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Magnetic resonance vessel wall imaging (MR-VWI) is an emerging imaging technology used to assess the progressive risk of unruptured intracranial aneurysms (UIAs). Unlike the standard evaluation model, MR-VWI is still debatable. This study aims to further define the potential relationship between aneurysm wall enhancement (AWE) and aneurysm stability. Using "intracranial aneurysm", "magnetic resonance", and "enhancement" as keywords, relevant studies were systematically searched in PubMed, Embase, and Cochrane, and the qualified studies were enrolled for further analysis. There were 13 case-control studies, 4 cohort studies, and 2,678 cases of intracranial aneurysms included in the meta-analysis. It was shown that AWE was correlated with intracranial aneurysm rupture (OR = 35.90, 95% CI: 15.58 to 82.75, p < 0.001), growth (OR = 6.69, 95% CI: 2.69 to 16.63, p < 0.001), and presence of symptoms (OR = 14.46, 95% CI: 9.07 to 23.05, p < 0.001). This finding had a high diagnostic value, but the correlation was probably not independent of aneurysm size. The pooled relative risks of the follow-up studies revealed that the risk of UIA progression was approximately 3.33 times higher with AWE than without AWE (RR = 3.33, 95% CI: 2.33 to 4.78, p < 0.001). In addition, the pooled results demonstrated that quantitative indices of VWI enhancement were equally linked with aneurysm stability (OR = 19.61, 95% CI: 10.63 to 36.17, p < 0.001). AWE is an effective imaging method to assess the stability of UIAs, and it can be a marker for the prophylactic treatment of small unruptured intracranial aneurysms in the future, which remains to be validated by prospective studies with large samples.

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The interhemispheric approach is very useful for the safe and reliable clipping of ruptured anterior communicating aneurysms. This approach enables surgeons to directly visualize the aneurysm and the surrounding vessels, including perforators, and provides a wide surgical corridor for clip insertion from multiple directions. Furthermore, in challenging situations, this approach facilitates vascular reconstruction without the need for graft harvesting. However, because of the procedural difficulty, many young and inexperienced neurosurgeons may hesitate to perform this technique. Therefore, this study aimed to provide useful tips, based on intraoperative photography, for skin and dural incisions, prevention of cerebrospinal fluid leakage and olfactory impairment, and fundamental steps for opening tight interhemispheric fissures. Finally, representative challenging cases that were adequately managed using the advantages of this approach are presented.

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For treating ruptured cerebral aneurysms, it is important to understand the setup and basic technique of coil embolization. Safe and effective embolization relies on preoperative considerations that determine the treatment strategy, guide the optimization of the therapeutic environment, and help in the selection of appropriate device systems. Moreover, during aneurysmal embolization, basic techniques for microcatheter shaping and navigation, safe coil introduction, and precise use of occlusion balloons are indispensable. Microcatheter shaping should be based on three-dimensional digital subtraction angiography findings as well as the axes of the parent artery and aneurysm. The operator must understand the advantages and disadvantages of the two methods for navigating the microcatheter into the aneurysm. Furthermore, it is essential to preoperatively simulate and understand the approaches for managing aneurysmal embolization-related complications, such as intraoperative aneurysmal rupture and thromboembolism. Mastery of these steps is mandatory before undertaking embolization of ruptured cerebral aneurysms.

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Intracranial aneurysms occur frequently; however, only a few of these rupture to cause subarachnoid hemorrhage. This presents a dilemma regarding the course of appropriate treatment. In the last decade, the wide utilization of magnetic resonance imaging-based vessel wall imaging(VWI) has facilitated the assessment of aneurysm wall enhancement(AWE), which has garnered significant attention. In 2013, initial reports highlighted that AWE was characteristic of ruptured aneurysms whereas, in 2014, AWE was identified as a characteristic feature of unruptured aneurysms with a high risk of rupture. Several studies have supported these findings since then. VWI, a novel modality that visualizes the inflammation of the aneurysmal wall, is considered highly useful for the diagnosis of aneurysms. This review discusses the key literature on AWE. Long-term prospective studies are warranted to determine whether AWE is an independent risk factor for aneurysmal progression.

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Despite advancements in neurosurgical techniques, subarachnoid hemorrhage(SAH) caused by the rupture of a partially thrombosed intracranial giant aneurysm remains a challenging clinical entity. This report describes the successful treatment of an 80-year-old male patient with SAH due to a ruptured, partially thrombosed intracranial giant aneurysm. The patient underwent a staged endovascular strategy using a flow diverter. The patient presented with SAH secondary to a ruptured, partially thrombosed intracranial giant aneurysm located at the C2 portion of the internal carotid artery and involving the origin of the posterior communicating artery(Pcom). Imaging revealed a dorsomedial rupture point on the aneurysm. A two-stage endovascular intervention(IVR) was performed. The first stage involved coil embolization aimed at covering the rupture point. Following the resolution of the vasospasm and the acute phase of SAH, the second stage involved the deployment of a pipeline embolization device. Digital subtraction angiography performed one month after the second stage IVR demonstrated a significant reduction in aneurysm filling, with preserved flow to the Pcom artery. We will discuss the technical details and rationale behind the staged endovascular approach in this complex case.

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Ruptured vertebral artery dissecting aneurysms(VADA) carry a poor prognosis owing to the high rates of rebleeding, stroke, and mortality without appropriate treatment. Various endovascular techniques are employed to treat these aneurysms. Deconstructive techniques, involving internal trapping with coils, often achieve complete angiographic occlusion at higher rates; however, they carry a risk of medullary infarction. Reconstructive techniques using neck-bridge stents preserve the parent vessel and reduce perioperative morbidity. Nevertheless, these techniques are associated with a higher rate of aneurysmal rebleeding or recurrence. Optimal treatment modalities should be chosen based on the anatomical characteristics of the aneurysm and the trade-off between risks and benefits.

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OBJECTIVE: Our aim is to demonstrate a rare cause of hemoperitoneum without vaginal bleeding resulting from the rupture of a uterine artery pseudoaneurysm after uncomplicated vaginal delivery. CASE REPORT: A 39-year-old woman who had experienced a normal vaginal delivery 8 days previously to being seen in our hospital, was presented to the emergency room with hypovolemic shock. Computed tomography angiography (CTA) showed massive internal bleeding and a ruptured pseudoaneurysm arising from the left uterine artery. The patient was successfully treated through transcatheter arterial embolization (TAE). CONCLUSION: A pseudoaneurysm is a rare disease which can occur during an uncomplicated vaginal delivery. The clinical presentation can vary from asymptomatic, vaginal bleeding or hemoperitoneum. The diagnosis can be made by using Doppler sonography, CTA or Magnetic Resonance Imaging. The use of TAE is now the most common treatment option and possesses a high success rate.

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BACKGROUND: Hemoptysis resulting from rupture of the pulmonary artery pseudoaneurysm (PAP) is massive and fatal, while factor contributing to the rupture of pseudoaneurysm remains elusive. This study aimed to elucidate the clinical and radiological features of PAP and identify the risk factors associated with rupture. METHODS: Patients who developed hemoptysis with PAP were collected from January 2019 to December 2022 retrospectively. Clinical data of the demographic characteristics, radiological findings, treatment strategies, and prognosis were collected. A comparative analysis was performed on the characteristics in the ruptured and non-ruptured cases. RESULTS: A total of 58 PAPs were identified in the 50 patients. The most common causes were infection (86%) and cancer (8%). The PAPs were located predominantly in the upper lobes of both lungs, and 57 (99.3%) were distributed in the segmental or subsegmental pulmonary arteries. The median diameter was 6.1(4.3-8.7) mm. A total of 29 PAPs were identified adjacent to pulmonary cavitations, with the median diameter of the cavity being 18.9 (12.4-34.8) mm. Rupture of pseudoaneurysm occurred in 21 cases (42%). Compared to unruptured group, the ruptured group had a significantly higher proportion of massive hemoptysis (57.1% vs. 6.9%, p < 0.001), larger pseudoaneurysm diameter (8.1 ± 3.2 mm vs. 6.0 ± 2.3 mm, p = 0.012), higher incidence of pulmonary cavitation (76.2% vs. 44.8%, p = 0.027), and larger cavitation diameters (32.9 ± 18.8 mm vs. 15.7 ± 8.4 mm, p = 0.005). The mean pulmonary artery pressure (mPAP) in the ruptured group was also significantly higher than that in the unruptured group [23.9 ± 7.4 mmHg vs. 19.2 ± 5.0 mmHg, p = 0.011]. Endovascular treatment was successfully performed in all 21 patients with ruptured PAP, of which the clinical success rate was 96.0%. Five patients experienced recurrent hemoptysis within one year. CONCLUSIONS: Massive hemoptysis, pseudoaneurysm diameter, pulmonary cavitation, and elevated mPAP were the risk factors for rupture of pseudoaneurysm. Our findings facilitate early identification and timely intervention of PAP at high risk of rupture.

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INTRODUCTION: Splenic artery aneurysm (SAA) is a focal dilation of the splenic artery with varying etiologies including atherosclerosis, arteritis, or trauma. Giant SAAs with a diameter of 10 cm is rare and can lead to severe complications like rupture and fistulas. Therefore, an accurate and timely diagnosis and treatment are important. PATIENT CONCERNS: A 50-year-old male presented with acute epigastric pain and hemorrhagic shock. Considering his symptoms and examination, ultrasound, multi-slice computed tomography and digital subtraction angiography results, a ruptured giant splenic artery aneurysm complicated with an exceptional gastric and transverse colonic fistula was suspected. DIAGNOSIS: Ruptured giant splenic artery aneurysm. INTERVENTIONS: Left anterolateral thoracotomy to control the severe aortic bleeding just above the diaphragm, aneurysmectomy, splenectomy, and closing the gastric and transverse colon perforations. OUTCOMES: Multi-slice computed tomography demonstrated the presence of splenic artery aneurysm in the distal third measuring (10 × 12 cm) in diameter with a true lumen measuring (7 × 3.5 cm) and a large hematoma extending to the greater and lesser gastric curvature. Intraoperatively, a large pulsating mass was detected occupying the epigastrium and the left hypochondrium with severe adhesions with the stomach and transverse colon. CONCLUSION: Giant SAA with a diameter of 10 cm is rare and is associated with severe complications. Therefore, successful treatment of splenic artery aneurysms involves prompt diagnosis, immediate surgical intervention to control bleeding, and tailored approaches like thoracotomy to control the thoracic aorta for better hemodynamic stabilization, aiming to eliminate the aneurysm and reduce complications effectively.

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Bifurcations are a common site for saccular aneurysms, but rarely can be a site for dissecting aneurysms. Identification of these aneurysms is extremely important because the management plan depends on it. We describe a rare case of a ruptured dissecting aneurysm at the right ICA bifurcation in a pre-teen child which posed a diagnostic dilemma but ultimately was successfully managed with flow diversion.

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The anterior communicating artery (AcoA) aneurysms represent the most complex aneurysms of the anterior circulation. For years, surgical challenges including the intricate anatomy and narrow surgical corridor have been overcome using supplementary techniques including extended craniotomies, wide opening of the cisterns, gyrus rectus resection and special clips like fenestrated clips. However, imaginative solutions such as intraoperative clip modification may be inevitable in particular cases for safe clipping. We retrospectively analyzed clinical records of two patients who required clip modification intraoperatively. Case #1 underwent microsurgical clipping of a ruptured, 4-mm AcoA aneurysm. Unfortunately, given the short distance between the two A2s, it was not possible to clip the aneurysm without a compromise to the contralateral A2 with the available shortest 3mm-fenestrated clip. We then used the clip modification technique intraoperatively by shortening the clip tips with mesh-plaque cutter and smoothening the remaining sharp ends using cautery sanding. Eventually, the aneurysm was clipped successfully with the modified-fenestrated clip. Post-clipping imagings confirmed complete occlusion of the aneurysm and patency of parent arteries. Case 2# underwent microsurgical clipping for a ruptured, 1-mm AcoA aneurysm. Like Case 1#, the initial clipping attempt with the available shortest 4mm-fenestrated clip failed given the excessive length of the tips. The patient, thus, required clip modification as described above. The aneurysm was then clipped successfully using the modified-fenestrated clip, protecting bilateral A2s. Post-clipping imagings demonstrated patency of parent arteries with no residual aneurysm filling. Clip modification seems to be an effective option in clipping the AcoA aneurysms when available clips are too long to secure them safely.

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OBJECTIVE: To evaluate the feasibility and durability of coil embolization for MCAB aneurysms by analyzing clinical and radiological results. METHODS: From January of 2008 to June of 2018, we treated a total of 1785 aneurysms using coil embolization. The aneurysms were treated by both coiling and stent-assisted coiling. Among these cases, 223 MCAB aneurysms were analyzed retrospectively. Clinical and radiological assessments were conducted at admission, after treatment, at discharge, and at last clinical follow-up. RESULTS: Coil embolization was performed on 223 MCAB aneurysms in 217 patients. Peri-procedural ischemic, hemorrhagic, and other complications within 30 days after coil embolization occurred at rates of 8.0 %, 8.0 %, and 2.0 %, respectively, in the ruptured group and at 2.9 %, 1.2 %, and 0 %, respectively, in the unruptured group. The overall morbidity and mortality rates associated with complications were 2.3 % and 2.0 %. The cumulative major recurrence rates were 5.1 % at 12 months, 7.1 % at 18 months, and 11.9 % at three years after coil embolization. The mean follow-up period was 33.27 ± 25.48 months. Independent risk factors for major recurrence after coil embolization for MCAB aneurysms were a ruptured aneurysm, initial incomplete occlusion, the aneurysm size, and the neck size. CONCLUSION: Coil embolization is a good alternative treatment option for MCAB aneurysms compared to surgical clipping. Considering the risk factors for major recurrence, the follow-up angiography should continue up to three years after coil embolization.

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Cerebral aneurysms are a silent yet prevalent condition that affects a significant global population. Their development can be attributed to various factors, presentations, and treatment approaches. The importance of selecting the appropriate treatment becomes evident upon diagnosis, as the severity of the disease guides the course of action. Cerebral aneurysms are particularly vulnerable in the circle of Willis and pose a significant concern due to the potential for rupture, which can lead to irreversible consequences, including fatality. The primary objective of this study is to predict the rupture status of cerebral aneurysms. To achieve this, we leverage a comprehensive dataset that incorporates clinical and morphological data extracted from 3D real geometries of previous patients. The aim of this research is to provide valuable insights that can help make informed decisions during the treatment process and potentially save the lives of future patients. Diagnosing and predicting aneurysm rupture based solely on brain scans is a significant challenge with limited reliability, even for experienced physicians. However, by employing statistical methods and machine learning techniques, we can assist physicians in making more confident predictions regarding rupture likelihood and selecting appropriate treatment strategies. To achieve this, we used 5 classification machine learning algorithms and trained them on a substantial database comprising 708 cerebral aneurysms. The dataset comprised 3 clinical features and 35 morphological parameters, including 8 novel morphological features introduced for the first time in this study. Our models demonstrated exceptional performance in predicting cerebral aneurysm rupture, with accuracy ranging from 0.76 to 0.82 and precision score from 0.79 to 0.83 for the test dataset. As the data are sensitive and the condition is critical, recall is prioritized as the more crucial parameter over accuracy and precision, and our models achieved outstanding recall score ranging from 0.85 to 0.92. Overall, the best model was Support Vector Machin with an accuracy and precision of 0.82, recall of 0.92 for the testing dataset and the area under curve of 0.84. The ellipticity index, size ratio, and shape irregularity are pivotal features in predicting aneurysm rupture, respectively, contributing significantly to our understanding of this complex condition. Among the multitude of parameters under investigation, these are particularly important. In this study, the ideal roundness parameter was introduced as a novel consideration and ranked fifth among all 38 parameters. Neck circumference and outlet numbers from the new parameters were also deemed significant contributors.

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OBJECTIVE: A retrospective study of cases of endovascular treatment of dissection of the vertebral artery with subarachnoid hemorrhage was conducted. MATERIAL AND METHODS: Data were 11 cases of vertebral artery dissecting aneurysm (VADA) among 291 consecutive subarachnoid hemorrhage patients who underwent clipping or endovascular treatment at Ota Memorial Hospital. Classified into 4 patterns based on the location of the dissection and posterior inferior cerebellar artery (PICA): pre-PICA, post-PICA, involved PICA, and non-PICA. And one of the cases had bilateral vertebral artery dissection, and computational fluid dynamics analysis was included in the study. RESULTS: Ruptured VADA occurred in 11 of the 291 patients (3.8%). Endovascular treatment was performed in 8 of these 11 patients. Postoperative diffusion-weighted imaging detected no high-intensity lesions and no postoperative ischemic complications or rebleeding occurred in any patient. In a case of bilateral VADA, computational fluid dynamics analysis of very low or high wall shear stress at the dissection, low aneurysm formation indicator, and high oscillatory shear index may be considered rupture factors. CONCLUSIONS: Treatment strategies for each branching pattern of PICA can prevent rupture and avoid ischemic complications. And prediction of the rupture side is important in patients with bilateral dissection to consider the appropriate treatment and timing.

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Subarachnoid hemorrhage due to the A1 segment of an anterior cerebral artery dissecting aneurysm is rare. Therefore, a standard treatment has not been established. Though several case reports of direct surgery exist, there are few reports on endovascular treatment. This is the first study to describe five patients who underwent endovascular treatment for ruptured A1 dissecting aneurysms. Between January 2001 and December 2022 in our affiliated centers, five cases of SAH-onset A1 dissecting aneurysms were treated with endovascular treatment. We describe in detail two representative cases, briefly summarize the other three, and analyze their complications and outcomes. In the five cases, four were female. Four were in their 50s, and one was in her 80s. The WFNS grades were as follows: three were 2, one was 4, and one was 5. No re-ruptures or symptomatic complications were observed. The modified Rankin Scale scores at the time of discharge were as follows; one was 0, one was 1, two were 2, and one was 5. One in five patients needed retreatment after endovascular trapping because of recanalization. Endovascular treatment may be an effective and viable treatment option for ruptured A1 dissecting aneurysms. Further studies are needed to collect detailed data on complications and outcomes.

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BACKGROUND: Contrast enhancement of intracranial aneurysm wall during MRI with targeted visualization of vascular wall correlates with previous aneurysm rupture and, according to some data, may be a predictor of further rupture of unruptured aneurysms. OBJECTIVE: To analyze possible causes of aneurysm contrast enhancement considering morphological data of aneurysm walls. MATERIAL AND METHODS: The study included 44 patients with intracranial aneurysms who underwent preoperative MRI between November 2020 and September 2022. Each aneurysm was assessed regarding contrast enhancement pattern. Microsurgical treatment of aneurysm was accompanied by resection of its wall for subsequent histological and immunohistochemical analysis regarding thrombosis, inflammation and neovascularization. Specimens were subjected to histological and immunochemical analysis. Immunohistochemical analysis was valuable to estimate inflammatory markers CD68 and CD3, as well as neurovascularization marker SD31. RESULTS: Aneurysms with contrast-enhanced walls were characterized by higher number of CD3+, CD68+, CD31+ cells and parietal clots. Intensity of contrast enhancement correlated with aneurysm wall abnormalities. CONCLUSION: Contrast enhancement of aneurysm wall can characterize various morphological abnormalities.

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A man in his 70s presented with a sudden onset stabbing back pain radiating to the chest and pre-syncopal symptoms. He underwent urgent investigations, including a CT angiogram aorta which did not reveal any abnormalities within the thorax, abdomen or pelvis and no cause of symptoms was identified. After being discharged, he re-presented 2 days later with syncopal episodes, abdominal pain and a significant drop in haemoglobin levels. This time, a CT mesenteric angiogram showed two hepatic artery pseudoaneurysms and a large haemoperitoneum. Following a hepatic artery embolisation, a workup showed that the likely cause of the pseudoaneurysms was a rare first presentation of polyarteritis nodosa. This case highlights the importance of considering the possibility of an aneurysmal rupture, especially when common causes of an acute abdomen have been excluded, and not relying on previous negative investigations to exclude pathology, as the outcomes can be detrimental.

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Giant ruptured distal anterior cerebral artery aneurysms are rare, challenging pathologies that may require a combination of microsurgical and endovascular techniques for optimal treatment [1-9]. We describe the case of a female in her 40 s who presented with a Hunt-Hess 4, Fisher 4 subarachnoid hemorrhage from a multiply ruptured, giant distal anterior cerebral artery aneurysm. The patient underwent coil and n-BCA glue embolization of the aneurysm and its feeding A2 anterior cerebral artery. She subsequently underwent decompressive craniectomy, intracerebral hematoma evacuation, and microsurgical trapping and resection of the aneurysm. Postoperative imaging demonstrated no further aneurysm filling, complete hematoma evacuation, and good decompression. The technical considerations and literature for the combined treatment of large and giant ruptured aneurysms are reviewed. The case presentation, operative nuances, and postoperative course with imaging are reviewed with detailed anatomical diagrams to orient the viewer. The patient consented to the procedure and to the publication of her imaging.

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