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Despite growing evidence over the last few years of the efficacy and safety of direct thrombus aspiration using a large bore distal access catheter as a type of mechanical thrombectomy procedure in acute stroke large-vessel occlusion patients, the experience and evidence of this technique for managing thromboembolic complications in endovascular aneurysm treatment is still limited and little research is available regarding this topic. We present a case of a thromboembolic occlusion of the left middle cerebral artery during the preprocedural angiograms of a large and fusiform left internal carotid artery aneurysm. This complication was successfully managed by navigating an already-placed distal access catheter intended for support during the opening of the flow-diverting stent; therefore, the thrombus was manually aspirated for two minutes, and Thrombolysis in Cerebral Infarction (TICI) scale 3 flow was restored. This case should encourage the use of a distal access catheter, already placed for aneurysm treatment, to perform zero-delay direct thrombus aspiration as a rescue approach for thromboembolic complications during endovascular treatments.

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OBJECTIVES: This study aimed to investigate the association between intracerebral aneurysms and cranial nerve (CN) palsies, focusing on nerves other than the oculomotor nerve. It sought to determine the prevalence, risk factors, and clinical outcomes of these nerve palsies and compare the effectiveness of microsurgical clipping versus endovascular coiling in restoring nerve function. METHODOLOGY: Following PRISMA guidelines, a comprehensive literature search was conducted using databases like PubMed, Scopus, and Google Scholar, covering studies from 1975 to April 2024. The inclusion criteria targeted patients with non-oculomotor nerve palsies diagnosed with cerebral aneurysms. Studies published before 1975 and non-English studies were excluded. Data extraction included study design, patient characteristics, and intervention outcomes. The Joanna Briggs Institute and Newcastle-Ottawa scales were used to assess study quality. Data were synthesized narratively and statistically analysed using SPSS v27. RESULTS: The analysis included 47 patients (53.2% female, mean age 44.8 years). The internal carotid artery (ICA) was the most common aneurysm site (44.7%), and the abducent nerve (CN VI) was most frequently affected. Ruptured aneurysms had better recovery outcomes (88.9%) than unruptured ones (66.7%). Hypertension was present in 9.2%. Unilateral aneurysms were seen in 80.9%, with 76.6% having a single nerve palsy. Non-ruptured aneurysms accounted for 58.1%, and ruptured for 41.9% of associated cranial nerve palsies. Treatment included microsurgical approaches (42.6%), endovascular approaches (34%), combined approaches (6.4%), and conservative management (17%). Recovery of the palsy was observed in 75.6%, with endovascular procedures showing higher recovery (93.3%) compared to conservative treatment (28.6%). CONCLUSION: Intracerebral aneurysms are significantly associated with non-oculomotor CN palsies. Endovascular procedures yield higher recovery rates than conservative management, particularly in ruptured aneurysms. Timely and appropriate treatment is crucial for improving nerve function recovery in these patients.

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PURPOSE: Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA. METHODS: An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability. RESULTS: In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25 mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac. CONCLUSIONS: The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach.

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Intrasaccular flow modification with devices like the Woven EndoBridge (WEB, MicroVention, Inc., Aliso Viejo, California, US) is an increasingly utilized endovascular treatment for bifurcation aneurysms. Among the potential complications of the procedure is branch vessel occlusion. There are no previous publications of rescue stenting for inadvertent branch vessel occlusion with the WEB device. We report two cases of rescue stenting following branch vessel occlusion after cerebral aneurysm embolization with the WEB device. In both cases, rescue stenting with a Neuroform Atlas stent Stryker, Fremont, CA, US) successfully revascularized the occluded vessel and led to good patient outcomes.

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BACKGROUND: Complex intracranial aneurysms (CIAs) comprise a subset of lesions with defiant vascular architecture, difficult access, and prior treatment. Surgical management of CIAs is often challenging and demands an assessment on a case-by-case basis. The generational evolution of bypass surgery has offered a long-standing potential for effective cerebral revascularization. Herein, we aim to illustrate a single-center experience treating CIAs. METHODS: The authors conducted a retrospective analysis of clinical records of patients treated with cerebral revascularization techniques at Hospital Nacional Dos de Mayo, Lima, Peru, during 2018-2022. Relevant data were collected, including patient history, aneurysm features on imaging, preoperative complications, the intraoperative course, aneurysm occlusion rates, bypass patency, neurological function, and postoperative complications. RESULTS: Seventeen patients (70.59% female; median age: 53 years) with 17 CIAs (64.7% saccular; 76.5% ruptured) were included. The most common clinical presentation included loss of consciousness (70.6%) and headaches (58.8%). Microsurgical treatment included first-, second-, and third-generation bypass. In 47.1% of cases, an anastomosis between the superficial temporal artery and the M3 segment was predominantly used, followed by an A3-A3 bypass (29.4%), a superficial temporal artery-M2 bypass (17.6%), and an external carotid artery to M2 bypass (5.9%). The intraoperative aneurysm rupture rate was 11.8%. Postoperative complications included ischemia (40%), cerebrospinal fluid fistulas (26.7%), and pneumonia (20%). At hospital discharge, the median Glasgow Coma Scale score was 14 (range: 10-15). At the 6-month follow-up, 82.4% of patients had a modified Rankin Scale score ≤2, bypass patency was present in all cases, and the morbidity rate was 17.6%. CONCLUSIONS: CIAs represent a spectrum of defiant vascular lesions with a poor natural history. Bypass surgery offers the potential for definitive treatment. Our case series illustrated the predominant role of cerebral revascularization of CIAs with a critical case-by-case approach to provide optimal outcomes in a limited-resource setting.

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INTRODUCTION: Intracranial aneurysms (IAs) occur in 3-5% of the general population and are characterized by localized structural deterioration of the arterial wall with loss of internal elastic lamina and disruption of the media. The risk of incidence and rupture of aneurysms depends on age, sex, ethnicity, and other different factors, indicating the influence of genetic and environmental factors. When an aneurysm ruptures, there is an estimated 20% mortality rate, along with an added 30-40% morbidity in survivors. The alterations in hormonal levels can influence IAs, while the rupture of an aneurysm can have various impacts on endocrine pathways and affect their outcome. AREA COVERED: This review explores the reciprocal relationship between endocrinological changes (estrogen, growth hormone, and thyroid hormones) and IAs, as well as the effects of aneurysm ruptures on endocrine fluctuations. EXPERT OPINION: Based on the data presented in this paper, we recommend further exploration into the influence of hormones on aneurysm formation and rupture. Additionally, we propose conducting endocrine assessments for patients who have experienced a rupture of IAs. Monitoring hormonal changes in patients with IAs could serve as a potential risk factor for rupture, leading to interventions in the approach to managing IAs.

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BACKGROUND: Ophthalmic artery aneurysm (OAA) can be secured in endovascular or microsurgical approaches. Still there are controversies in technique selection and their long term outcomes. METHODS: All the patients with OAA were treated microsurgically and followed. Demographic data, neurological status, physical examination findings, angiographic data, operation details, and intraoperative and postoperative events were recorded and analyzed. P < 0.05 was considered significant. RESULTS: Among 55 patients, 38 were females (69.1%). Median preoperative glasgow coma scale (GCS), Fisher Grade, and Hunt and Hess(HH) scores were 15, 1 and 1, respectively. The most common neurologic manifestation was visual problems (n = 15). The most common anatomical projection was medial (43.6%) oriented lesions. 85.5% of them only had 1 ophthalmic aneurysm while multiple aneurysms were reported in 14.6%. In 52 patients temporary clip was used. in 21 patients (38.2%) intraoperative aneurysm rupture occurred. Larger aneurysm size and preoperative hydrocephalus were associated with higher rates of aneurysm rupture (P = 0.003 and 0.031). 28.5% of the patients with visual problems had clinical improvement in the postoperative period. The mean follow-up period was 5 years. Follow-up angiography showed a 100% obliteration rate with a 0.0% recurrence rate. Median values for follow-up glasgow outcome scale and modified Rankin scale were 5 and 0, respectively. favorable neurological outcomes were associated with better primary GCS and HH scores. CONCLUSION: OAA microsurgery is an effective and safe procedure with significant improvement in both visual and neurological status. Low recurrence rate and excellent clinical recovery are the most important advantages of microsurgery in OAA treatment.

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One of the main causes of the dismal prognosis in patients who survive the initial bleeding after aneurysmal subarachnoidal hemorrhage is the delayed cerebral ischaemia caused by vasospasm. Studies suggest that cerebral magnesium and pH may potentially play a role in the pathophysiology of this adverse event. Using phosphorous magnetic resonance spectrocopy (31P-MRS), we calculated the cerebral magnesium (Mg) and pH levels in 13 patients who suffered from aSAH. The values between the group that developed clinically significant vasospasm (n = 7) and the group that did not (n = 6) were compared. The results of this study show significantly lower cerebral Mg levels (p = 0.019) and higher pH levels (p < 0.001) in the cumulative group (all brain voxels together) in patients who developed clinically significant vasospasm. Further clinical studies on a larger group of carefully selected patients are needed in order to predict clinically significant vasospasm.

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BACKGROUND: Copy number variations (CNVs) have emerged as significant contributors to the elusive genetic causality of inherited eye diseases. In this study, we describe a case with optic atrophy and a brain aneurysm, in which a de novo CNV 3q29 deletion was identified. CASE PRESENTATION: A 40-year-old female patient was referred to our department after undergoing aneurysm transcatheter arterial embolization for a brain aneurysm. She had no history of systemic diseases, except for unsatisfactory best-corrected visual acuity (BCVA) since elementary school. Electrophysiological tests confirmed the findings in retinal images, indicating optic nerve atrophy. Chromosomal microarray analysis revealed a de novo deletion spanning 960 kb on chromosome 3q29, encompassing OPA1 and six neighboring genes. Unlike previously reported deletions in this region associated with optic atrophy, neuropsychiatric disorders, and obesity, this patient displayed a unique combination of optic atrophy and a brain aneurysm. However, there is no causal relationship between the brain aneurysm and the CNV. CONCLUSION: In conclusion, the optic atrophy is conclusively attributed to the OPA1 deletion, and the aneurysm could be a coincidental association. The report emphasizes the likelihood of underestimating OPA1 deletions due to sequencing technology limitations. Recognizing these constraints, healthcare professionals must acknowledge these limitations and consistently search for OPA1 variants/deletions in Autosomal Dominant Optic Atrophy (ADOA) patients with negative sequencing results. This strategic approach ensures a more comprehensive exploration of copy-number variations, ultimately enhancing diagnostic precision in the field of genetic disorders.

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BACKGROUND: Brain strokes comprise the third leading cause of death worldwide. Microsurgical clipping is recognized as being one of the most effective approaches to the treatment of brain aneurysms. The incomplete closure of the distal-side aneurysm neck is the most common cause of the persistent filling of the dome. Since the diameter of the neck increases when the neck of the aneurysm is squeezed closed by the blades of the clip, the blades should be correspondingly longer. This study provided an assessment of whether the presurgical selection of clips using a 3D planning system is feasible in terms of selecting the most suitable clip for aneurysm occlusion. METHODS: The computational model was created based on computer tomography data obtained from nine brain aneurysms. The closing of the aneurysm was provided in two steps. The first the length of the blades used for closing corresponded to the length of the aneurysm neck as confirmed by the radiological measurements. The second the length of the blades was adjusted according to stage one, so as to determine the minimum required for the closure of all the gaps in the interior space of the aneurysm neck. RESULTS: No differences were detected between the radiological measurement of the aneurysm neck size and the measurements obtained from the reconstructed stereolithographic 3D models. It was observed that the size of the aneurysm neck increased following clipping by 40% to 60% of its original size. The larger the aneurysm neck, the greater the deformation of the aneurysm. CONCLUSION: Firstly, the 3D reconstruction of CT/MRI data did not result in any loss of accuracy and the measurement of the neck of the aneurysm was the same for both of the methods employed. The second, and more important, outcome was that the deformation of the neck of the cerebral aneurysm is at least 1.4x greater than its original size. This information is essential in terms of the pre-selection of the size of the clip.

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We present the case of a 58-year-old male with a 3-day history of sudden onset headache, loss of consciousness, and uncontrolled vomiting. The patient had 3/5 quadriparesis and a Glasgow coma scale (GCS) score of 8, which merited neurocritical intensive care. Brain imaging suggested the presence of two lesions: (i) a fusiform aneurysm of 12 × 7 mm in an accessory A2 artery of the anterior cerebral artery and (ii) an unruptured saccular aneurysm of 3.3 × 2.8 mm in the distal segment of the basilar artery. He was deemed a candidate for microsurgical management. Postoperatively, he had 4/5 quadriparesis, paresis of the right oculomotor nerve, and a GCS score of 13. A 3-month follow-up showed a significant improvement in neurological function with a score of 2 on the modified Rankin scale. The presented case illustrates the relevance of a nuanced acquaintance to operate in diseased anatomical variants and complex pathologies of narrow corridors.

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Over the last decades, minimally invasive techniques have revolutionized the endovascular treatment (EVT) of brain aneurysms. In parallel, the development of conscious sedation (CS), a potentially less harmful anesthetic protocol than general anesthesia (GA), has led to the course optimization of surgeries, patient outcomes, and healthcare costs. Nevertheless, the feasibility and safety of EVT of brain aneurysms under CS have yet to be assessed thoroughly. Herein, we systematically reviewed the medical literature about this procedure. In accordance with the PRISMA guidelines, four databases (PubMed, EMBASE, SCOPUS, and Cochrane Library) were queried to identify articles describing the EVT of brain aneurysms under CS. Successful procedural completion, complete aneurysm occlusion outcomes, intraoperative complications, clinical outcomes, and mortality rates assessed the feasibility and safety. Our search strategy yielded 567 records, of which 11 articles were included in the qualitative synthesis. These studies entailed a total of 1142 patients (40.7% females), 1183 intracranial aneurysms (78.4% in the anterior circulation and 60.9% unruptured at presentation), and 1391 endovascular procedures (91.9% performed under CS). EVT modalities under CS included coiling alone (63.2%), flow diversion (17.7%), stent-assisted coiling (10.6%), stenting alone (6.5%), onyx embolization alone (1.7%), onyx + stenting (0.2%), and onyx + coiling (0.2%). CS was achieved by combining two or more anesthetics, such as midazolam, fentanyl, and remifentanil. Selection criteria for CS were heterogenous and included patients' history of pulmonary and cardiovascular diseases, outweighing the benefits of CS versus GA, a Hunt and Hess score of I-II, a median score of 3 in the American Society of Anesthesiology scale, and patient's compliance with elective CS. Procedures were deemed successful or achieving complete aneurysm occlusion in 88.1% and 9.4% of reported cases, respectively. Good clinical outcomes were described in 90.4% of patients with available data at follow-up (mean time: 10.7 months). The procedural complication rate was 16%, and the mortality rate was 2.8%. No complications or mortality were explicitly attributed to CS. On the other hand, procedure abortion and conversion from CS to GA were deemed necessary in 5% and 1% of cases, respectively. The present study highlights the feasibility of performing EVT of brain aneurysms under CS as an alternative anesthetic protocol to GA. However, the limited nature of observational studies, methodological quality, the predominant absence of a comparative GA group, and clinical data during follow-up restrict a conclusive statement about the safety of EVT under CS. Accordingly, further research endeavors are warranted toward a higher level of evidence that can be translated into surgical practice.

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Autosomal dominant polycystic kidney disease (ADPKD) is the leading cause of inherited kidney disease with significant contributions to CKD and end-stage kidney disease. The underlying polycystin proteins (PC1 and PC2) have widespread tissue expression and complex functional roles making ADPKD a systemic disease. Vascular complications, particularly intracranial aneurysms (ICA) are the most feared due to their potential for devastating neurological complications and sudden death. Intracranial aneurysms occur in 8-12% of all patients with ADPKD, but the risk is intensified 4-5-fold in those with a positive family history. The basis for this genetic risk is not well understood and could conceivably be due to features of the germline mutation with a significant contribution of other genetic modifiers and/or environmental factors. Here we review what is known about the natural history and genetics of unruptured ICA in ADPKD including the prevalence and risk factors for aneurysm formation and subarachnoid hemorrhage. We discuss two alternative screening strategies and recommend a practical algorithm that targets those at highest risk for ICA with a positive family history for screening.

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Takotsubo syndrome (TS) is an acute heart disease that mimics the typical features of acute coronary syndrome (ACS). TS is generally reported after subarachnoid hemorrhage (SAH) due to a ruptured aneurysm, and has an incidence rate of 0.8 (17%). Here, we report a rare case of TS with unruptured intracranial aneurism. A 54-year-old woman had a history of systemic arterial hypertension and migraine. She went to a secondary hospital 2 h after sudden-onset chest pain, which irradiated to the left upper limb and back. The initial electrocardiogram (ECG) was normal but showed a troponin curve, which led us to suspect acute non-ST elevation myocardial infarction. Serial ECG showed dynamic changes in ST-segment elevation in DIII, AvF, V5, and V6. Emergency cardiac catheterisation was performed and did not show any obstructive lesions. However, ventriculography revealed hypokinesia of the inferoapical wall. During hospitalization, the patient had a severe refractory headache. Computed tomography (CT) and CT angiography were performed, which identified "mirror" saccular aneurysms. A supraclinoid internal carotid artery aneurysm was embolized with two stents. The patient's condition progressed satisfactorily. The association between takotsubo syndrome and aneurysmal SAH with some populations has already been reported. Due to this prior knowledge, and severe headache, it was necessary to perform screening for SAH and the discovery of an unruptured aneurysm in this case report. The present case report differs from most reported cases of takotsubo syndrome described in the literature because it presents unruptured mirror aneurysms, while most cases are diagnosed after intracranial hemorrhage.

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Neuroinflammation and microthrombosis may be underlying mechanisms of brain injury after aneurysmal subarachnoid hemorrhage (aSAH), but they have not been studied in relation to each other. In postmortem brain tissue, we investigated neuroinflammation by studying the microglial and astrocyte response in the frontal cortex of 11 aSAH and 10 control patients. In a second study, we investigated the correlation between microthrombosis and microglia by studying the microglial surface area around vessels with and without microthrombosis in the frontal cortex and hippocampus of 8 other aSAH patients. In comparison with controls, we found increased numbers of microglia (mean ± SEM 50 ± 8 vs 20 ± 5 per 0.0026 mm³, p < 0.01), an increased surface area (%) of microglia (mean ± SEM 4.2 ± 0.6 vs 2.2 ± 0.4, p < 0.05), a higher intensity of the astrocytic intermediate filament protein glial fibrillary acidic protein (GFAP) (mean ± SEM 184 ± 28 vs 92 ± 23 arbitrary units, p < 0.05), and an increased GFAP surface area (%) (mean ± SEM 21.2 ± 2.6 vs 10.7 ± 2.1, p < 0.01) in aSAH tissue. Microglia surface area was approximately 40% larger around vessels with microthrombosis than those without microthrombosis (estimated marginal means [95% CI]; 6.1 [5.4-6.9] vs 4.3 [3.6-5.0], p < 0.001). Our results show that the microglial and astrocyte surface areas increased after aSAH and that microthrombosis and microglia are interrelated.

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BACKGROUND: Flow diversion using the pipeline embolization device (PED) for unruptured aneurysms is associated with high occlusion and low morbidity and mortality. However, most reports have limited follow-up of 1-2 years. Therefore, we sought to report our outcomes after PED for unruptured aneurysms in patients with at least 5-years of follow-up. METHODS: Review of patients undergoing PED for unruptured aneurysms from 2009 to 2016. RESULTS: Overall, 135 patients with 138 aneurysms were included for analysis. Seventy-eight percent of aneurysms (n=107) over a median radiographic follow-up of 5.0 years underwent complete occlusion. Among aneurysms with at least 5-years of radiographic follow-up (n=71), 79% (n=56) achieved complete obliteration. No aneurysm recanalized after radiographic obliteration. Furthermore, over a median clinical follow-up period of 4.9 years, 84% of patients (n=115) self-reported mRS scores between 0 and 2. For patients with at least 5-years of clinical follow-up, 88% (n=61) reported mRS between 0 and 2. In total, 3% (n=4) of patients experienced a major, non-fatal neurologic complication related to the PED, 5% (n=7) of patients experienced a minor neurologic complication related to PED placement, and 2% (n=3) died from either delayed aneurysm rupture, delayed ipsilateral hemorrhage after PED placement, or delayed (9 months after treatment) neural compression after progressive thrombosis of a PED-treated dolichoectactic vertebrobasilar aneurysm. CONCLUSIONS: Treatment of unruptured aneurysms with the PED is associated with high rates of long-term angiographic occlusion and low, albeit clinically important, rates of major neurologic morbidity and mortality. Thus, flow diversion via PED placement is safe, effective, and durable.

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PURPOSE: To evaluate clinical and imaging characteristics of pediatric brain aneurysms. MATERIALS AND METHODS: A retrospective review of 1458 MR angiograms of pediatric patients (≤18 years old) obtained between 2006 and 2021 was performed. A non-infundibular arterial luminal outpouching larger than 1mm in size was identified as an "Intracranial aneurysm." Patient demographics, clinical presentations, and predisposing risk factors, including family history and underlying medical conditions, were reviewed. MRA images were analyzed for aneurysm location, number, maximum diameter, and interval changes on follow-up. RESULTS: Forty-nine (3.3%) patients (30 females, 19 males) with 64 intracranial aneurysms were identified with an average age of 13.71 ± 3.67 years. Eleven (22.4%) patients had multiple aneurysms. An underlying systemic illness was observed in 81.6% (40/49) cases, with sickle cell disease as the most frequent (25/49, 51%) diagnosis. A first-degree family history of intracranial aneurysms was recognized in 36/1458 (2.5%) patients. However, no intracranial aneurysm was found in this group. While 02/49 (4%) patients presented with acute SAH, headache was the most common (16/49, 32.7%) symptom at presentation in unruptured cases. The majority (47/64, 73.4%) of the aneurysms were located in the anterior circulation, with the ICA ophthalmic segment being most frequently (24/47, 51%) involved. Most (54/64, 84.4%) aneurysms were smaller than 4mm in size at the time of diagnosis. At least one follow-up MRA was obtained in 72.3% (34/47) of the unruptured aneurysms cohort. There was no change in the aneurysm size and morphology in 31/34 (91.2 %) patients over an average imaging follow-up of 39.6 months. Three (6%) patients demonstrated an interval increase in the aneurysm size. SAH patients (n=2) and two unruptured aneurysm patients with an interval increase in size were successfully treated with endovascular techniques. CONCLUSION: Female predominance with a higher frequency of small and unruptured intracranial aneurysms was recognized in our cohort. A higher incidence of an underlying systemic illness, especially sickle cell disease, was also noted. Most intracranial aneurysms in children appear to remain stable. However, there seems to be the risk of an aneurysm size increase which warrants regular clinical and imaging follow-up.

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BACKGROUND: Dysnatremia occurs commonly in patients with aneurysmal subarachnoid hemorrhage (aSAH). The mechanisms for development of sodium dyshomeostasis are complex, including the cerebral salt-wasting syndrome, the syndrome of inappropriate secretion of antidiuretic hormone, diabetes insipidus. Iatrogenic occurrence of altered sodium levels plays a role, as sodium homeostasis is tightly linked to fluid and volume management. METHODS: Narrative review of the literature. RESULTS: Many studies have aimed to identify factors predictive of the development of dysnatremia, but data on associations between dysnatremia and demographic and clinical variables are variable. Furthermore, although a clear relationship between serum sodium serum concentrations and outcomes has not been established-poor outcomes have been associated with both hyponatremia and hypernatremia in the immediate period following aSAH and set the basis for seeking interventions to correct dysnatremia. While sodium supplementation and mineralocorticoids are frequently administered to prevent or counter natriuresis and hyponatremia, evidence to date is insufficient to gauge the effect of such treatment on outcomes. CONCLUSIONS: In this article, we reviewed available data and provide a practical interpretation of these data as a complement to the newly issued guidelines for management of aSAH. Gaps in knowledge and future directions are discussed.

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Cerebral vasospasm remains the most frequent and devastating complication after subarachnoid aneurysmal hemorrhage because of secondary cerebral ischemia and its sequelae. The underlying pathophysiology involves vasodilator peptide release (such as CGRP) and nitric oxide depletion at the level of the precapillary sphincters of the cerebral (internal carotid artery network) and dural (external carotid artery network) arteries, which are both innervated by craniofacial autonomic afferents and tightly connected to the trigeminal nerve and trigemino-cervical nucleus complex. We hypothesized that trigeminal nerve modulation could influence the cerebral flow of this vascular network through a sympatholytic effect and decrease the occurrence of vasospasm and its consequences. We conducted a prospective double-blind, randomized controlled pilot trial to compare the effect of 10 days of transcutaneous electrical trigeminal nerve stimulation vs. sham stimulation on cerebral infarction occurrence at 3 months. Sixty patients treated for aneurysmal SAH (World Federation of Neurosurgical Societies scale between 1 and 4) were included. We compared the radiological incidence of delayed cerebral ischemia (DCI) on magnetic resonance imaging (MRI) at 3 months in moderate and severe vasospasm patients receiving trigeminal nerve stimulation (TNS group) vs. sham stimulation (sham group). Our primary endpoint (the infarction rate at the 3-month follow-up) did not significantly differ between the two groups (p = 0.99). Vasospasm-related infarctions were present in seven patients (23%) in the TNS group and eight patients (27%) in the sham group. Ultimately, we were not able to show that TNS can decrease the rate of cerebral infarction secondary to vasospasm occurrence. As a result, it would be premature to promote trigeminal system neurostimulation in this context. This concept should be the subject of further research.

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Background: pCONus2 device has been used in some countries as coadyuvant in the treatment of wide-neck bifurcation aneurysms with coils. Objective: To present the first series of brain aneurysms treated with pCONus2 in the Mexican Institute for Social Security (IMSS). Material and methods: We retrospectively present the first 13 aneurysms treated from October 2019 to February 2022 with pCONus2 device at a third level hospital. Results: 6 aneurysms located at anterior communicating artery, 3 at middle cerebral artery bifurcation, 2 at internal carotid artery bifurcatión, and 2 at the tip of basilar artery were treated. Device deployment was performed without complications and it was possible to embolize aneurysms with coils in 12 patients (92%), while on an internal carotid bifurcation aneurysm (8%) there was an incident of a pCONus2 petal migration toward vascular lumen caused by coils mesh pressure, situation that was solved by placing an nitinol self-expandable microstent. In 7 cases (54%) we performed coiling technique after microcatheter passage through pCONus2, while in 6 cases (46%) we used the jailing technique without complications. Conclusions: pCONus2 is a useful device for wide-neck bifurcation aneurysms embolization. In Mexico our experience is yet limited; however, the first cases have been successful. Furthermore, we showed the first cases treated using jailing technique. Much more cases are required in order to carry out a statistically conclusive analysis and to establish the effectiveness and safety of the device.

Introducción: el dispositivo pCONus2 ha sido usado en algunos países como coadyuvante en el tratamiento con coils de los aneurismas de cuello ancho localizados en las bifurcaciones. Objetivo: presentar los primeros aneurismas tratados con pCONus2 en el Instituto Mexicano del Seguro Social (IMSS). Material y métodos: se exponen retrospectivamente 13 casos de pacientes tratados con pCONus2 de octubre de 2019 a febrero de 2022 en un hospital de tercer nivel del IMSS. Resultados: se trataron 6 aneurismas de la arteria comunicante anterior, 2 de la bifurcación de la arteria carótida interna, 3 en la bifurcación de la arteria cerebral media y 2 del tope de la arteria basilar. El uso del pCONus2 se hizo sin complicaciones ni incidentes en 12 pacientes (92%), mientras que en un aneurisma de la bifurcación de carótida interna (8%) ocurrió la migración de un pétalo del dispositivo hacia la luz vascular, motivado por la presión de la malla de coils, que se solucionó con un microstent. Siete aneurismas (54%) fueron embolizados con coils después del paso del microcatéter a través del pCONus2, mientras que en 6 (46%) se utilizó la técnica jailing, sin complicaciones ni incidentes. Conclusiones: el pCONus2 es un dispositivo útil en la embolización de aneurismas localizados en bifurcaciones arteriales. En México la experiencia todavía es poca, pero los primeros casos han sido exitosos. Mostramos, además, los primeros casos tratados con la técnica de jailing. Se requieren más casos en nuestro país para hacer un análisis estadísticamente concluyente y determinar la efectividad y seguridad del dispositivo.

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