Intracranial Mirror Aneurysm: Epidemiology, Rupture Risk, New Imaging, Controversies, and Treatment Strategies

Comprehensive analysis of risk factors for intracranial aneurysm rupture: a retrospective cohort study

Background

Intracranial aneurysms (IAs) can lead to subarachnoid hemorrhage, a life-threatening event associated with high morbidity and mortality. Identifying individuals at elevated risk is crucial for guiding timely interventions and improving patient outcomes.

Methods

In this retrospective cohort study, 850 patients who received interventional or surgical treatment for IAs between January 2018 and January 2024 were included. Demographic data (e.g., age, sex), lifestyle factors, and comorbidities were recorded. Hematologic, biochemical, and coagulation parameters were measured to evaluate their potential association with IA rupture. A univariate logistic regression was first conducted, followed by a multivariate logistic regression with a backward stepwise approach to derive the final predictive model. The model's performance was assessed using the area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis.

Results

Younger age, female sex, higher neutrophil count, lower hematocrit, and elevated markers of inflammation and coagulation (including fibrinogen and D-dimer) emerged as key risk factors. Electrolyte imbalances, such as low potassium, and elevated lactate dehydrogenase were also significantly associated with rupture. The optimized model achieved an AUC of 0.815, with good calibration and clinical utility indicated by decision curve analysis.

Conclusion

These findings highlight the interplay of demographic, inflammatory, metabolic, and coagulation parameters in determining rupture risk in patients with IAs. Incorporating these risk factors into clinical practice may enhance early detection, guide targeted prevention strategies, and ultimately improve outcomes for high-risk individuals.

A study on the therapeutic effect of precise clipping of intracranial aneurysms assisted by CTA and 3D-slicer software

Objective

To evaluate the application of Computed Tomography Angiography (CTA) combined with 3D-Slicer software reconstruction technology in the diagnosis and preoperative planning of intracranial aneurysms, and to explore its positive significance in improving surgical outcomes for patients.

Methods

From January 2021 to December 2023, a total of 24 patients diagnosed with intracranial aneurysms (25 cases) underwent craniotomy clipping surgery. We utilized 3D-Slicer to render and fuse preoperative CTA image data, and to formulate individualized surgical plans, including approach, bone window, anticipated protection of the aneurysm-bearing artery and perforating arteries, and compared these with the actual surgical procedures. The actual intraoperative conditions were used as the diagnostic reference standard to compare and analyze the morphology of intracranial aneurysms, assessing the consistency between preoperative planning and actual operations. Additionally, intraoperative and postoperative complications and prognosis were analyzed.

Results

It was confirmed that among the 25 intracranial aneurysms, the combination of CTA and 3D-Slicer could effectively detect and reconstruct these aneurysms; quantifying the extent of bone window grinding could reduce the need for multiple bone grinding after opening the dura mater; the consistency in determining the stenosis of the aneurysm-bearing artery intraoperatively, the difficulty of reconstructing and separating the aneurysm neck, and the condition of the perforating arteries near the aneurysm was good, with Kappa values of 0.865, 0.779, and 0.635, respectively. However, the consistency in predicting the rupture orientation of the aneurysm was poor, with a Kappa value of 0.186. All aneurysms in this group were completely clipped, and no new signs of bleeding were found in the head CT within 24 h after surgery, and no signs of aneurysm recurrence were observed in the head CTA within 7 days.

Conclusion

In summary, combining 3D-Slicer technology with CTA can accurately assess intracranial aneurysms and provide key anatomical information required for craniotomy clipping surgery to formulate surgical plans, which has a positive significance in reducing surgical complications. These findings not only lay the foundation for further exploration of related issues but also provide clinical doctors with more scientifically effective guidance for diagnosis and surgical planning.

Silent magnetic resonance angiography diagnostic value of intracranial unruptured aneurysms

Silent magnetic resonance angiography (S-MRA) is primarily utilized to assess the blood flow in aneurysms and parent vessels of treated intracranial aneurysms. This study aimed to compare the diagnostic value of S-MRA and three-dimensional time of flight (3D-TOF) MRA for unruptured intracranial aneurysms. We included patients diagnosed with unruptured intracranial aneurysms using digital subtraction angiography (DSA) who subsequently underwent S-MRA and 3D-TOF MRA. Two independent neuroimaging and neurointerventional doctors evaluated the DSA images and measured aneurysm dimensions. Using DSA results as the gold standard, we determined the sensitivity and specificity of S-MRA and 3D-TOF MRA, as well as their accuracy in measuring aneurysm size and identifying aneurysms with daughter sacs. We detected a total of 41 intracranial aneurysms (in 37 patients) on both S-MRA and 3D-TOF MRA, with both techniques achieving a sensitivity and specificity of 100%. For aneurysm height, the intraclass correlation coefficient (ICC) was 0.977 (P < 0.001) between S-MRA and DSA, and 0.908 (P < 0.001) between 3D-TOF MRA and DSA. For neck width, the ICC was 0.663 (P < 0.001) between S-MRA and DSA, and 0.563 (P < 0.001) between 3D-TOF MRA and DSA. In terms of daughter aneurysm detection, 3D-TOF MRA Sensitivity 40%; specificity 92%: positive predictive value 100%; S-MRA sensitivity 60%; specificity 89%; positive predictive value 42%. In conclusion, S-MRA and 3D-TOF MRA did not significantly differ in aneurysm detection ability. For the detection of aneurysm with dauthger sacs indicators, the sensitivity is also higher.

Single frontotemporal approach for microsurgical clipping of bilateral ophthalmic artery aneurysms: a case report

Bilateral ophthalmic aneurysms represent a distinct niche of brain aneurysms located in a complex skull base region. When considering surgical treatment, a single-stage approach is often advantageous to minimize operative time, tissue manipulation, and damage to neural and vascular structures compared to a two-stage surgery. Nonetheless, this procedure is not exempt from risks, given that through knowledge, preoperative and intraoperative judgment can be necessary to reduce the significant risk of bilateral vision loss. Thus, a tailored approach often is needed. In this study, we present the case of a 53-year-old female who was diagnosed with bilateral ophthalmic aneurysms during the work-up for chronic headaches. Because of the growth pattern and imminent risk of rupture, she underwent elective microsurgical treatment. A frontotemporal approach ipsilateral to the most lobulated aneurysm was performed. Both aneurysms were successfully clipped in a single craniotomy. Her postoperative imaging demonstrated adequate clipping and an uneventful clinical course. Our case outlines the feasibility of a single approach and contributes to the tailored selection for patients when considering microsurgical treatment for these complex lesions.

Endovascular Treatment of Mirror Aneurysms in Subarachnoid Hemorrhage Patients: Single Stage or Multiple Stage?

OBJECTIVE

The study evaluated the effectiveness and safety of single-stage versus multistage endovascular treatment in subarachnoid hemorrhage patients with Mirror Aneurysms.

MATERIALS AND METHODS

Our research team performed a prospective study, focusing on the radiographic and clinical data of patients diagnosed with subarachnoid hemorrhage, specifically those who presented with Mirror Aneurysms upon admission to our institutions. According to the different endovascular treatment stages, these patients were grouped into the multistage cohort and the single-stage cohort.

RESULT

A total of 216 aneurysms were identified among the 108 patients, with every patient having one ruptured aneurysm. The duration of follow-up was 2 years in both groups. In the single-stage cohort, all 114 aneurysms in 57 patients were managed during a single session. During the 2-year follow-up, it was observed that 49 patients achieved a modified Rankin Scale score ≤2. Five complications were encountered, including cerebral vasospasm in three patients, cerebral hemorrhage in one patient, and thromboembolism in one patient. In the multistage cohort, only the ruptured aneurysm (amounting to 51 in total) received treatment at the initial occurrence, while the remaining 51 aneurysms were addressed subsequently. Throughout the 2-year follow-up period, 46 subjects exhibited a modified Rankin scale score ≤2. Overall, four complications were documented, including cerebral vasospasm in two patients, a subarachnoid hemorrhage in one patient, and thromboembolism in one patient.

CONCLUSION

The safety and effectiveness of both endovascular treatment groups have been verified for patients with Mirror Aneurysms suffering from subarachnoid hemorrhage. If feasible, single-stage embolization should be considered a viable treatment option for these patients.

Comparative efficacy and safety of therapeutic strategies for mirror aneurysms: A systematic review and meta-analysis

Mirror aneurysms are rare and pose therapeutic challenges, with both endovascular and microsurgical options available. Single-stage and two-stage procedures are employed, but the optimal strategy remains unclear. This systematic review and meta-analysis evaluate the efficacy and safety of different therapeutic strategies for managing mirror aneurysms. The study adhered to PRISMA guidelines and comprehensively analyzed data from multiple databases, including Pubmed, Scopus, Embase, Web of Science, and the Cochrane Library, up to 30th September 2024. Statistical analysis utilized the Comprehensive Meta-analysis (CMA) software version 3.0. This systematic review encompasses 42 studies, with 11 studies undergoing meta-analysis. The meta-analysis included 629 participants. Both microsurgical clipping and endovascular interventions achieved high rates of complete occlusion (RROC 1) (ES = 0.896; 95% CI: 0.840 to 0.931; P < 0.001) with low to moderate heterogeneity (I2 = 46.46%). Favorable neurological outcomes (mRS ≤ 2) were significantly achieved among all patients (ES = 0.924; 95% CI: 0.891 to 0.948; P < 0.001) with low heterogeneity (I2 = 15.52%). Subgroup analysis revealed that microsurgical clipping demonstrated superior occlusion rates and more consistent neurological outcomes compared to endovascular treatment. Also, complications were reported in seven studies (n = 492) and included cerebral infarction, hydrocephalus, and vasospasm. As well, mortality and recurrence were rare. Both microsurgical clipping and endovascular interventions are effective and safe for treating mirror aneurysms, with clipping showing superior occlusion rates and consistent outcomes. Single-stage procedures and unilateral craniotomy are associated with better neurological outcomes when feasible.

Exploring the roles and therapeutic implications of melatonin-mediated KLF6 in the development of intracranial aneurysm

BACKGROUND

Intracranial aneurysm (IA) is a cerebrovascular disease with a high mortality rate due to ruptured subarachnoid hemorrhage. While Krüppel-like factor 6 (KLF6) dysregulation has been implicated in cancer and cardiovascular diseases, its role in IA remains unclear.

MATERIALS AND METHODS

The GSE122897 and GSE15629 datasets were downloaded from the Gene Expression Omnibus database. Immune cell infiltration and hypoxia analysis were performed to explore the effects of KLF6 on IA. Weighted gene co-expression network analysis was used to identify hub genes related to KLF6 expression for subsequent analyses. Hypoxia-related genes were identified. Drug prediction was performed for IA. Samples from healthy individuals and patients with IA were collected to detect the expression of endothelin-1 (ET-1), vascular hematoma factor (vWF), and KLF6. A model of H2O2-induced human brain vascular smooth muscle cells (HBVSMC) injury was constructed to explore the effects of KLF6 and melatonin to treat IA.

RESULTS

T cells CD4 memory resting and monocytes were significantly different in the KLF6 high and low expression groups. Four hypoxia-related gene sets were significantly enriched in the KLF6 high-expression group. Six hypoxia-related hub genes were obtained, which were significantly associated with KLF6. Drug prediction showed that melatonin may be a potential drug for IA. The levels of ET-1, vWF, and KLF6 were significantly upregulated in patients with IA. KLF6 exacerbates H2O2-induced injury in HBVSMC, ameliorated by melatonin.

CONCLUSION

KLF6 may be a potential target for IA treatment, with melatonin-mediated KLF6 effects playing a crucial role in the development of IA.

Analysis of the Surgical Efficacy and Risk Factors of a One-stage Unilateral Approach for Clipping Bilateral MCA Mirror Aneurysms

BACKGROUND

Numerous microsurgical approaches are available for treating middle cerebral artery (MCA) mirror aneurysms. However, a definitive conclusion regarding which approach yields the best outcome has yet to be reached.

METHODS

Thirty-three patients with MCA aneurysms were categorized into 2 groups: one-stage unilateral approach and other surgical approaches. Prognostic differences were compared using the Modified Rankin Scale (mRS). In addition, the length of hospital stay and costs were also compared. Among the patients with a proposed preoperative one-stage unilateral approach, they were divided into success and failure groups, and these factors were collected, including Hunt-Hess grade, contralateral aneurysm orientation and maximum diameter, contralateral A1+M1 length, and contralateral ICA bifurcation angle. These parameters were analyzed using multivariate logistic regressions to identify the risk factors.

RESULTS

The prognosis of patients in the one-stage unilateral approach group did not differ significantly from that of other surgical approaches. However, patients in the one-stage unilateral approach group experienced shorter hospital stays and incurred lower hospital expenses. In the multivariate regressions, the length of the contralateral A1+M1 was identified as an independent risk factor.

CONCLUSIONS

The one-stage unilateral pterional approach for clipping bilateral aneurysms is an effective method of treating MCA mirror aneurysms. However, in cases where patients have an excessive length of A1+M1 on the contralateral side, this approach may result in surgical failure.

Clinical relevance of critical plasma homocysteine levels in predicting rupture risk for small and medium-sized intracranial aneurysms

Plasma homocysteine (Hcy) has been globally recognized as an independent risk factor for various neurovascular diseases. In this study, the authors investigated the relationship between critical Hcy concentration and the risk of rupture in intracranial aneurysms (IAs). This study collected data from 423 patients with both ruptured and unruptured IAs. We compared demographic data, vascular rupture risk factors, and laboratory test results between the two groups. Multivariable logistic regression analysis was employed to determine the correlation between critical plasma Hcy levels and the risk of rupture in small to medium-sized IAs. A total of 330 cases of ruptured intracranial aneurysms (RIA) and 93 cases of unruptured intracranial aneurysms (UIA) were included. Univariate analysis revealed statistically significant differences between the ruptured and unruptured groups in terms of hypertension, hyperlipidemia, plasma Hcy levels, and IA morphology (all P < 0.05). Multivariable logistic regression analysis indicated that hypertension (odds ratio [OR] 0.504; 95% confidence interval [CI] 0.279-0.911; P = 0.023), hyperlipidemia (OR 1.924; 95% CI 1.079-3.429; P = 0.027), and plasma Hcy levels (OR 1.420; 95% CI 1.277-1.578; P < 0.001) were independently associated with the rupture of small to medium-sized IAs, all with statistical significance (P < 0.05). Our study suggests that critical plasma Hcy levels are an independent risk factor for increased rupture risk in small to medium-sized intracranial aneurysms. Therefore, reducing plasma Hcy levels may be considered a valuable strategy to mitigate the risk of intracranial vascular abnormalities rupture and improve patient prognosis.

Effect of Siphon Morphology on the Risk of C7 Segment Aneurysm Formation : A Case-control CFD Study

PURPOSE

Tortuosity of the internal carotid artery (ICA) is associated with intracranial aneurysms (IAs). The siphon is the most curved segment of the ICA, but its morphology has controversial effects on IAs. This study aimed to explore the morphometric features of the siphon and the potential hemodynamic mechanisms that may affect C7 aneurysm formation.

METHODS

In this study 32 patients with C7 aneurysms diagnosed at Xiangya Hospital between 2019 and 2021 and 32 control subjects were enrolled after propensity score matching. Computed tomography angiography (CTA) images were acquired to measure morphologic features, and then, by combining clinical data, simplified carotid siphon models were constructed, and computational fluid dynamics (CFD) analysis was performed.

RESULTS

The presence of C7 aneurysms was associated with the height of the C4-C6 curved arteries (odds ratio [OR] 0.028, 95% confidence interval [CI] 0.003-0.201; P < 0.001). The heights of the C4-C6 curved arteries in the aneurysm group were significantly shorter than those in the control group. The CFD analysis revealed that shorter C4-C6 bends led to greater blood velocity and pressure in the C7 segment arteries.

CONCLUSION

A shorter C4-C6 bend was associated with distal C7 aneurysm formation, and an elaborate hemodynamic mechanism may underlie this association.

Identification of differentially expressed autophagy-related genes in cases of intracranial aneurysm: Bioinformatics analysis

OBJECTIVE

Recent research indicates that autophagy is essential for the rupture of intracranial aneurysm (IA). This study aimed to examine and validate potential autophagy-related genes (ARGs) in cases of IA using bioinformatics analysis.

METHODS

Two expression profiles (GSE54083 and GSE75436) were obtained from the Gene Expression Omnibus database. Differentially expressed ARGs (DEARGs) in cases of IA were screened using GSE75436, and enrichment analysis and Protein-Protein Interaction (PPI) networks were used to identify the hub genes and related pathways. Furthermore, a novel predictive diagnostic signature for IA based on the hub genes was constructed. The area under the Receiver Operating Characteristic curve (AUC) was used to evaluate the signature performance in GSE75436.

RESULTS

In total, 75 co-expressed DEARGs were identified in the GSE75436 and GSE54083 dataset (28 upregulated and 47 downregulated genes). Enrichment analysis of DEARGs revealed several enriched terms associated with proteoglycans in cancer and human immunodeficiency virus 1 infection. PPI analysis revealed interactions between these genes. Hub DEARGs included insulin-like growth factor 1, clusters of differentiation 4, cysteine-aspartic acid protease 8, Bcl-2-like protein 11, mouse double mutant 2 homolog, toll-like receptor 4, growth factor receptor-bound protein 2, Jun proto-oncogene, AP-1 transcription factor subunit, hypoxia inducible factor 1 alpha, and erythroblastic oncogene B-2. Notably, the signature showed good performance in distinguishing IA (AUC = 0.87). The sig calibration curves showed good calibration.

CONCLUSION

Bioinformatic analysis identified 75 potential DEARGs in cases of IA. This study revealed that IA is affected by autophagy, which could explain the pathogenesis of IA and aid in its diagnosis and treatment. However, future research with experimental validation is necessary to identify potential DEARGs in cases of IA.

Prognostic Factors for Anterior Cerebral Artery Aneurysms: A Single-Center Series

OBJECTIVE

The aim of the present study is to summarize the characteristics of anterior cerebral artery aneurysms and to explore the prognostic factors of microsurgical clipping treatment for anterior cerebral artery aneurysms.

MATERIALS AND METHODS

A total of 90 anterior cerebral artery aneurysms (ACAAs) are reviewed from January 2000 to July 2019. Patients are categorized into good outcome group and poor outcome group according to Glasgow outcome scale scores. Multiple factors, including clinical characteristics and aneurysms' characteristics, are evaluated to identify the independent risk factors associated with prognosis of ACAAs.

RESULTS

This analysis reveals that in the ACAAs database the number of SAH (P=0.01), high H-H grade (P<0.001) and high Fisher grade (P<0.001) are correlated with prognosis of ACAAs. Finally, age (P=0.007, odds ratio=1.124, 95% CI: 1.033-1.223) and Hunt-Hess (grade III-V, P=0.022, odds ratio =59.77, 95% CI: 1.794-1991.298) are found to be independent risk factors for prognosis.

CONCLUSIONS

The age and high Hunt-Hess grade seem to be important factors affecting the prognosis of ACAAs.

Comparative Analysis of Circular RNAs Expression and Function between Aortic and Intracranial Aneurysms

An aneurysm is an abnormal enlargement or bulging of the wall of a blood vessel. Most often, aneurysms occur in large blood vessels - the aorta (Thoracic Aortic Aneurysm (TAA) and Abdominal Aortic Aneurysm (AAA)) and brain vessels (Intracranial Aneurysm (IA)). Despite the presence of significant differences in the pathogenesis of the development and progression of IA and TAA/AAA, there are also similarities. For instance, both have been shown to be strongly influenced by shear stress, inflammatory processes, and enzymatic destruction of the elastic lamellae and extracellular matrix (ECM) proteins of the vascular wall. Moreover, although IA and TAA are predominantly considered arteriopathies with different pathological mechanisms, they share risk factors with AAA, such as hypertension and smoking. However, there is a need for a more in- -depth study of the key elements that may influence the formation and progression of a particular aneurysm to find ways of therapeutic intervention or search for a diagnostic tool. Today, it is known that the disruption of gene expression is one of the main mechanisms that contribute to the development of aneurysms. At the same time, growing evidence suggests that aberrant epigenetic regulation of gene function is strongly related to the genesis of aneurysms. Although much has been studied of the known protein-coding genes, circular RNAs (circRNAs), a relatively new and rapidly evolving large family of transcripts, have recently received much scientific attention. CircRNAs regulate gene expression through the sponging of microRNAs (miRNAs) and can also be used as therapeutic targets and biomarkers. Increasing evidence has implicated circRNAs in the pathogenesis of multiple cardiovascular diseases, including the development of aneurysms. However, the mechanism of dysregulation of certain circRNAs in a particular aneurysm remains to be studied. The discovery of circRNAs has recently advanced our understanding of the latest mode of miRNAs/target genes regulation in the development and progression of IA and TAA/AAA. The aim of this study is to compare the expression profiles of circRNAs to search for similar or different effects of certain circRNAs on the formation and progression of IA and TAA/AAA.

The Rate and Predictors of 30-Day Readmission in Patients Treated for Unruptured Cerebral Aneurysms: A Large Single-Center Study

BACKGROUND AND OBJECTIVES

Numerous studies of various populations and diseases have shown that unplanned 30-day readmission rates are positively correlated with increased morbidity and all-cause mortality. In this study, we aim to provide the rate and predictors of 30-day readmission in patients undergoing treatment for unruptured intracranial aneurysms.

METHODS

This is a retrospective study of 525 patients presenting for aneurysm treatment between 2017 and 2022. All patients who were admitted and underwent a successful treatment of their unruptured intracerebral aneurysms were included in the study. The primary outcome was the rate and predictors of 30-day readmission.

RESULTS

The rate of 30-day readmission was 6.3%, and the mean duration to readmission was 7.8 days ± 6.9. On univariate analysis, factors associated with 30-day readmission were antiplatelet use on admission (odds ratio [OR]: 0.4, P = .009), peri-procedural rupture (OR: 15.8, P = .007), surgical treatment of aneurysms (OR: 2.2, P = .035), disposition to rehabilitation (OR: 9.5, P < .001), and increasing length of stay (OR: 1.1, P = .0008). On multivariate analysis, antiplatelet use on admission was inversely correlated with readmission (OR: 0.4, P = .045), whereas peri-procedural rupture (OR: 9.5, P = .04) and discharge to rehabilitation (OR: 4.5, P = .029) were independent predictors of 30-day readmission.

CONCLUSION

In our study, risk factors for 30-day readmission were aneurysm rupture during the hospital stay and disposition to rehabilitation, whereas the use of antiplatelet on admission was inversely correlated with 30-day readmission. Although aneurysm rupture is a nonmodifiable risk factor, more studies are encouraged to focus on the correlation of antiplatelet use and rehabilitation disposition with 30-day readmission rates.

Predictors of Oculomotor Nerve Palsy with Posterior Communicating Aneurysm Clipping in a Surgically Treated Series of 585 Patients: A Single-Center Study

BACKGROUND

Oculomotor nerve palsy (OMNP) is a known risk in surgical management of intracranial aneurysms. The aim of this study was to determine the risk factors for surgery-induced OMNP.

METHODS

This retrospective study examined 585 patients with posterior communicating artery aneurysms treated surgically between January 2000 and July 2019. The patients were categorized into 2 groups according to whether they experienced OMNP. Multiple factors, including sex, age, history of subarachnoid hemorrhage, Hunt and Hess grade, Fisher grade, preoperative time, sizes, sides, number, orientation, intraoperative rupture, and morphology, were analyzed to identify factors associated with surgery-induced OMNP.

RESULTS

The overall OMNP rate was 4.4%. In univariate analysis, large size (P < 0.001), posterior infratentorial projection (P = 0.003), number of subarachnoid hemorrhages (P = 0.005), and late preoperative time (P < 0.001) were associated with increased risk of OMNP. Overall, multivariate logistic regression analysis showed that size (10.1-25 mm: odds ratio [OR] 30.083, P = 0.001, 95% confidence interval [CI], 3.703-244.419; >25 mm: OR 62.179, P = 0.012, 95% CI, 2.402-1609.418), intraoperative rupture (OR 3.018, P = 0.035, 95% CI, 1.083-8.412), and preoperative time (>14 days: OR 10.985, P < 0.001, 95% CI, 3.840-31.428) were independent risk factors of surgery-induced OMNP.

CONCLUSIONS

This study showed that size, intraoperative rupture, and preoperative time were independent predictors of surgery-induced OMNP. Use of advanced technologies during the operation can assist in avoiding this complication.

Trends in admissions for intracranial dissections in the United States

INTRODUCTION

Intracranial artery dissection (IAD) is rarer than cervical artery dissections (CeAD), and information is based on limited series with small cohorts. There are only several small-scale studies attempting to characterize the natural history of the disease. Herein, we analyze the prevalence of IADs in hospitalized patients using a national database.

METHODS

The National Inpatient Sample was queried from 2016-2019 for patients with a diagnosis of unruptured intracranial dissection (uIAD) using ICD-10-CM codes (I67.0). Moreover, patients with acute ischemic stroke (AIS) and CeAD were extracted to compare its prevalence among patients with concomitant AIS (+/-dissections). The Cochrane-Armitage test was conducted to assess trends in the prevalence of uIADs among those with concomitant AIS or among all craniocervical dissections.

RESULTS

There were 725 hospitalizations involving uIAD, while there were 62,220 involving CeADs. uIADs represented 5.1 per million hospitalizations across 2016-2019. The average age of presentation was 56.9 years (SE: 1.62), while it was 54.4 (SE: 0.17) for CeADs (p = 0.13). Females were represented among 44.8% (n = 325) of uIADs, a similar proportion compared to CeADs (44.3%%, n = 27,530; p = 0.89). Compared to CeADs, AIS and motor deficits were more common in uIAD (71.72% vs. 47.0%; p < 0.001). There were 18.6 uIAD with concomitant AIS per 100,000 with AIS. uIADs represented 1.75% of all dissections with concomitant AIS (n = 520/29,750). There was no trend in the average age of presentation for uIADs. Proportion of females among those with uIADs increased from 36.8% in 2016 to 59.5% in 2019 (trend: +9.46% per year; 95% CI: 3.13 to 15.8; p = 0.004). There was no trend in the proportion of races among those with uIADs.

CONCLUSION

The prevalence of uIADs among hospitalized patients is very low, and only 1.75% of craniocervical dissection-related AIS is due to uIAD. Compared to CeADs, patients were more likely to be male, and uIAD more commonly led to acute ischemic stroke and motor deficits. The trend in age remained stable across the four years analyzed, while the proportion of females increased. There was no trend in the proportion of races among uIADs, however.

A web-based dynamic nomogram for rupture risk of posterior communicating artery aneurysms utilizing clinical, morphological, and hemodynamic characteristics

Background

Predicting rupture risk is important for aneurysm management. This research aimed to develop and validate a nomogram model to forecast the rupture risk of posterior communicating artery (PcomA) aneurysms.

Methods

Clinical, morphological, and hemodynamic parameters of 107 unruptured PcomA aneurysms and 225 ruptured PcomA aneurysms were retrospectively analyzed. The least absolute shrinkage and selection operator (LASSO) analysis was applied to identify the optimal rupture risk factors, and a web-based dynamic nomogram was developed accordingly. The nomogram model was internally validated and externally validated independently. The receiver operating characteristic (ROC) curve was used to assess the discrimination of nomogram, and simultaneously the Hosmer–Lemeshow test and calibration plots were used to assess the calibration. Decision curve analysis (DCA) and clinical impact curve (CIC) were used to evaluate the clinical utility of nomogram additionally.

Results

Four optimal rupture predictors of PcomA aneurysms were selected by LASSO and identified by multivariate logistic analysis, including hypertension, aspect ratio (AR), oscillatory shear index (OSI), and wall shear stress (WSS). A web-based dynamic nomogram was then developed. The area under the curve (AUC) in the training and external validation cohorts was 0.872 and 0.867, respectively. The Hosmer–Lemeshow p > 0.05 and calibration curves showed an appropriate fit. The results of DCA and CIC indicated that the net benefit rate of the nomogram model is higher than other models.

Conclusion

Hypertension, high AR, high OSI, and low WSS were the most relevant risk factors for rupture of PcomA aneurysms. A web-based dynamic nomogram thus established demonstrated adequate discrimination and calibration after internal and external validation. We hope that this tool will provide guidance for the management of PcomA aneurysms.

Nomogram model for predicting oculomotor nerve palsy in patients with intracranial aneurysm

AIM

To explore the risk factors of oculomotor nerve palsy (ONP) in patients with intracranial aneurysm (IA) and develop a nomogram model for predicting ONP of IA patients.

METHODS

A total of 329 IA patients were included. Logistic regression analysis was applied to identify independent factors, which were then integrated into the nomogram model. The performance of the nomogram model was evaluated by calibration curve, receiver operating curve (ROC), and decision curve analysis.

RESULTS

Univariate and multivariate logistic regression analysis indicated posterior communicating artery (PCoA) aneurysm [hazard ratio (HR)=17.13, P<0.001] and aneurysm diameter (HR=1.31, P<0.001) were independent risk factors of ONP in IA patients. Based on the results of logistic regression analysis, a nomogram model for predicting the ONP in IA patients was constructed. The calibration curve indicated the nomogram had a good agreement between the predictions and observations. The nomogram showed a high predictive accuracy and discriminative ability with an area under the curve (AUC) of 0.863. The decision curve analysis showed that the nomogram was powerful in the clinical decision. PCoA aneurysm (HR=3.38, P=0.015) was identified to be the only independent risk factor for ONP severity.

CONCLUSION

PCoA aneurysm and aneurysm diameter are independent risk factors of ONP in IA patients. The nomogram established is performed reliably and accurately for predicting ONP. PCoA aneurysm is the only independent risk factor for ONP severity.

Clinical Usage of Different Doses of Cis-Atracurium in Intracranial Aneurysm Surgery and Its Effect on Motor-Evoked Potentials

The objective of this work was to investigate the effect of different doses of cis-atracurium on patients undergoing general anesthesia induction (GAI) during intracranial aneurysm surgery (ICAS). In this work, 90 patients who underwent ICAS under the elective motor-evoked potential (MEP) monitoring in the First Affiliated Hospital of Northwest University (Xi'an No. 1 Hospital) from January 2021 to May 2022 were enrolled as the research objects. Randomly, they were rolled into a S1 group (30 cases, 2 times 95% effective dose (ED95) cis-atracurium), a S2 group (30 cases, 3 times ED95 cis-atracurium), and a S3 group (30 cases, 4 times ED95 cis-atracurium). The endotracheal intubation conditions, the train-of-four (TOF) rate (TOFR), body movement, and spontaneous breathing were compared among the three groups of patients. The results showed that the MEP inhibition time of the patients in the S3 group was much longer than that of the S1 and S2 groups, but it showed no significant difference between the S1 group and S2 group (P > 0.05). The good rates of endotracheal intubation conditions in the S2 group (100%) and S3 group (100%) were obviously higher than the rate in the S1 group (43.33%). The TOFRs of patients in S2 and S3 groups at time t2 and t3 were lower obviously to that at time t0, while the TOFRs of patients in S3 group at time t2 and t3 were still lower in contrast to the S2 group (P < 0.05). The mean arterial pressure (MAP) and heart rate (HR) of patients in all groups were lower at t1, t2, and t3 than at t0 (P < 0.05), while the differences among different groups were not remarkable (P > 0.05). Finally, using 3 times ED95 cis-atracurium for GAI could reduce the risk of intraoperative body movement and spontaneous breathing, as well as the residual degree of muscle relaxation, in patients with ICAS, without affecting MEP monitoring, improving endotracheal intubation conditions, and increasing safety during open neurosurgery operations.

Could outcomes of intracranial aneurysms be better predict using serum creatinine and glomerular filtration rate?

Purpose:

To analyze the role of serum creatinine levels as a biomarker of intracranial aneurysm outcomes.

Methods:

This is a prospective analysis of outcomes of patients with intracranial aneurysm. One hundred forty-seven patients with serum creatinine at admission and 6 months follow up were included. Linear and logistic regressions were used to analyze the data. Modified Rankin scale (mRS) was used to assess outcome.

Results:

Creatinine level was not directly related to aneurysm outcome nor aneurysm rupture (p > 0.05). However, patients with a glomerular filtration rate (GFR) lower than 72.50 mL·min^–1 had an odds ratio (OR) of 3.049 (p = 0.006) for worse outcome. Similarly, aneurysm rupture had an OR of 2.957 (p = 0.014) for worse outcomes. Stepwise selection model selected 4 variables for outcomes prediction: serum creatinine, sex, hypertension and treatment. Hypertensive patients had, on average, an increase in 0.588 in mRS (p = 0.022), while treatment with microsurgery had a decrease in 0.555 (p = 0.038).

Conclusions:

Patients with higher GFR had better outcomes after 6 months. Patients with higher GFR had better outcomes after 6 months. Creatinine presented an indirect role in GFR values and should be included in models for outcome prediction.

Identification of Potential Core Genes for the Rupture of Intracranial Aneurysms by a Bioinformatics Analysis

Background: Previous studies, using autopsy and angiography, have shown that 3.6–6% of the population have intracranial aneurysms, and the rupture of aneurysm can lead to brain dysfunction or even death in patients.

Methods: To explore potential preventional target genes for the ruptured of aneurysm, we analyze three gene expression datasets (GSE13353, GSE15629 and GSE54083) derived from the GEO database. We confirm DEGs associated with the unrupture of aneurysms by R package. DAVID version provides functional classification and annotation analyses of associated genes, including GO and KEGG pathway. PPI of these DEGs is analyzed based on the string database and visualized by Cytoscape software. DEGs are verified by qRT-PCR using samples isolated from the patients.

Results: 249 overlapping DEGs, including 96 up-regulated genes and 153 down-regulated genes are screened using the Venn diagram webtool. The GO term and KEGG pathways analysis results indicate that these DEGs are mainly enriched in protein phosphorylation, apoptotic process and inflammatory response in the BP term and focal adhesion, thyroid hormone signaling pathway, ErbB signaling pathway, cytokine-cytokine receptor interaction and some disease processes in the KEGG pathways. 6 candidates are confirmed by Cytoscape software and qRT-PCR, including APP, JUN, GSK3B, ErbB2, PPBP and THBS1.

Conclusions: Our data and previous studies show that ErbB2 and THBS1 are crucial to prevent aneurysm rupture, while APP, JUN, GSK3B and PPBP performs the opposite role, and further experiments are needed to verify these findings.

Effect and Blood Flow Parameters of Biomaterials-Based Endovascular Interventional Embolization and Craniotomy Clipping in the Treatment of Cerebral Aneurysms

Objective: The effects of interventional embolization and craniotomy clipping on the treatment of intracranial aneurysms were investigated in this study, as well as their influence on the hemodynamics of postoperative patients. Methods: 102 patients with intracranial aneurysms were selected as the research objects, and they were rolled into an experimental (group A) and a control group (group B) according to the random number table method, with 51 cases in each group. The group A was treated with intravascular interventional embolization, and the group B received craniotomy clipping. Besides, a biodegradable magnesium titanium alloy biological stent was independently developed in this study, which was applied to endovascular interventional embolization in the group A. The hemodynamic model was established by using three-dimensional (3D) computer hemodynamic numerical simulation technology. Besides, the effects of all the patients before and after treatment were evaluated, in terms of blood pressure (BP), average wall shear stress (WSS) (AWSS), AWSS gradient (AWSSG), oscillatory shear index (OSI), aneurysm formation index (AFI), gradient oscillation number (GON), and intraoperative complication rate. Results: After 3 days of treatment, the BP, AWSS, and AWSSG of patients from the two groups were higher than those before treatment. The index values of the group A were greater markedly than the values of the group B (P < 0.05); the BP of the group A and the group B at the 0th day, 1st day, 3rd day, 5th day, and 7th day after treatment was 21±5.1 Versus 20.1±4.7, 22±4.8 Versus 21.1± 5.17, 26±6.2 Versus 22.31±5.21, 27±5.77 Versus 24.02±5.11, and 30±6.09 Versus 24.99±5.03, respectively; AWSSG values were 120±10.11 Versus 120.1±10.98, 130.1±10.36 Versus 123.3±11.06, 162.5±9.92 Versus 131.31±10.97, 171±8.13 Versus 155.02±8.36, and 200.1±7.22 Versus 180.01±8.98 in turn. GON and OSI were both decreased, and the values of various indexes in the group A were sharply lower than those of the group B (P < 0.05); the values of GON at the 0th day, 1st day, 3rd day, 5th day, and 7th day after treatment in the group A and the group B were 0.077±0.01 Versus 0.08±0.011, 0.07±0.012 Versus 0.073 ± 0.01, 0.051 ± 0.02 Versus 0.071 ± 0.011, 0.045 ± 0.01 Versus 0.069 ± 0.011, and 0.042 ± 0.012 Versus 0.063±0.013, respectively; OSI values were 4.8±0.51 Versus 4.9±0.52, 3.6±0.52 Versus 3.62±0.51, 2.82±0.51 Versus 3.1 ± 0.57, 1.9 ± 0.512 Versus 2.91 ± 0.51, and 0.5 ± 0.51 Versus 1.8 ± 0.501 in turn. By comparing the intraoperative complications and postoperative mortality risk score (MRS) of patients in the two groups, it was found that the incidence of intraoperative complications and postoperative MRS scores in the group A were lower steeply than those of the group B, suggesting that endovascular interventional embolization had a better effect on the treatment of intracranial aneurysms. Conclusion: Endovascular interventional embolization based on biodegradable magnesium alloy coated scaffold could better improve the distribution of shear stress on the vascular wall, stabilize vascular blood flow, and achieve better therapeutic effect for patients.

Hemodynamic and Morphological Parameters of Ruptured Mirror Posterior Communicating Artery Aneurysms

Objective: Morphological and hemodynamic parameters might predict rupture of intracranial aneurysms (IAs). A practical model for the study is patients with ruptured mirror IAs in which one is ruptured and the other is unruptured. Although there have been analyses of the morphology and hemodynamics of ruptured mirror posterior communicating artery aneurysms (PComAAs), the sample sizes in these studies were small and only considered hemodynamics or morphological characters. Therefore, this study aimed to investigate the morphological and hemodynamic parameters associated with ruptured mirror PComAAs. Methods: We considered 72 patients with ruptured mirror PComAAs using computational fluid dynamics (CFDs). Ruptured mirror PComAAs were divided into ruptured and unruptured groups. Fourteen morphological and eight hemodynamic parameters were calculated and compared. Significant parameters were analyzed by the multivariate logistic regression to identify independent risk factors. Receiver operating characteristic (ROC) analysis was performed, and the area under the ROC curve (AUC) was calculated for all independent risk factors to determine the predictability and identify the optimal threshold. Results: Four hemodynamic and three morphological parameters were significantly different between ruptured and unruptured groups: normalized wall shear stress (NWSS), mean WSS, low wall shear WSS area (LSA%), size, aspect ratio (AR), size ratio (SR), and inflow angle (IA). Multivariate logistic regression analysis showed that AR, SR, NWSS, mean WSS, and LSA% were all independent factors significantly associated with PComAAs rupture. The ROC analysis for independent risk factors indicated that AR (0.751), NWSS (0.755), mean WSS (0.69), and LSA (0.778) had merely acceptable AUC values. Only SR (0.803) had a high acceptable AUC value. The threshold value of SR was 1.96. Conclusions: SR (>1.96) was the most significant parameter associated with IA rupture, whereas AR, NWSS, mean WSS, and LSA independently characterized the status of IA rupture.

Flow diverter device placement for cerebral aneurysm is not effective for the patient with parent artery occlusion for contralateral aneurysm

PURPOSE

There have been many reports on the risks of enlargement and rupture of residual aneurysms and de novo aneurysm formation in the contralateral internal carotid artery after parent artery occlusion (PAO). In the present study, we investigated the efficacy of flow diverter device placement (FDDP) for the treatment of contralateral internal carotid artery aneurysms after PAO.

METHODS

After 11 patients, who had bilateral large or giant internal carotid aneurysms, were treated for either side with PAO or FDDP, they underwent FDDP for residual lesions in our hospital between October 2015 and June 2018. The patients were divided into two groups, depending on the prior procedure: PAO or FDDP. The embolic state after subsequent FDDP was evaluated by angiography. The embolic state was graded using the O'Kelly Marotta scale. Patients' characteristics and the embolic state of intracranial aneurysms after FDDP were compared between the two groups.

RESULTS

Comparing patients' characteristics between the PAO group and FDDP group, statistically significant differences were observed in laterality of the lesions and the interval between prior treatment and FDDP for residual aneurysms (p < 0.05). The embolic state at the one-year follow-up revealed that there could be significantly sufficient embolisation in the FDDP group (p < 0.05).

CONCLUSION

When FDDP is performed for the contralateral lesion after PAO treatment, it is difficult to attain sufficient embolisation of intracranial aneurysms because haemodynamic load in this procedure is large compared to that in a regular FDDP.