaluation. In 22 aneurysms focal irregularities were identified within this rim effect. Areas of such irregularities showed significantly higher values in wall shear stress and vorticity compared to areas with a clearly visible rim effect (p = 0.043 in both).

CONCLUSIONS

A hyperintense rim effect along the vessel wall was observed in most cases. Focal irregularities within this rim effect showed higher values of the mean wall shear stress and vorticity when compared by CFD analyses. Therefore, these findings indicate alterations in blood flow in IAs within these areas.

High wall shear stress beyond a certain range in the parent artery could predict the risk of anterior communicating artery aneurysm rupture at follow-up

OBJECTIVE

Among clinical and morphological criteria, hemodynamics is the main predictor of aneurysm growth and rupture. This study aimed to identify which hemodynamic parameter in the parent artery could independently predict the rupture of anterior communicating artery (ACoA) aneurysms by using multivariate logistic regression and two-piecewise linear regression models. An additional objective was to look for a more simplified and convenient alternative to the widely used computational fluid dynamics (CFD) techniques to detect wall shear stress (WSS) as a screening tool for predicting the risk of aneurysm rupture during the follow-up of patients who did not undergo embolization or surgery.

METHODS

One hundred sixty-two patients harboring ACoA aneurysms (130 ruptured and 32 unruptured) confirmed by 3D digital subtraction angiography at three centers were selected for this study. Morphological and hemodynamic parameters were evaluated for significance with respect to aneurysm rupture. Local hemodynamic parameters were obtained by MR angiography and transcranial color-coded duplex sonography to calculate WSS magnitude. Multivariate logistic regression and a two-piecewise linear regression analysis were performed to identify which hemodynamic parameter independently characterizes the rupture status of ACoA aneurysms.

RESULTS

Univariate analysis showed that WSS (p < 0.001), circumferential wall tension (p = 0.005), age (p < 0.001), the angle between the A1 and A2 segments of the anterior cerebral artery (p < 0.001), size ratio (p = 0.023), aneurysm angle (p < 0.001), irregular shape (p = 0.005), and hypertension (grade II) (p = 0.006) were significant parameters. Multivariate analyses showed significant association between WSS in the parent artery and ACoA aneurysm rupture (p = 0.0001). WSS magnitude, evaluated by a two-piecewise linear regression model, was significantly correlated with the rupture of the ACoA aneurysm when the magnitude was higher than 12.3 dyne/cm2 (HR 7.2, 95% CI 1.5-33.6, p = 0.013).

CONCLUSIONS

WSS in the parent artery may be one of the reliable hemodynamic parameters characterizing the rupture status of ACoA aneurysms when the WSS magnitude is higher than 12.3 dyne/cm2. Analysis showed that with each additional unit of WSS (even with a 1-unit increase of WSS), there was a 6.2-fold increase in the risk of rupture for ACoA aneurysms.

Sidewall Aneurysm Geometry as a Predictor of Rupture Risk Due to Associated Abnormal Hemodynamics

Background: Hemodynamics play an important role in intracranial aneurysm (IA) initiation, growth, and rupture. Yet there remains no definitive quantitative analysis between abnormal hemodynamics and geometrical risk of IA development.

Objective: The present study aims to investigate whether abnormal hemodynamics in IA sacs can be predicted by surrogate geometric markers.

Methods: Computational fluid dynamics (CFD) simulations were performed on paraclinoid aneurysms derived from digital subtraction angiography (DSA) of 104 IAs in 104 patients. Four basic IA geometric parameters including maximum height, perpendicular height, maximum width, and neck diameter were measured. Abnormal hemodynamics were defined and quantified as the surface area exposed to low wall shear stress (WSS) and high oscillatory shear index (OSI) using objectively-defined thresholds. Relationships between abnormal hemodynamics and specific geometric parameters were analyzed via multiple linear regression.

Results: Adjusting for age, sex, and other clinical characteristics, multiple linear regression revealed a significant relationship (p < 0.001) between abnormal hemodynamics and both maximum width (β ≈ 1.2) and neck diameter (β ≈ −0.4), but not maximum height or perpendicular height. These findings were shown to be independent of the choice of abnormal hemodynamic indicators and threshold levels.

Conclusions: Maximum width and neck diameter of IA sacs are robust surrogates of exposure to abnormal hemodynamics. Risk of rupture may be increased with wider aneurysms with narrower necks for paraclinoid aneurysms.

The Role of One-Dimensional Model-Generated Inter-Subject Variations in Systemic Properties on Wall Shear Stress Indices of Intracranial Aneurysms

Variations in systemic properties of the arterial tree, such as aging-induced vessel stiffness, can alter the shape of pressure and flow waveforms. As a consequence, the hemodynamics around a cerebral aneurysm change, and therefore, also the corresponding in- and outlet boundary conditions (BCs) used for three-dimensional (3D) calculations of hemodynamic indices. In this study, we investigate the effects of variations in systemic properties on wall shear stress (WSS) indices of a cerebral aneurysm. We created a virtual patient database by varying systemic properties within physiological ranges. BCs for 3D-CFD simulations were derived using a pulse wave propagation model for each realization of the virtual database. WSS indices were derived from the 3D simulations and their variabilities quantified. Variations in BCs, caused by changes in systemic properties, yielded variabilities in the WSS indices that were of the same order of magnitude as differences in these WSS indices between ruptured and unruptured aneurysms. Sensitivity analysis showed that the systemic properties impacted both in- and outlet BCs simultaneously and altered the WSS indices. We conclude that the influence of variations in patient-specific systemic properties on WSS indices should be evaluated when using WSS indices in multidisciplinary rupture prediction models.

The Morphological and Hemodynamic Characteristics of the Intraoperative Ruptured Aneurysm

Background and Objectives

Intraoperative aneurysm rupture (IOR) is a difficult event during the clipping process for intracranial aneurysms, and could result in a bad prognosis. Preoperative discrimination of aneurysms with high risk of IOR is vital for operators. The aim of this study was to explore the hemodynamic-morphological risk factors for the IOR.

Methods

In the present study, patients admitted for unruptured IA from January 2012 to April 2018 were retrospectively reviewed. A propensity score matching was performed to match patients. The morphological features and the hemodynamic features were extracted. Differences in the morphologic and hemodynamic parameters were compared. Risk factors associated with IOR were explored. Subsequently, the hemodynamic characteristics in different rupture stages and different regions in IOR aneurysm were compared.

Results

96 cases of patients with aneurysms, were found by the matching process in each group. The statistically significant difference was found in the maximum length (L) (p = 0.041), maximum diameter of body (D) (p = 0.032), aspect ratio (AR) (p < 0.001), non-sphericity index (NSI) (p < 0.001), normalized wall shear stress maximum (NWSSm) (p < 0.001) and oscillatory shear index (OSI) (p < 0.001). A regression analysis demonstrated AR (OR = 7.03, p < 0.001), NWSSm (OR = 15.55, p = 0.014) and OSI (OR = 28.30, p < 0.001) as the independent risk factors for IOR. AR was much larger, and NWSSm and NWSSa were much lower for IAs that ruptured in early or pre-dissection stage than those for IAs that ruptured in dissection stage or clip application stage. NWSSa and NWSSm in rupture area were both lower than those in adjacent area.

Conclusion

AR, NWSSm, and OSI are considered three independent risk factors for intraoperative aneurysm rupture, which could serve as predictors. A selection of intervention methods for aneurysms with high AR, low NWSSm, and high OSI should carefully be considered.

[Construction of finite element model of left atrial diverticulum based on computed tomography and reverse engineering softwares]

This paper aims to explore the feasibility of building a finite element model of left atrial diverticulum (LAD) using reverse engineering software based on computed tomography (CT) images. The study was based on a three-dimensional cardiac CT images of a atrial fibrillation patient with LAD. The left atrium and LAD anatomical features were accurately reproduced by using Geomagic Studio 12 and Mimics 15 reverse engineering software. In addition, one left atrial model with LAD and one without LAD were created with ANSYS finite element analysis software, and the validity of the two models were verified. The results show that it is feasible to establish the LAD finite element model based on cardiac three-dimensional CT images using reverse engineering software. The results of this paper will lay a theoretical foundation for further hemodynamic analysis of LAD.

Low Wall Shear Stress Is Associated with Local Aneurysm Wall Enhancement on High-Resolution MR Vessel Wall Imaging

BACKGROUND AND PURPOSE

Some retrospective studies have found that the aneurysm wall enhancement on high-resolution MR vessel wall postgadolinium T1WI has the potential to distinguish unstable aneurysms. This study aimed to identify hemodynamic characteristics that differ between the enhanced and nonenhanced areas of the aneurysm wall on high-resolution MR vessel wall postgadolinium T1WI.

MATERIALS AND METHODS

TOF-MRA and high-resolution MR vessel wall T1WI of 25 patients were fused to localize the enhanced area of the aneurysm wall. Using computational fluid dynamics, we studied the aneurysm models. Mean static pressure, mean wall shear stress, and oscillatory shear index were compared between the enhanced and nonenhanced areas.

RESULTS

The aneurysmal enhanced area had lower wall shear stress (P < .05) and a lower oscillatory shear index (P = .021) than the nonenhanced area. In addition, the whole aneurysm had lower wall shear stress (P < .05) and a higher oscillatory shear index (P = .007) than the parent artery.

CONCLUSIONS

This study suggests that there are hemodynamic differences between the enhanced and nonenhanced areas of the aneurysm wall on high-resolution MR vessel wall postgadolinium T1WI.

A Novel Scoring System for Rupture Risk Stratification of Intracranial Aneurysms: A Hemodynamic and Morphological Study

Objective: The aim of the present study is to investigate the potential morphological and hemodynamic risk factors related to intracranial aneurysms (IAs) rupture and establish a system to stratify the risk of IAs rupture to help the clinical decision-making. Methods: Patients admitted to our hospital for single-IAs were selected from January 2012 and January 2018. A propensity score matching was conducted to match patients. The morphological parameters were obtained from high solution CTA images, and the hemodynamic parameters were obtained in accordance with the outcomes of computational fluid dynamics (CFDs) simulation. Differences in the morphologic and hemodynamic parameters were compared. The significant parameters were selected to establish a novel scoring system (Intracranial Aneurysm Rupture Score, IARS). The comparison was drawn between the discriminating accuracy of IARS and the Rupture Resemblance Score (RRS) system to verify the value of IARS. Then, a group of patients with unruptured IAs was stratified into the high risk and low risk groups by IARS and RRS system separately and was followed up for 18-27 months to verify the value of IARS. The outcome of different stratifications was compared. Results: The matching process yielded 167 patients in each group. Differences of statistical significance were found in aneurysm length (p = 0.001), perpendicular height (H) (p < 0.001), aspect ratio (AR) (p < 0.001), size ratio (SR) (p < 0.001), deviated angle (DA) (p < 0.001), normalized average wall shear stress (NWSSa) (p < 0.001), wall shear stress gradient (WSSG) (p < 0.001), low shear area ratio (LSAR) (p = 0.01), and oscillatory shear index (OSI) (p = 0.01). Logistic regression analysis further demonstrated that SR, DA, NWSSa, LSAR, and OSI were the independent risk factors of IAs rupture. SR, DA, LSAR, and OSI were finally selected to establish the IARS. Our present IARS showed a higher discriminating value (AUC 0.81 vs. 0.77) in comparison with the RRS (SR, NWSSa, and OSI). After follow-up, seven patients were subject to IAs rupture. 5/26 in high risk group stratified by IARS, yet 7/57 in high risk group stratified by RRS. The accuracy of IARS was further verified (19.2% vs. 12.3%, AUC for the IARS and the RRS was 0.723 and 0.673, respectively). Conclusion: SR, DA, NWSSa, LSAR, and OSI were considered the independent risk factors of IAs rupture. Our novel IARS showed higher accuracy in discriminating IA rupture in comparison with RRS.

STUDY ON THE RELATIONSHIP BETWEEN WALL SHEAR STRESS AND ASPECT RATIO OF CEREBRAL ANEURYSMS WITH DIFFERENT PRESSURE DIFFERENCES USING CFD SIMULATIONS

CFD simulations were performed for 60 human cerebral aneurysms (30 previously ruptured and 30 previously unruptured) to study the behavior of the time-averaged wall shear stress (TAWSS) with respect to the aspect ratio (AR), implementing a set of low, normal, and high-pressure differences between the inlet and the outlets of each artery. It is well known that there exists a direct relationship between TAWSS and the rupture. In this investigation, we presented an important result because the condition of the pressure among the branches and the AR may be measured in any patient, then a slope may be associated, and finally a TAWSS may be estimated. We found that when the pressure difference increased, the absolute slopes between TAWSS and AR increased as well. Also, the magnitude of the slope in the previously unruptured aneurysms was 4.7 times the slope in the previously ruptured aneurysms. On the other hand, TAWSS was higher in the previously unruptured aneurysm than previously ruptured aneurysms due to the unruptured aneurysms that have a smaller surface area. Furthermore, we analyzed the relationship between TAWSS and other geometric parameters of the aneurysm, such as bottleneck and non-sphericity index; however, no correlation was found for either cases.

The role of wall shear stress in the parent artery as an independent variable in the formation status of anterior communicating artery aneurysms

OBJECTIVES

The study aimed to determine which hemodynamic parameters independently characterize anterior communicating artery (AcomA) aneurysm formation and explore the threshold of wall shear stress (WSS) of the parent artery to better illustrate the correlation between the magnitude of WSS and AcomA aneurysm formation.

METHODS

Eighty-one patients with AcomA aneurysms and 118 patients without intracranial aneurysms (control population), as confirmed by digital subtraction angiography (DSA) from January 2014 to May 2017, were included in this cross-sectional study. Three-dimensional-DSA was performed to evaluate the morphologic characteristics of AcomA aneurysms. Local hemodynamic parameters were obtained using transcranial color-coded duplex (TCCD). Multivariate logistic regression and a two-piecewise linear regression model were used to determine which hemodynamic parameters are independent predictors of AcomA aneurysm formation and identify the threshold effect of WSS of the parent artery with respect to AcomA aneurysm formation.

RESULTS

Univariate analyses showed that the WSS (p < 0.0001), angle between the A1 and A2 segments of the anterior cerebral artery (ACA) (p < 0.001), hypertension (grade II) (p = 0.007), fasting blood glucose (FBG; > 6.0 mmol/L) (p = 0.005), and dominant A1 (p < 0.001) were the significant parameters. Multivariate analyses showed a significant association between WSS of the parent artery and AcomA aneurysm formation (p = 0.0001). WSS of the parent artery (7.8-12.3 dyne/cm²) had a significant association between WSS and aneurysm formation (HR 2.0, 95% CI 1.3-2.8, p < 0.001).

CONCLUSIONS

WSS ranging between 7.8 and 12.3 dyne/cm² independently characterizes AcomA aneurysm formation. With each additional unit of WSS, there was a one-fold increase in the risk of AcomA aneurysm formation.

KEY POINTS

• Multivariate analyses and a two-piecewise linear regression model were used to evaluate the risk factors for AcomA aneurysm formation and the threshold effect of WSS on AcomA aneurysm formation. • WSS ranging between 7.8 and 12.3 dyne/cm ² was shown to be a reliable hemodynamic parameter in the formation of AcomA aneurysms. The probability of AcomA aneurysm formation increased one-fold for each additional unit of WSS. • An ultrasound-based TCCD technique is a simple and accessible noninvasive method for detecting WSS in vivo; thus, it can be applied as a screening tool for evaluating the probability of aneurysm formation in primary care facilities and community hospitals because of the relatively low resource intensity.

Morphological parameters and anatomical locations associated with rupture status of small intracranial aneurysms

Characterization of the rupture risk factors for small intracranial aneurysms (SIAs, ≤5 mm) is clinically valuable. The present study aims to identify image-based morphological parameters and anatomical locations associated with the rupture status of SIAs. Two hundred and sixty-three patients with single SIAs (128 ruptured, 135 unruptured) were included, and six morphological parameters, including size, aspect ratio (AR), size ratio (SR), height–width ratio (H/W), flow angle (FA) and aneurysm width–parent artery diameter ratio, and the aneurysm locations were evaluated using three-dimensional geometry, and were used to identify a correlation with aneurysm rupture. Statistically significant differences were observed between ruptured and unruptured groups for AR, SR, H/W, FA, and aneurysm locations, from univariate analyses. Logistic regression analysis further revealed that AR (p = 0.034), SR (p = 0.004), H/W (p = 0.003), and FA (p < 0.001) had the strongest independent correlation with ruptured SIAs after adjustment for age, gender and other clinical risk factors. A future study on a larger SIA cohort need to establish to what extent the AR, SR, H/W and FA increase the risk of rupture in patients with unruptured SIAs in terms of absolute risks.

Difference in aneurysm characteristics between ruptured and unruptured aneurysms in patients with multiple intracranial aneurysms

Background:

The risk of aneurysmal rupture is dependent upon numerous factors, however, there are inconsistencies in the results between studies, which may be due to confounding factors. This can be avoided by comparing the characteristics of ruptured and unruptured aneurysms within the same patient. We sought to analyze the aneurysm characteristics of patients with acute aneurysmal subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms.

Methods:

We reviewed our prospectively maintained institutional database, between 01/10/2007 and 01/01/2017, for all patients with confirmed SAH and >1 aneurysm. We recorded the size, location, and morphology and calculated secondary geometric indices such as bottleneck factor and aspect ratio.

Results:

During the study period, a total of 694 patients with aneurysmal SAH were admitted to our institution. We identified 113 patients (74.3% female, average age 51.7 ± 12.3). The majority of patients had only one associate unruptured aneurysm (79.6%). The average unruptured aneurysm was 3.1 ± 1.5 mm and the average ruptured aneurysm was 5.7 ± 2.7 mm (P < 0.001). In the multivariate analysis, aneurysm location, aneurysm morphology, and size were independently associated with rupture. A complex aneurysm morphology was the strongest risk factor for rupture (OR, 29.27; 95% CI 14.33–59.78; P < 0.001) with size >7 mm (OR, 17.74; 95% CI 4.07–77.35; P < 0.001), and AcomA location also showing a strong independent association.

Conclusion:

Size plays an important part in determining rupture risk, however, other factors such as location and in particular morphology must also be considered. We believe that the introduction of vessel wall imaging will help to risk stratify aneurysms.

Macrophage Polarization in Cerebral Aneurysm: Perspectives and Potential Targets

Cerebral aneurysms (CAs) have become a health burden not only because their rupture is life threatening, but for a series of devastating complications left in survivors. It is well accepted that sustained chronic inflammation plays a crucial role in the pathology of cerebral aneurysms. In particular, macrophages have been identified as critical effector cells orchestrating inflammation in CAs. In recent years, dysregulated M1/M2 polarization has been proposed to participate in the progression of CAs. Although the pathological mechanisms of M1/M2 imbalance in CAs remain largely unknown, recent advances have been made in the understanding of the molecular basis and other immune cells involving in this sophisticated network. We provide a concise overview of the mechanisms associated with macrophage plasticity and the emerging molecular targets.