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Molinaro S, Mistretta F, Piano M, Fantoni M, Comelli S, Gallesio I, Boghi A, Sanfilippo G, Venturi F, Remida P, Russo R, Bergui M. Single-stage endovascular treatment in aneurysmal subarachnoid haemorrhage with multiple intracranial aneurysms: Systematic review of the literature and multicentric retrospective experience. Interv Neuroradiol 2023:15910199231196954. [PMID: 37614045 DOI: 10.1177/15910199231196954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVES The presence of multiple intracranial aneurysms in patients with acute subarachnoid haemorrhage is a condition with no evidence of optimal treatment strategy, especially in case of uncertain haemorrhage patterns on cumputed tomography. The aim of this study was to analyse the safety and efficacy profile of single-stage endovascular treatment of multiple intracranial aneurysms with aneurysmal subarachnoid haemorrhage in the literature and in a retrospective case series. MATERIALS AND METHODS A systematic review of the present literature was conducted to identify studies related to single-stage endovascular treatment for ≥2 aneurysms; in addition, a retrospective multicentric review was performed. Data on clinical presentation, aneurysm size and location, occlusion rates, intracranial complications and clinical outcome were recorded. RESULTS Thirteen articles were identified (all little case series) reporting 189 patients harbouring 389 aneurysms. And 85.6% presented with a Hunt-Hess scale 1-3, and 14.4% 4-5. Intracranial complications rate was 11.5%. Baseline and follow-up (20.5 months) occlusion rates were adequate (Raymond-Roy occlusion scale I-II) in 93% and 96.2%, respectively. 81% of patients had favourable clinical outcomes (modified Rankin Scale (mRS) ≤2; Glasgow outcome scale (GOS) 5-4) and 19% poor (mRS 3-6; GOS 3-1). The retrospective database identified 53 patients with 115 aneurysms. Clinical presentation was Hunt-Hess (HH) 1-3/WNFS 1-2 75% and HH 4-5/WNFS 3-5 25%. Intracranial complication rate was 24.5%. Occlusion rate RROC I-II was 78.7% at baseline and 15 months and 90.2% at follow up. Clinical outcome at 3 months was mRS ≤2 68.6% and mRS 3-6 31.4%. CONCLUSIONS Single-staged endovascular treatment can be feasible, although a higher risk of intraprocedural complications, with clinical presentation being the major factor to influence the outcome.
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Affiliation(s)
- Stefano Molinaro
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Interventional Neuroradiology, Torino, Piemonte, Italy
| | - Francesco Mistretta
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Interventional Neuroradiology, Torino, Piemonte, Italy
| | - Mariangela Piano
- ASST Grande Ospedale Metropolitano Niguarda, Neuroradiology, Milano, Italy
| | - Matteo Fantoni
- Hopital Lariboisiere, Neuroradiology, Paris, Île-de-France, France
| | - Simone Comelli
- Azienda Ospedaliera Brotzu, Interventional Radiology and Neuroradiology, Cagliari, Italy
| | - Ivan Gallesio
- Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Radiology, Alessandria, Piemonte, Italy
| | - Andrea Boghi
- Ospedale San Giovanni Bosco, Interventional Radiology and Neuroradiology, Torino, Piemonte, Italy
| | - Giuseppina Sanfilippo
- Fondazione IRCCS Policlinico San Matteo, Interventional Neuroradiology Unit, Pavia, Lombardia, Italy
| | | | - Paolo Remida
- Ospedale San Gerardo, Neuroradiology, Monza, Lombardia, Italy
| | - Riccardo Russo
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Interventional Neuroradiology, Torino, Piemonte, Italy
| | - Mauro Bergui
- University of Turin, Neuroradiology, Torino, Piemonte, Italy
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Muacevic A, Adler JR. The Exceedingly Rapid Development of an Intracranial Aneurysm. Cureus 2022; 14:e32636. [PMID: 36654536 PMCID: PMC9842106 DOI: 10.7759/cureus.32636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2022] [Indexed: 12/23/2022] Open
Abstract
Despite significant diagnostic and technical progress in managing intracranial aneurysms, there are still open questions in understanding their pathophysiology: how fast can they form and grow? We had the chance to observe the "de novo" genesis and rupture of an aneurysm of a left MCA posterior trunk M3 branch within 14 days in one of our patients. We were in the position to compare an initially inconspicuous vessel, assessed during a diagnostic cerebral angiogram with 3D acquisitions, performed as an elective follow-up to monitor the decade stability of a transitional aneurysm in the same vascular territory, and the same vessel only two weeks after, harboring a new small ruptured aneurysm. Several studies along the intracranial aneurysms' pathophysiology have been reported but primarily oriented toward identifying uncommon conditions such as inherent defects in collagen synthesis, genetic or familial factors, or basic anatomic variations or abnormalities in the cerebral vasculature. Suppose this case report does not pretend to provide a clear answer to these questions. However, it is up to date, the shortest time (14 days) reported in the literature for a well-documented "de novo" genesis and rupture of an intracranial aneurysm "in vivo" in humans. The purpose of this case report is not only to underscore the unpredictability of this vascular disease but, even more, to support the idea that further investigation, with more modern methodologies, is of paramount importance in determining the etiopathogenesis and behavior of this stealthy disease.
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Capone S, Roy A, Kole M, Blackburn SL. Wide-Necked Middle Cerebral Artery Aneurysm Clipping Following Failed Occlusion After Woven EndoBridge Placement: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e294-e295. [PMID: 36103344 PMCID: PMC10593257 DOI: 10.1227/ons.0000000000000359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 05/24/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Stephen Capone
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Anil Roy
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Matthew Kole
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Spiros L. Blackburn
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Yang Y, Richard SA, Lan Z. The impact of residual hematoma after evacuation on the outcomes of patients with ruptured intracranial aneurysms with intracerebral hematoma: A longitudinal single-center observational study. Medicine (Baltimore) 2022; 101:e30129. [PMID: 36086761 PMCID: PMC10980503 DOI: 10.1097/md.0000000000030129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 07/04/2022] [Indexed: 11/26/2022] Open
Abstract
Intracerebral hematoma (ICH) as a result of ruptured of intracranial aneurysms often arises in patients with subarachnoid hemorrhage. Few studies focused on risk factors for ICH and not the impact of residual hematoma after evacuation on the outcomes of the patients. Therefore, 2 questions need to be answered: does residual hematoma after evacuation have impact on the outcome of patients who present with ICH as a result of ruptured intracranial aneurysms? Is radical pursuit of the hematoma necessary? The study was a single-center longitudinal observational type. Data of 2044 consecutive patients with subarachnoid hemorrhage from January 2009 to December 2019 were reviewed. ICHs were established and the locations of aneurysms as well as hematoma volumes were measured by computed tomographic scan before aneurysm occlusion. Only patients who received aneurysm clipping were included. Patients were stratified into hematoma evacuation without residuals versus residual hematoma after evaluation groups, and outcome was assessed according to the modified Rankin Scale (mRS) at 6 months. Out of the 1365 patients who received clipping, 476 patients presented in poor grade, whereas 889 patients' good grade. Our mRS scores revealed that patients who attained hematoma evacuation without residuals in the good-grade category attained better functional outcome than those with residual hematoma after evacuation. Contrarily, our mRS scores did not establish any significant difference in outcome between the poor-grade patients with hematoma evacuation without residuals and patients with residual hematoma after evacuation. Furthermore, our logistic regression model showed that advance age, poor Hunt-Hess grade, and vascular injury due to surgery were contributing factors for poor outcome of patients with ICH. Our data suggested that aggressive hematoma evacuation may not benefit the poor-grade patients. Majority of poor outcomes were due to surgical complications which were vascular related as a result of excessive pursuit of ICH.
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Affiliation(s)
- Yifan Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P. R. China
- Department of Medicine, Princefield University, Ho-Volta Region, West Africa
| | - Zhigang Lan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P. R. China
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Madhusankha KHD, Rathnayaka D, Samaranayake M, Dharmasiri M, Wickramasingha R. Fourteen-Year-Old Boy With Intracranial Internal Carotid Artery Aneurysm Presenting as Mood Disorder. Cureus 2021; 13:e18324. [PMID: 34722088 PMCID: PMC8549576 DOI: 10.7759/cureus.18324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 12/03/2022] Open
Abstract
Intracranial aneurysms (IA) are very uncommon to find in the pediatric population. If present, it is usually associated with other genetic illnesses. Most of the intracranial aneurysm has been presented due to mass effect of the aneurysm or as subarachnoid hemorrhage. We report this young Asian kid who has had a possible ictus of subarachnoid hemorrhage (SAH) with depressive symptoms, later presenting with classic features of SAH due to rupture of intracranial internal carotid artery aneurysm. The use of Sertraline to treat depressive episodes may aggregate the condition due to its antiplatelet effect. The patient showed significant improvement following microsurgical clipping of the aneurysm. This case is another example that young patients coming with the first episode of mood disorder should be carefully excluded for other intracranial pathology, including intracranial aneurysms, before coming to the final diagnosis.
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Affiliation(s)
| | - Dilruk Rathnayaka
- Department of Emergency Medicine, National Hospital Sri Lanka, Colombo, LKA
| | | | - Mahima Dharmasiri
- Department of Emergency Medicine, National Hospital Kandy, Kandy, LKA
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Konovalov A, Shekhtman O, Pilipenko Y, Okishev D, Ershova O, Oshorov A, Abramyan A, Kurzakova I, Eliava S. External Ventricular Drainage in Patients With Acute Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping: Our 2006-2018 Experience and a Literature Review. Cureus 2021; 13:e12951. [PMID: 33643744 PMCID: PMC7885737 DOI: 10.7759/cureus.12951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction The placement of an external ventricular drain (EVD) is widely practiced in neurosurgery for various diseases and conditions accompanied by impaired cerebrospinal fluid (CSF) circulation, intracranial hypertension (ICHyp), intraventricular hemorrhage (IVH), and hydrocephalus. Specialists have been using this method in patients with acute aneurysmal subarachnoid hemorrhage (aSAH) for more than 50 years. Extensive experience gained at the Burdenko Neurosurgical Center (BNC) in Moscow, the Russian Federation, in the surgical treatment of patients with acute aSAH enabled us to describe the results of using an EVD in patients after microsurgery. The objective of the research was to assess the effectiveness and safety of the EVD and clarify the indications for the microsurgical treatment of aneurysms in patients with acute SAH. Materials and methods From 2006 until the end of 2018, 645 patients registered in the BNC database underwent microsurgery for acute (0-21 days) aSAH. During the case study, we assessed the severity of hemorrhage according to the Fisher scale, the condition of patients on the Hunt-Hess (H-H) scale during surgery, the time of placement of EVD (before, during, and after surgery), and the duration of EVD. The number of patients with parenchymal intracranial pressure (ICP) transducers was assessed by the degree of correlation of ICP data through the EVD and parenchymal ICP transducer. One of the aims of the research was to compare the frequency of using EVD and decompressive craniectomy (DCH). The incidence of EVD-associated meningitis was analyzed. The need for a ventriculoperitoneal shunt (VPS) in patients after using EVD was also assessed. Overall outcomes were assessed using a modified Rankin scale (mRS) at the time of patient discharge. Exclusion criteria were as follows: patients aged less than 18 years and the lack of assessed data. Patients undergoing endovascular and conservative treatments also were excluded. Results Among the patients enrolled in the study, 22% (n=142) had EVD. Among these, 99 cases (69.7%) had EVD installed in the operating room just before the start of the surgical intervention. In some cases, ventriculostomy was performed on a delayed basis (16.3%). A satisfactory outcome (mRS scores of 1 and 2) was observed in 24.7% (n=35). Moderate and profound disability at the time of discharge was noted in 55.7% (n=79). Vegetative outcome at discharge was noted in 8.4% (n=12), and mortality occurred in 12.3% (n=15). Conclusion EVD ensures effective monitoring and reduction of ICP. EVD is associated with a relatively low risk of infectious, liquorodynamic, and hemorrhagic complications and does not worsen outcomes when used in patients with aSAH. We propose that all patients in the acute stage of SAH with H-H severity of III-V should receive EVD immediately before surgery.
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Affiliation(s)
- Anton Konovalov
- Vascular Surgery, Burdenko Neurosurgical Center, Moscow, RUS
| | - Oleg Shekhtman
- Neurosurgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Yury Pilipenko
- Vascular Surgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Dmitry Okishev
- Vascular Surgery, Burdenko Neurosurgical Center, Moscow, RUS
| | - Olga Ershova
- Epidemiology and Public Health, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Andrey Oshorov
- Internal Medicine: Critical Care, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Arevik Abramyan
- Vascular Surgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Irina Kurzakova
- Vascular Surgery, Burdenko Neurosurgical Center, Moscow, RUS
| | - Shalva Eliava
- Vascular Surgery, Burdenko Neurosurgical Center, Moscow, RUS
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Abstract
Patients with spinal abnormalities infrequently present with intradural intramedullary bleeding. The more common causes include spinal trauma, arteriovenous malformations and saccular aneurysms of spinal arteries. On occasion, spinal cord tumors either primary or metastatic may cause intramedullary bleed with ependymoma of the conus medullaris. Spinal nerve sheath tumors such as schwannomas only rarely cause intradural intramedullary bleed, especially in the absence of spinal cord or nerve root symptoms. We report a case of spinal intradural schwannoma presenting with acute onset of quadriparesis. Cerebral angiography studies were negative but magnetic resonance imaging (MRI) of the spine revealed a large hemorrhagic tumor in the thoracolumbar junction. However, we suggest that the patients with intradural intramedullary bleed should be evaluated for underlying spine disease.
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Affiliation(s)
- Muhammad Nadeem
- MBBS, FCPS, Department of Urology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | - Salman Mansoor
- Department of Neurology, Shifa International Hospital, Islamabad, Pakistan
| | - Salman Assad
- Department of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Fariha Ilyas
- Department of Medicine, University of Texas at Austin, Dell Medical School, Austin, TX, USA
| | - Ahmed H Qavi
- Department of Medicine, Montefiore New Rochelle Hospital, Albert Einstein College of Medicine, New Rochelle, NY, USA
| | - Shoab Saadat
- Department of Nephrology, Shifa International Hospital, Islamabad, Pakistan
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Abstract
Nitric oxide (NO), also known as endothelium-derived relaxing factor, is produced by endothelial nitric oxide synthase (eNOS) in the intima and by neuronal nitric oxide synthase (nNOS) in the adventitia of cerebral vessels. It dilates the arteries in response to shear stress, metabolic demands, pterygopalatine ganglion stimulation, and chemoregulation. Subarachnoid haemorrhage (SAH) interrupts this regulation of cerebral blood flow. Hemoglobin, gradually released from erythrocytes in the subarachnoid space destroys nNOS-containing neurons in the conductive arteries. This deprives the arteries of NO, leading to the initiation of delayed vasospasm. But such vessel narrowing increases shear stress, which stimulates eNOS. This mechanism normally would lead to increased production of NO and dilation of arteries. However, a transient eNOS dysfunction evoked by an increase of the endogenous competitive nitric oxide synthase (NOS) inhibitor, asymmetric dimethyl-arginine (ADMA), prevents this vasodilation. eNOS dysfunction has been recently shown to be evoked by increased levels of ADMA in CSF in response to the presence of bilirubin-oxidized fragments (BOXes). A direct cause of the increased ADMA CSF level is most likely decreased ADMA elimination due to the disappearance of ADMA-hydrolyzing enzyme (DDAH II) immunoreactivity in the arteries in spasm. This eNOS dysfunction sustains vasospasm. CSF ADMA levels are closely associated with the degree and time-course of vasospasm; when CSF ADMA levels decrease, vasospasm resolves. Thus, the exogenous delivery of NO, inhibiting the L-arginine-methylating enzyme (IPRMT3) or stimulating DDAH II, may provide new therapeutic modalities to prevent and treat vasospasm. This paper will present results of preclinical studies supporting the NO-based hypothesis of delayed cerebral vasospasm development and its prevention by increased NO availability.
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Affiliation(s)
- R M Pluta
- Surgical Neurology Branch, National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD 20892, USA.
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van der Schaaf IC, Wermer MJH, Velthuis BK, Buskens E, Bossuyt PMM, Rinkel GJE. Psychosocial impact of finding small aneurysms that are left untreated in patients previously operated on for ruptured aneurysms. J Neurol Neurosurg Psychiatry 2006; 77:748-52. [PMID: 16705198 PMCID: PMC2077475 DOI: 10.1136/jnnp.2005.079194] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES In patients with previous subarachnoid haemorrhage (SAH) undergoing follow up screening, the authors assessed the impact of finding but not treating very small aneurysms by comparing quality of life (QOL), anxiety, and depression between patients with a newly detected aneurysm that was left untreated (cases) and patients with a negative screening (controls) as this should be incorporated in the evaluation of effectiveness of screening. METHODS In patients with previous SAH undergoing screening for new aneurysms the authors compared QOL (SF-36, EURO-QOL, and a screening related questionnaire), anxiety, and depression (Hospital Anxiety and Depression Scale (HADS)) between cases and controls. Differences in scores on the SF-36, EURO-QOL, and HADS were assessed with Student's t test and differences in proportions of patients with HADS scores in the pathological range and screening related changes with chi2 analysis. The authors powered the study to detect a moderate, clinically relevant difference. RESULTS Thirty five cases and 34 controls were included. Trends for health related QOL, anxiety, depression, and consequences in daily life pointed in the same direction of a less favourable situation for cases but all effects were small, and did not reach statistical significance. On the screenings specific questionnaire, cases more often (but not statistically significant) reported changes in daily life. CONCLUSIONS The authors found no major or moderate impact on QOL, anxiety, and depression of the awareness of having an untreated aneurysm, which was detected at screening, although most items showed a trend towards more negative effects for cases. Minor effects on individual level cannot be excluded by this study.
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Affiliation(s)
- I C van der Schaaf
- Department of Radiology E01.132, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, Netherlands.
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Abstract
Cerebral blood vessels are innervated by sensory nerves that store several neurotransmitters among which calcitonin gene-related peptide (CGRP) is the most abundant. In primary headaches, there is a clear association between the head pain and the release of CGRP. In cluster headache there is an additional release of vasoactive intestinal peptide (VIP). In connection with administration of triptans, the headache subsides and the neuropeptide release normalises, in part via a presynaptic effect. In subarachnoid hemorrhage (SAH), CGRP is released to counterbalance the blood-induced vasospasm. In severe cases, the stored CGRP may be exhausted while infusion of CGRP may limit cerebral vasospasm. Thus, interactions with the trigeminovascular system at CGRP receptors may be a useful target for understanding of cerebrovascular disease and to design novel treatments.
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Affiliation(s)
- Lars Edvinsson
- Department of Internal Medicine, Lund University Hospital, S-221 85 Lund, Sweden.
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