Unruptured Intracranial Aneurysms- Pathogenesis and Individualized Management

Two-Sample Bidirectional Mendelian Randomization Study With Causal Association Between Metabolic Syndrome and Cerebral Aneurysm

BACKGROUND

We used a two-sample mendelian randomization (MR) method to comprehensively investigate the causality of metabolic syndrome (MetS) or its components, including MetS, triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), fasting blood glucose (FBG), waist circumference (WC), and hypertension (HP), with cerebral aneurysm including nonruptured and ruptured aneurysmal subarachnoid hemorrhage (SAH).

METHODS

By leveraging large-scale genome-wide association study (GWAS) summary statistics of MetS or its components and cerebral aneurysm (nonruptured and SAH) from European, MR, reverse-direction MR, and sensitivity analysis were utilized to quantify the genetic correlations and causal relationships. In addition, we adjusted for multiple comparisons using the false discovery rate (FDR) correction.

RESULTS

Two-sample MR analysis showed that HP was a risk factor for cerebral aneurysm (nonruptured and SAH) with odds ratio (OR) of 58.959 (95% confidence interval [95% CI] = 12.073-287.920, p < 0.001, q < 0.001), and 32.290 (95% CI = 5.615-185.671, p < 0.001, q < 0.001), respectively. HDL-C (OR = 0.836, 95% CI = 0.728-0.960, p = 0.011, q = 0.039) and FBG (OR = 0.626, 95% CI = 0.426-0.919, p = 0.017, q = 0.039) were negatively correlated with cerebral aneurysm (nonruptured). The HDL-C result was inconsistent after adjusting for TG and LDL-C by multivariable MR analysis. In reverse MR analysis, we found that there was no statistical causal association between cerebral aneurysm (nonruptured) and MetS or its components. Genetic liability to cerebral aneurysm (SAH) was inversely associated with HDL-C and FBG but was not associated with others, however, sensitivity analysis showed that few instrumental variables made a big difference.

CONCLUSIONS

Genetically determined elevated FBG level reduces the risk of cerebral aneurysm (nonruptured). However, hypertension increases the risk of cerebral aneurysm (nonruptured and SAH).

Preliminary outcomes of Neuroform Atlas stent-assisted coiling for intracranial aneurysms with small parent vessels

BACKGROUND

Although stent-assisted coiling has become a standard approach for treating intracranial aneurysms (IAs), there are limited reports on its safety and effectiveness in parent artery less than 2.5 mm in diameter. This study evaluates the feasibility, safety, and short-term outcomes of using Neuroform Atlas stent-assisted coiling for IAs with small parent vessels.

METHODS

This study reviewed and analyzed the clinical data of 50 IAs in 50 patients with a parent artery diameter of ≤ 2.5 mm, treated with Neuroform Atlas stent-assisted coiling at a single center between November 2020 and April 2024. Immediate postoperative angiographic outcomes were assessed using the modified Raymond-Roy classification. Follow-up imaging included computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA). Clinical outcomes were evaluated using the modified Rankin Scale (mRS).

RESULTS

The procedures achieved a 100% success rate. Immediately after treatment, 24 cases were classified as Raymond-Roy grade I, 11 as grade II, and 15 as grade III. Follow-up angiography in 28 cases revealed three instances of aneurysm recurrence, with a secondary procedure performed in one case. One patient reported poor neurological status, and two cases experienced procedure-related adverse events during telephone or clinical follow-up. Conclusions the Atlas stent demonstrated favorable outcomes in the treatment of aneurysms in small parent arteries (< 2.5 mm), with a low complication rate. The timely postoperative use of tirofiban may further reduce the risk of ischemic complications.

Evaluation of AI-Powered Routine Screening of Clinically Acquired cMRIs for Incidental Intracranial Aneurysms

Objectives: To quantify the clinical value of integrating a commercially available artificial intelligence (AI) algorithm for intracranial aneurysm detection in a screening setting that utilizes cranial magnetic resonance imaging (cMRI) scans acquired primarily for other clinical purposes. Methods: A total of 907 consecutive cMRI datasets, including time-of-flight-angiography (TOF-MRA), were retrospectively identified from patients unaware of intracranial aneurysms. cMRIs were analyzed by a commercial AI algorithm and reassessed by consultant-level neuroradiologists, who provided confidence scores and workup recommendations for suspicious findings. Patients with newly identified findings (relative to initial cMRI reports) were contacted for on-site consultations, including cMRI follow-up or catheter angiography. The number needed to screen (NNS) was defined as the cMRI quantity that must undergo AI screening to achieve various clinical endpoints. Results: The algorithm demonstrates high sensitivities (100% for findings >4 mm in diameter), a 17.8% MRA alert rate and positive predictive values of 11.5-43.8% (depending on whether inconclusive findings are considered or not). Initial cMRI reports missed 50 out of 59 suspicious findings, including 13 certain intradural aneurysms. The NNS for additionally identifying highly suspicious and therapeutically relevant (unruptured intracranial aneurysm treatment scores balanced or in favor of treatment) findings was 152. The NNS for recommending additional follow-/workup imaging (cMRI or catheter angiography) was 26, suggesting an additional up to 4% increase in imaging procedures resulting from a preceding AI screening. Conclusions: AI-powered routine screening of cMRIs clearly lowers the high risk of incidental aneurysm non-reporting but results in a substantial burden of additional imaging follow-up for minor or inconclusive findings.

Construction of a poor prognosis prediction and visualization system for intracranial aneurysm endovascular intervention treatment based on an improved machine learning model

Objective

To evaluate the clinical utility of improved machine learning models in predicting poor prognosis following endovascular intervention for intracranial aneurysms and to develop a corresponding visualization system.

Methods

A total of 303 patients with intracranial aneurysms treated with endovascular intervention at four hospitals (FuShun County Zigong City People's Hospital, Nanchong Central Hospital, The Third People's Hospital of Yibin, The Sixth People's Hospital of Yibin) from January 2022 to September 2023 were selected. These patients were divided into a good prognosis group (n = 207) and a poor prognosis group (n = 96). An improved machine learning model was employed to analyze patient clinical data, aiding in the construction of a prediction model for poor prognosis in intracranial aneurysm endovascular intervention. This model simultaneously performed feature selection and weight determination. Logistic multivariate analysis was used to validate the selected features. Additionally, a visualization system was developed to automatically calculate the risk level of poor prognosis.

Results

In the training set, the improved machine learning model achieved a maximum F1 score of 0.8633 and an area under the curve (AUC) of 0.9118. In the test set, the maximum F1 score was 0.7500, and the AUC was 0.8684. The model identified 10 key variables: age, hypertension, preoperative aneurysm rupture, Hunt-Hess grading, Fisher score, ASA grading, number of aneurysms, intraoperative use of etomidate, intubation upon leaving the operating room, and surgical time. These variables were consistent with the results of logistic multivariate analysis.

Conclusions

The application of improved machine learning models for the analysis of patient clinical data can effectively predict the risk of poor prognosis following endovascular intervention for intracranial aneurysms at an early stage. This approach can assist in formulating intervention plans and ultimately improve patient outcomes.

tRF-AspGTC Promotes Intracranial Aneurysm Formation by Controlling TRIM29-Mediated Galectin-3 Ubiquitination

Transfer RNA-derived small RNAs, a recently identified class of small noncoding RNAs, play a crucial role in regulating gene expression and are implicated in cerebrovascular diseases. However, the specific biological roles and mechanisms of transfer RNA-derived small RNAs in intracranial aneurysms (IAs) remain unclear. In this study, we identified that the transfer RNA-Asp-GTC derived fragment (tRF-AspGTC) is highly expressed in the IA tissues of both humans and mice. tRF-AspGTC promotes IA formation by facilitating the phenotypic switching of vascular smooth muscle cells, increasing of matrix metalloproteinase 9 expression, and inducing of oxidative stress and inflammatory responses. Mechanistically, tRF-AspGTC binds to galectin-3, inhibiting tripartite motif 29-mediated ubiquitination and stabilizing galectin-3. This stabilization activates the toll-like receptor 4/MyD88/nuclear factor kappa B pathway, further driving phenotypic switching and inflammation. Clinically, circulating exosomal tRF-AspGTC demonstrates strong diagnostic efficacy for IAs and is identified as an independent risk factor for IA occurrence. These findings highlight the potential of tRF-AspGTC as a promising diagnostic biomarker and therapeutic target for IAs.

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.

Uncovering SPP1+ Macrophage, Neutrophils and Their Related Diagnostic Biomarkers in Intracranial Aneurysm and Subarachnoid Hemorrhage

Background

Intracranial aneurysms (IA) frequently cause subarachnoid hemorrhage (SAH) and have poor prognosis. However, the molecular mechanisms and diagnostic biomarkers associated with IA and ruptured IA (rIA) remain poorly understood.

Methods

In this study, single-cell and transcriptome datasets were obtained from the GEO database. The cell populations were annotated to identify potential pathogenic subpopulations, followed by intercellular communication, pseudotime, and SCENIC analyses. Proteome-wide and transcriptome-wide Mendelian randomization (MR) analyses were conducted to identify risk factors for IA and SAH. The major pathological changes and diagnostic biomarkers of IA and SAH were identified based on the transcriptome datasets. A clinical cohort was established to identify the diagnostic biomarkers and validate the results.

Results

Macrophages and neutrophils were predominantly increased in IA and rIA tissues, and neutrophils were markedly upregulated in the blood of SAH patients. SPP1+ Macrophage was progressively elevated in aneurysms, promoting vascular smooth muscle cell (VSMC) phenotypic transformation and collagen matrix remodeling through the SPP1 and TGF-β pathways. Furthermore, HIF1α regulon was enriched in SPP1+ Macrophage, mediating inflammation and metabolic reprogramming, which contributed to IA progression. Integrated MR analysis identified CD36 as a risk factor for both IA and SAH, and it has been recognized as an effective blood biomarker for SAH. Neutrophils and their related indicators have emerged as excellent biomarkers of SAH in clinical cohorts.

Conclusion

This study highlighted the detrimental role of SPP1+ Macrophage in IA and SAH using single-cell sequencing and MR analyses. CD36 was identified as a risk factor for IA and SAH and was also an efficient blood biomarker for SAH. In a clinical cohort, neutrophils and related indicators were valuable for the early diagnosis of SAH.

Efficacy of endovascular embolization versus microsurgical clamping in the treatment of intracranial aneurysms: a meta-analysis

Intracranial aneurysms (IA) can induce increased intracranial pressure, headache, and the development of nausea and vomiting if not treated in time, and failure to receive timely diagnosis and treatment can lead to disability or death. However, the efficacy and prognostic value of craniotomy and endovascular embolization in patients with IA remains a controversial topic. This meta-analysis systematically evaluated the efficacy of endovascular coiling versus cranial aneurysm clamping on the immediate postoperative outcome and prognosis of patients with IA. PubMed, EMBASE, and the Cochrane Library databases were searched for retrieval of relevant references. Literature was screened according to pre-defined inclusion and exclusion criteria, and data were extracted and assessed for quality. A total of 10 studies, including 2,654 cases, were included in the analysis. Among them, 1,313 cases underwent craniotomy clipping surgery (clip group), and 1,341 cases underwent endovascular coiling (coil group). The quality of the studies in 8 articles evaluated using the Newcastle-Ottawa Scale (NOS) was ≥6. Meta-analysis was conducted using Rev Man 5.3 and Stata 17 software. The results of meta-analysis showed that no significant difference in complete occlusion rate [OR=1.76, 95% CI (0.78, 3.96), P=0.17] when comparing the clip and coil group. Compared to the clip group, the coil group had a better clinical short-term outcome [OR=1.55, 95% CI (1.05, 2.27), P=0.03], but an increased rate of postoperative residual or recurrence [OR=0.40, 95% CI (0.17, 0.91), P=0.03]. In addition, there were no significance differences identified in terms of complications, including the rates of postoperative rebleeding [OR=1.60, 95% CI (0.97, 2.63), P=0.07], ischemic stroke [OR=1.12, 95% CI (0.45, 2.79), P=0.81], and cerebral vasospasm [OR=0.90, 95% CI (0.13, 6.03), P=0.91]. Subsequently, we conducted experimental sequence analysis for each indicator, and the results were consistent with the results of meta-analysis. According to the recent clinical prognosis, a funnel plot was constructed, showing significant asymmetry on both sides, indicating some publication bias. However, the results of Begg's test with P=0.734 and Egger's test with P=0.633 suggest no significant publication bias. In general, endovascular coiling and microsurgical clipping appear to be equally effective in achieving vascular occlusion. Endovascular coiling may be more effective in improving the short-term clinical outcomes for patients. However, this approach may increase the rate of postoperative residual issue or recurrence.

The impact of refined nursing intervention on neurological function recovery and prognosis improvement in patients undergoing intracranial aneurysm intervention

BACKGROUND

This study aims to explore the application of refined nursing intervention in patients undergoing unruptured intracranial aneurysm intervention, evaluating its impact on neurological function recovery and prognosis improvement.

METHODS

Patients diagnosed with intracranial aneurysms and undergoing treatment at our hospital from February 2022 to June 2023 were included in this study. After applying complete inclusion and exclusion criteria to ensure sample representativeness, a total of 92 patients were enrolled. Using a randomization method, patients were divided into an observation group and a control group. The control group received routine nursing care, while the observation group received refined nursing intervention. Nursing effects were compared between the two groups, and statistical analysis was conducted using appropriate methods, with content analysis summarizing the results.

RESULTS

The observation group, post-intervention, exhibited significantly improved Neurological Function Deficit (NFD) scores compared to the control group (p = 0.023). Additionally, the observation group showed higher proportions of Grade V patients in the Glasgow Outcome Scale (GOS) post-intervention (p = 0.031). Moreover, Fugl Meyer Assessment (FMA) scores for motor function were notably higher in the observation group than the control group (p = 0.003). The observation group also reported lower headache intensity and fewer adverse outcomes than the control group (p = 0.018, 0.038).

CONCLUSION

Refined nursing intervention in patients undergoing intracranial aneurysm intervention demonstrates better outcomes in terms of neurological function recovery and prognosis improvement. It reduces uncertainty in nursing practices, effectively enhancing nursing outcomes, and warrants clinical application and promotion.

Circular RNAs in intracranial aneurysms: Emerging roles in pathogenesis, diagnosis and therapeutic intervention

Intracranial aneurysms (IAs) present a substantial health threat, given the potential for catastrophic ruptures and subarachnoid hemorrhages (SAH). Swift and effective measures for diagnosis and treatment are paramount to enhance patient outcomes and alleviate the associated healthcare burden. In this context, circular RNAs (circRNAs) have emerged as an intriguing area of investigation, offering promise as both diagnostic biomarkers and therapeutic targets for IAs. CircRNAs have demonstrated their influence on critical molecular and cellular processes underpinning IAs pathogenesis, revealing their pivotal role in understanding this complex ailment. Beyond their diagnostic potential, circRNAs hold great potential as prognostic markers, providing crucial insights into IAs rupture risk. The unique circular structure and their regulatory functions make circRNAs an enticing avenue for innovative therapeutic approaches. The ongoing study of circRNAs in the context of IAs is an exciting and rapidly evolving field that has the potential to revolutionize approaches to diagnosis, treatment, and prevention of this life-threatening condition. As research continues to unravel the intricate roles of circRNAs, they are poised to become invaluable tools in clinical practice, enhancing patient care and ultimately reducing the impact of cerebral aneurysms on both individuals and healthcare systems. This comprehensive review delves deeply into the world of circRNAs in the realm of IAs, elucidating their multifaceted roles in the onset and progression of this condition. Moreover, this review ventures into the diagnosis and therapeutic potential of circRNAs, exploring their possible applications in gene therapy and as targets for novel treatment modalities.

Cost-effectiveness of WEB Embolization, Coiling and Stent-assisted Coiling for the Treatment of Unruptured Intracranial Aneurysms

PURPOSE

Information about the cost-effectiveness of a certain treatment is relevant for decision-making and healthcare providers. This study compares the cost-effectiveness of the novel Woven Endobridge (WEB) for intracranial aneurysm treatment with conventional coiling and stent-assisted coiling (SAC) from the perspective of the German Statutory Health Insurance.

METHODS

A patient-level simulation was constructed to simulate 55-year-old patients with an unruptured middle cerebral artery aneurysm (size: 3-11 mm) considering WEB treatment, coiling or SAC in terms of morbidity, angiographic outcome, retreatment, procedural and rehabilitation costs and rupture rates. Incremental cost-effectiveness ratios (ICERs) were calculated as costs per quality-adjusted life years (QALYs) and costs per year with neurologic morbidity avoided. Uncertainty was explored with deterministic and probabilistic sensitivity analyses. The majority of data were obtained from prospective multi-center studies and meta-analyses of non-randomized studies.

RESULTS

In the base case, lifetime QALYs were 13.24 for the WEB, 12.92 for SAC and 12.68 for coiling. Lifetime costs were 20,440 € for the WEB, 23,167 € for SAC, and 8200 € for coiling. Compared to coiling, the ICER for the WEB was 21,826 €/QALY, while SAC was absolutely dominated by WEB. Probabilistic sensitivity analysis revealed that at a willingness-to-pay of ≥ 30,000 €/QALY, WEB was the preferred treatment. Deterministic sampling showed that the discount rate, material costs and retreatment rates had the largest impact on the ICERs.

CONCLUSION

The novel WEB showed at least comparable cost-effectiveness to SAC for treatment of broad-based unruptured aneurysms. Considering all three modalities, coiling had the least costs; however this modality is often not appropriate for the treatment of wide-necked aneurysms.

ICGA combined with EP monitoring in microclipping of cerebral aneurysms

Cerebral aneurysm is one of the common cerebrovascular diseases in neurosurgery, and rupture of cerebral aneurysm is the most important cause of spontaneous subarachnoid hemorrhage. How to precisely clip the aneurysm has been a topic worth discussing, so the authors explore the value of ICGA combined with electrophysiological monitoring in the microclipping of cerebral aneurysms. Using the method of retrospective analysis of cases, 661 patients with cerebral aneurysms admitted to the Department of Neurosurgery, Zhongnan Hospital of Wuhan University, from 2021.8 to 2022.10 were studied, 390 patients with aneurysm clipping were included, and patients with Hunt-Hess classification ≥ 4 were excluded, and whether to use ICGA combined with EP in microclipping of the ruptured and unruptured aneurysm in pterional approach was investigated at the time of discharge, respectively. The MRS and total hospital days were compared to investigate the value of ICGA combined with EP in the microclipping of cerebral aneurysms. All 390 patients enrolled in the group had successful aneurysm clipping, 178 patients were screened for ruptured aneurysm pterional approach and 120 patients for unruptured aneurysm pterional approach access; the MRS at discharge was significantly lower in the ICGA combined with EP group than in the no-EP group for ruptured aneurysm pterional approach microclipping (p < 0.001), and the mean number of days in hospital was significantly lower (p < 0.01). Patients in the ICGA combined with EP group in microclipping of unruptured aneurysms with pterional approach also had significantly lower MRS at discharge compared with patients in the ICGA alone group (p < 0.001), with no statistically significant difference in the mean number of days in hospital (p = 0.09). In open cerebral aneurysm microclipping, ICGA combined with EP monitoring for both ruptured and unruptured aneurysms can effectively reduce the false-negative rate of ICGA, significantly reduce the incidence of postoperative neurological deficits, and shorten the total hospital stay to some extent. ICGA combined with EP monitoring may be an effective means to reduce the rate of false clipping of the penetrating vessels and to avoid stenosis or occlusion of the aneurysm-carrying artery and is worth promoting in microclipping of cerebral aneurysms except for Hunt-Hess ≥ 4.

Predictive value of IOM in clipping of unruptured intracranial aneurysms - A prospective study from the surgeon's point of view

Introduction

Intraoperative neuromonitoring (IOM) of motor/somatosensory evoked potentials is a well-established approach for reducing ischemic complications after aneurysm clipping.

Research question

To determine the predictive validity of IOM for postoperative functional outcome and its perceived added value for intraoperative real-time feedback of functional impairment in the surgical treatment of unruptured intracranial aneurysms (UIAs).

Material and methods

Prospective study of patients scheduled for elective clipping of UIAs between 02/2019-02/2021. Transcranial motor evoked potentials (tcMEP) were used in all cases, a significant decline was defined as loss of ≥50% in amplitude or 50% latency increase. Clinical data were correlated to postoperative deficits. A surgeon's questionnaire was conceived.

Results

47 patients were included, median age 57 years (range 26-76). IOM was successful in all cases. In 87.2%, IOM was stable throughout surgery, although 1 patient (2.4%) demonstrated a permanent postoperative neurological deficit. All patients with an intraoperatively reversible tcMEP-decline (12.7%) showed no surgery-related deficit, regardless of the decline duration (range 0.5-40.0 ​min; mean: 13.8). Temporary clipping (TC) was performed in 12 cases (25.5%), with a decline in amplitude in 4 patients. After clip-removal, all amplitudes returned to baseline. IOM provided the surgeon with a higher sense of security in 63.8%.

Discussion and conclusion

IOM remains invaluable during elective microsurgical clipping, particularly during TC of MCA and AcomA-aneurysms. It alerts the surgeon of impending ischemic injury and offers a way of maximizing the time frame for TC. IOM has highly increased surgeons' subjective feeling of security during the procedure.

Deep Learning for Detection of Intracranial Aneurysms from Computed Tomography Angiography Images

The accuracy of computed tomography angiography (CTA) image interpretation depends on the radiologist. This study aims to develop a new method for automatically detecting intracranial aneurysms from CTA images using deep learning, based on a convolutional neural network (CNN) implemented on the DeepMedic platform. Ninety CTA scans of patients with intracranial aneurysms are collected and divided into two datasets: training (80 subjects) and test (10 subjects) datasets. Subsequently, a deep learning architecture with a three-dimensional (3D) CNN model is implemented on the DeepMedic platform for the automatic segmentation and detection of intracranial aneurysms from the CTA images. The samples in the training dataset are used to train the CNN model, and those in the test dataset are used to assess the performance of the established system. Sensitivity, positive predictive value (PPV), and false positives are evaluated. The overall sensitivity and PPV of this system for detecting intracranial aneurysms from CTA images are 92.3% and 100%, respectively, and the segmentation sensitivity is 92.3%. The performance of the system in the detection of intracranial aneurysms is closely related to their size. The detection sensitivity for small intracranial aneurysms (≤ 3 mm) is 66.7%, whereas the sensitivity of detection for large (> 10 mm) and medium-sized (3-10 mm) intracranial aneurysms is 100%. The deep learning architecture with a 3D CNN model on the DeepMedic platform can reliably segment and detect intracranial aneurysms from CTA images with high sensitivity.

DNA methylation and mRNA expression of glutathione S-transferase alpha 4 are associated with intracranial aneurysms in a gender-dependent manner

Objective: We performed a case-control study to investigate the correlation between DNA methylation and mRNA expression of the glutathione S-transferase alpha 4 (GSTA4) gene and the risk of intracranial aneurysm (IA) in the Chinese Han population. Methods: After propensity score matching, 44 pairs of cases and controls were collected in this study. Fasting blood samples were collected for DNA and RNA extraction within 24 h of admission. Nine CpG dinucleotides were selected from the GSTA4 promoter region for DNA methylation pyrosequencing. mRNA expression of GSTA4 was measured by quantitative real-time polymerase chain reaction (RT-qPCR). In vitro cell experiments were conducted to verify the association between 5-aza-2'-deoxycytidine induced DNA hypomethylation and GSTA4 mRNA expression. Results: The mean methylation level of GSTA4 was much lower in IA patients, especially in IA patients, especially in unruptured IA (UIA), than that in controls (IA vs. Control, p < .001; ruptured IA (RIA) vs. Control, p = .005; UIA vs. Control, p < .001). With sex stratification, we further found that the association between GSTA4 methylation and IA risk presented only in women (mean methylation level: IA vs. Control, p < .001; RIA vs. Control, p = .009; UIA vs. Control, p < .001). GSTA4 mRNA expression was significantly higher in the IA group than in the control group (p < .01) and negatively correlated with DNA methylation in all individuals (r = -.746, p < .001). DNA hypomethylation can increase GSTA4 mRNA expression in human primary artery smooth muscle cells. The receiver operating characteristic (ROC) curve showed that GSTA4 mean methylation (AUC = .80, p < .001) was a reliable predictor of women intracranial aneurysm, among which CpG 1 exhibited the best predictive value (AUC = .89, p < .001). In addition, GSTA4 expression levels could also predict the risk of IA in women (AUC = .87, p = .005). Conclusion: Decreased DNA methylation and increased mRNA expression of the GSTA4 gene are associated with the risk of IA in women.

Integrated analysis identifies the IL6/JAK/STAT signaling pathway and the estrogen response pathway associated with the pathogenesis of intracranial aneurysms

OBJECTIVE

We intended to identify the potential key biomarker and pathways that correlated with infiltrating immune cells during the pathogenesis of intracranial aneurysms (IA), to develop a diagnostic model, and to predict therapeutic drugs.

METHODS

Three datasets containing intracranial aneurysm tissue samples and normal artery control samples from Gene Expression Omnibus (GEO) were included. Gene-set variation analysis(GSVA) and gene set enrichment analysis (GSEA) were conducted to find the significant differentially expressed pathways in IA formation. The least absolute shrinkage and selection operator (LASSO) regression and the multivariate logistic regression analysis were performed to identify the characteristic genes in the IL6/JAK/STAT signaling pathway (ISP) and the estrogen response pathway (ERP). A diagnostic model was constructed. xCell was used to identify immune cell types in IA pathogenesis. We used the weighted gene co-expression network analysis (WGCNA) algorithm to explore the correlations between the key modules and the four traits. Potential therapeutic drugs were investigated in Enrichr and Drugbank database.

RESULTS

The ISP is significant positively correlated with IA onset. The biological function of the ISP is positively correlated with that of the ERP, and is significantly associated with immune cells activities. CSF2RB, FAS, IL6, PTPN1, STAT2, TGFB1 of the ISP gene set and ALDH3A2, COX6C, IGSF1, KRT18, MICB, NPY1R of the ERP gene set were proved to be the characteristic genes. The STAT2 gene can be the potential biomarker of IA onset. The immune score of IA samples was significantly higher than the controls. The STAT2 gene expression is associated with infiltration of immune cells. The WGCNA results were consistent with our finds. Acetaminophen can be a potential therapeutic drug for IA targeting STAT2.

CONCLUSIONS

We identified that the ISP was one of the most significant positively correlated pathways in IA onset, and it was activated in this process concordant with the ERP and immune responses. Except for beneficial effects, complex and multiple roles of estrogen may be involved in IA formation. STAT2 could be a potential biomarker and a promising therapeutic target of IA pathogenesis.

Analysis of Clinical Effects of Comprehensive Nursing Based on Enhanced Recovery after Surgery in Patients with Embolization for Intracranial Aneurysms

Objective. This research sets out to elucidate the clinical effect of comprehensive nursing based on the concept of enhanced recovery after surgery (ERAS) in patients with embolization for intracranial aneurysms (IAs). Methods. This study enrolled 119 patients with embolization for IAs in the Zhongnan Hospital of Wuhan University from January 2020 to January 2021 and divided them into two groups according to the perioperative care they received: a control group ( $n=39$ ) treated with routine perioperative nursing and an observation group ( $n=80$ ) treated with ERAS-based comprehensive nursing. Surgical indicators, neurological function (National Institute of Health Stroke Scale (NIHSS) score; Scandinavian Stroke Scale (SSS) score), anxiety and depression (Self-Rating Anxiety Scale (SAS) score; Self-Rating Depression Scale (SDS) score), incidence of adverse events, and patient satisfaction were compared. Results. The observation group had better surgical indicators and lower scores of NIHSS, SSS, SAS, and SDS than the control group, accompanied by a lower incidence of adverse events and higher patient satisfaction. Conclusions. ERAS-based comprehensive nursing can better promote patients’ neurological recovery after embolization for IAs, relieve unhealthy emotions (depression, anxiety, etc.), and reduce the occurrence of adverse reactions, facilitating patient discharge.

Delayed Leukoencephalopathy and Foreign Body Reaction After Endovascular Treatment in Patients With Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage-A Systematic Review of the Literature

Background: Delayed leukoencephalopathy and foreign body reaction are rare complications after endovascular treatment of intracranial aneurysms. However, cases are increasingly being described, given the rising case numbers and complexity.

Methods: Clinical presentation, differentials, diagnostics, treatment, and formerly published data were reviewed in light of available cases. A systematic search of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Results: This article provides an extensive literature review of previously described cases, and discusses the causes and management of this rare and delayed complication by referring to 17 articles on this topic, with a total of 50 cases with sufficient data in the literature. Furthermore, we present the case of a 53-year-old female patient with subarachnoid hemorrhage from a large anterior communicating artery aneurysm with tortuous cervical vessels who was treated with endovascular coiling and has suffered delayed leukoencephalopathy 6 weeks after discharge. Diagnostics, treatment, and clinical course of this rare complication are presented on this case and based on formerly published literature. The patient timely recovered under high dose corticosteroid treatment and follow up MRI showed almost complete remission of the described lesions within 10 days in accordance with previously published data.

Conclusion: Foreign body reaction might result in delayed leukoencephalopathy, especially following complex endovascular aneurysm treatment. Early high dose followed by low dose ongoing corticosteroid treatment might result in timely remission.

Emerging Applications of Radiomics in Neurological Disorders: A Review

Radiomics has achieved significant momentum in radiology research and can reveal image information invisible to radiologists' eyes. Radiomics first evolved for oncologic imaging. Oncologic applications (histopathology, tumor grading, gene mutation analysis, patient survival, and treatment response prediction) of radiomics are widespread. However, it is not limited to oncologic analysis, and any digital medical images can benefit from radiomics analysis. This article reviews the current literature on radiomics in non-oncologic, neurological disorders including ischemic strokes, hemorrhagic stroke, cerebral aneurysms, and demyelinating disorders.

Case Report: Persistent Primitive Hypoglossal Artery Accompanied by a Basilar Bifurcation Aneurysm Treated by Y-Stent-Assisted Coil Embolization

Successful embolization of a basilar bifurcation aneurysm associated with a persistent primitive hypoglossal artery (PPHA) using Y-stent-assisted coiling.

Impact of Virtual Reality in Arterial Anatomy Detection and Surgical Planning in Patients with Unruptured Anterior Communicating Artery Aneurysms

Anterior-communicating artery (ACoA) aneurysms have diverse configurations and anatomical variations. The evaluation and operative treatment of these aneurysms necessitates a perfect surgical strategy based on review of three-dimensional (3D) angioarchitecture using several radiologic imaging methods. We analyzed the influence of 3D virtual reality (VR) reconstructions versus conventional computed tomography angiography (CTA) scans on the identification of vascular anatomy and on surgical planning in patients with unruptured ACoA aneurysms. Medical files were retrospectively analyzed regarding patient- and disease-related data. Preoperative CTA scans were retrospectively reconstructed to 3D-VR images and visualized via VR software to detect the characteristics of unruptured ACoA aneurysms. A questionnaire was used to evaluate the influence of VR on the identification of aneurysm morphology and relevant arterial anatomy and on surgical strategy. Twenty-six patients were included and 520 answer sheets were evaluated. The 3D-VR modality significantly influenced detection of the aneurysm-related vascular structure (p = 0.0001), the recommended head positioning (p = 0.005), and the surgical approach (p = 0.001) in the planning of microsurgical clipping. Thus, reconstruction of conventional preoperative CTA scans into 3D images and the spatial presentation in VR models enabled greater understanding of the anatomy and pathology, provided realistic haptic feedback for aneurysm surgery, and influenced operation planning and strategy.