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The role of a low-profile visualized intraluminal support stent (LVIS) and Enterprise in the treatment of unruptured intracranial aneurysms is well established. Although previous studies have investigated one single type of stent for the treatment of ruptured intracranial aneurysms (RIA), the safety and efficacy between the two types of stents has not been fully explored. Herein we conducted a study to compare the outcomes of the two stents for treatment of RIA. This is a prospective registry database of aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to a single institution between 2018 and 2021. We collected patient baseline information, secondary complications, follow-up angiographic data, long-term prognostic outcomes, and conducted propensity score matching (PSM) analysis with 1:1 ratio and a multivariable logistic regression to compare the outcomes of the two types of stents. A total of 231 patients with RIAs were included in this study, with 108 treated using the LVIS device and 123 treated using the Enterprise device. Before PSM analysis, only the incidence of poor prognosis after 12 months was higher in the Enterprise group comparing to the LVIS group (20% vs. 10%, P = 0.049). After PSM analysis, there was a higher occurrence of delayed cerebral ischemia (DCI) in the Enterprise group compared to the LVIS group (odds ratio [OR] 3.95, 95% confidence interval [CI] [1.20-13.01], P = 0.024). However, no significant difference in prognosis was observed after PSM adjustment. Furthermore, subgroup analysis revealed that patients with female (P = 0.019), hypertension (P = 0.048), and anterior circulation aneurysms (P = 0.019) receiving the Enterprise device had a higher risk of DCI. The overall efficacy of LVIS and Enterprise in the treatment of RIA is comparable, while the incidence of DCI in the LVIS group is lower than that in the Enterprise group after PSM analysis. Registration number: NCT05738083 ( https://clinicaltrials.gov/ ).

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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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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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In aneurysmal subarachnoid hemorrhage, the highest therapeutic priority is to ensure immediate hemostasis without intraprocedural complications. This article outlines the possible intraoperative coil embolization complications for ruptured intracranial aneurysms and discuss strategies for their prevention and treatment.

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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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Regarding intracranial aneurysm treatment, the clip versus coil debate remains inconclusive and lacking studies in Brazil. To examine trends in the management of intracranial aneurysms in Brazil over time, both ruptured and unruptured. A descriptive and exploratory study was conducted based on data of neurovascular procedures for aneurysm treatment using the Brazilian Public Health System database (DATASUS). The variables analyzed were the number of procedures, mortality rates, length of hospital stays, and global costs of hospitalization, from 2010 to 2019. Temporal trend analysis and statistical comparisons were conducted to assess changes over time and differences between the treatment options. The mean annual number of aneurysm treatments with endovascular embolization was 2206.30 (± 309.5), with a non-significant increasing trend (B = 55.66; p = 0.104). Conversely, microsurgical clipping exhibited a significant decreasing trend (B = -69.97; p < 0.001) with a mean of 1133.1 (± 223.12) procedures. The mortality rate associated with clipping procedure was higher in the period, with a mean difference of 5.23 (± 0.39); ([CI95%: 4.36; 6.10]; p < 0.001) and showed an increase trend, while embolization showed a stable trend. The length of in-hospital stay remained stable for clipping but increased for embolization. Costs associated with clipping increased over time, whereas costs for embolization decreased. This study highlights a significant shift in the treatment of aneurysm towards Endovascular Embolization. Despite higher costs, endovascular procedures were associated with lower mortality rates and shorter hospital stays. These findings provide valuable insights into aneurysm treatment patterns and indicators in a middle-income country's Public Health System.

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Background and Objectives: Aneurysmal subarachnoid hemorrhage (ASAH) is defined as bleeding in the subarachnoid space caused by the rupture of a cerebral aneurysm. About 11% of people who develop ASAH die before receiving medical treatment, and 40% of patients die within four weeks of being admitted to hospital. There are limited data on single-center experiences analyzing intrahospital mortality in ASAH patients treated with an endovascular approach. Given that, we wanted to share our experience and explore the risk factors that influence intrahospital mortality in patients with ruptured intracranial aneurysms treated with endovascular coil embolization. Materials and Methods: Our study was designed as a clinical, observational, retrospective cross-sectional study. It was performed at the Department for Radiology, University Clinical Center Kragujevac in Kragujevac, Serbia. The study inclusion criteria were ≥18 years, admitted within 24 h of symptoms onset, acute SAH diagnosed on CT, aneurysm on DSA, and treated by endovascular coil embolization from January 2014 to December 2018 at our institution. Results: A total of 66 patients were included in the study-48 (72.7%) women and 18 (27.3%) men, and 19.7% of the patients died during hospitalization. After adjustment, the following factors were associated with in-hospital mortality: a delayed ischemic neurological deficit, the presence of blood in the fourth cerebral ventricle, and an elevated urea value after endovascular intervention, increasing the chances of mortality by 16.3, 12, and 12.6 times. Conclusions: Delayed cerebral ischemia and intraventricular hemorrhage on initial head CT scan are strong predictors of intrahospital mortality in ASAH patients. Also, it is important to monitor kidney function and urea levels in ASAH patients, considering that elevated urea values after endovascular aneurysm embolization have been shown to be a significant risk factor for intrahospital mortality.

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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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With the popularization of cerebrovascular imaging technology, the clinical detection rate of unruptured intracranial aneurysm (UIA) is increasing. UIA has a low risk of rupture, but once ruptured, it can seriously affect human health. The treatment of UIA is highly controversial and has attracted widespread clinical attention. The Society of Neurosurgery of the Chinese Medical Association, the Society of Cerebrovascular Surgery of the Chinese Stroke Association, the National Center for Neurological Diseases, and the National Center for Clinical Research on Neurological Diseases jointly formulate "Chinese guideline for the clinical management of patients with unruptured intracranial aneurysm management (2024)", which adopts a modular format, highlighting management recommendations and indicating current research deficiencies and future research directions. It provides comprehensive clinical management recommendations on UIA epidemiology, population screening, clinical imaging and diagnosis, rupture risk assessment, treatment decisions and choices, postoperative follow-up, and long-term management. The evidence sources are divided into the Chinese population and other populations, which helps guide clinical practice in China.

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Unruptured intracranial aneurysm (UIA) has an estimated prevalence of about 7% among adults aged 35-75 in China. With the aging population trend, the detection rate of UIA is increasing. Most UIA are incidentally discovered and typically asymptomatic. There has been ongoing debate regarding the choice between aggressive treatment and conservative management. Although UIA has a low annual risk of rupture, once rupture occurs, the mortality and disability rates are high. Based on evidence-based medicine, this clinical management guideline provides 44 recommendations on population screening, clinical imaging diagnosis, risk assessment of growth and rupture, treatment strategies and selection, postoperative follow-up, and management of special populations with UIA. Aiming to provide clinical guidance for clinical doenrs and relevant professionals.

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Subarachnoid hemorrhage caused by intracranial aneurysm (aneurysmal subarachnoid hemorrhage,aSAH) poses a significant threat to the health of the Chinese people. The prognosis of aSAH patients is poor, with a mortality of up to 50%, which is a public health problem in China. The clinical evaluation, surgical ctrategies, and perioperative management are important parts of clinical management for aSAH patients. This clinical management guideline consists of 112 recommendations on epidemiology, clinical imaging diagnosis, prognosis evaluation, treatment strategies and selection, anesthesia management, perioperative care, and management of special populations with aSAH, aiming to provide clinical guidance for clinical doctors and related professionals.

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Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening neurological emergency with high mortality, and even patients receiving optimal medical care may develop long-term disability, which seriously affects their quality of life and increases the heavy medical burden on society and families. To provide comprehensive clinical management advice, the Society of Neurosurgery of the Chinese Medical Association, the Society of the Chinese Stroke Association of the National Medical Center for Neurological Diseases, and the National Clinical Research Center for Neurological Diseases jointly formulate "Chinese Guidelines for the Clinical Management of Patients With Ruptured Intracranial Aneurysms in 2024". The evidence sources are divided into the Chinese population and other populations, using a modular format to provide recommendations, summaries of relevant opinions, and future research directions on epidemiology, clinical imaging diagnosis, prognosis evaluation, treatment strategies and choices, anesthesia management, perioperative care, and recommendations for the management of aSAH in special populations. It provides practical clinical guidance and recommendations for doctors and related professionals.

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BACKGROUND: To analyze the outcomes of clipping and coiling for ruptured intracranial aneurysms (RIAs) based on data from the National Health Insurance Service in South Korea, with a focus on variations according to region and hospital size. METHODS: This study analyzed the one-year mortality rates for patients with RIAs who underwent clipping or coiling in 2018. Coiling was further categorized into non-stent assisted coiling (NSAC) and stent assisted coiling (SAC). Hospitals were classified as tertiary referral general hospitals (TRGHs), general hospitals (GHs), or semi-general hospitals (sGHs) based on size. South Korea's administrative districts were divided into 15 regions for analysis. RESULTS: In 2018, there were 2,194 (33.1%) clipping procedures (TRGH, 985; GH, 827; sGH, 382) and 4,431 (66.9%) coiling procedures (TRGH, 1,642; GH, 2076; sGH, 713) performed for RIAs treatment. Among hospitals performing more than 20 treatments, the one-year mortality rates following clipping or coiling were 11.2% and 16.0%, respectively, with no significant difference observed. However, there was a significant difference in one-year mortality between NSAC and SAC (14.3% vs. 19.5%, P = 0.034), with clipping also showing significantly lower mortality compared to SAC (P = 0.019). No significant differences in other treatment modalities were observed according to hospital size, but clipping at TRGHs had significantly lower mortality than at GHs (P = 0.042). While no significant correlation was found between the number of treatments and outcomes at GHs, at TRGHs, a higher volume of clipping procedures was significantly associated with lower total mortality (P = 0.023) and mortality after clipping (P = 0.022). CONCLUSION: Using Korea NHIS data, mortality rates for RIAs showed no significant variation by hospital size due to coiling's prevalence. However, differences in clipping outcomes by hospital size and volume in TRGH highlight the need for national efforts to improve clipping skills and standardization. Additionally, the higher mortality rate with SAC emphasizes the importance of precise indications for its application.

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It has been shown that living alone is one of the risk factors for unfavorable outcomes in ischemic stroke patients, mostly due to delay in receiving appropriate treatment. A single-center retrospective observational study was conducted to evaluate whether living alone was associated with unfavorable outcomes in aneurysmal subarachnoid hemorrhage (SAH) patients. Among 451 SAH patients admitted to our institution between January 2013 and December 2022, 43 patients who lived alone had sustained SAH at home (group A) and 329 patients who lived with family had sustained SAH at home (group F). The mortality rate (46.5% vs. 29.8%, p = 0.04) and a tendency for having unfavorable outcomes were higher in group A than in group F. The incidence of concomitant hydrocephalus was significantly higher in the former (37.2% vs. 21.3%, p = 0.03). Group A was further classified to the Able to Call (n = 15, group AC) and Unable to Call (n = 28, group UC) subgroups based on their ability to call for help by themselves. Group AC tended to have favorable outcomes (27% vs. 4%, p = 0.04). Treatment to obliterate a ruptured aneurysm had particularly been challenging in group UC, in which the accurate time of onset often remained unidentifiable: Their overall mortality was as high as 57% and their capability to undergo surgical/interventional treatment was only 67%. Perioperative complications resulting from delayed presentation had been common. Considering the present finding that most of those who lived alone could not call for help, further effort is warranted to facilitate early detection of those patients.

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PURPOSE: Despite growing evidence for the effectiveness of stent-assisted coil embolization (SAC) in treating acutely ruptured aneurysms, the safety of stent placement in acute phase remains controversial because of concerns for stent-induced thromboembolism and hemorrhagic events attributable to the necessity of antiplatelet therapy. Therefore, we investigated the safety and efficacy of SAC with periprocedural dual antiplatelet therapy (DAPT) compared with the coiling-only technique to determine whether it is a promising treatment strategy for ruptured aneurysms. METHODS: We retrospectively evaluated 203 enrolled patients with acutely ruptured aneurysms, categorizing them into two groups: SAC and coiling-only groups. Comparative analyses between the two groups regarding angiographic results, clinical outcomes, and procedure-related complications were performed. A subgroup analysis of procedural complications was conducted on patients who did not receive chronic antithrombotic medications to alleviate their influence before hospitalization. RESULTS: 130 (64.0%) patients were treated using the coiling-only technique, whereas 73 (36.0%) underwent SAC. There was a trend to a higher complete obliteration rate (p = 0.061) and significantly lower recanalization rate (p = 0.030) at angiographic follow-up in the SAC group compared to the coiling-only group. Postprocedural cerebral infarction occurred less frequently in the SAC group (8.2%) than in the coiling-only group (17.7%), showing a significant difference (p = 0.044). Although the ventriculostomy-related hemorrhage rate was significantly higher in the SAC group than in the coiling-only group (26.2% vs. 9.3%, p = 0.031), the incidence of symptomatic ventriculostomy-related hemorrhage was comparable. Subgroup analysis excluding patients receiving chronic antithrombotic medications showed similar results. CONCLUSION: SAC with periprocedural DAPT could be a safe and effective treatment strategy for acutely ruptured aneurysms. Moreover, it might have a protective effect on postprocedural cerebral infarction without increasing the risk of symptomatic hemorrhagic complications.

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OBJECTIVES: Periodic imaging follow-up for patients with unruptured intracranial aneurysms (UIA) is crucial, as studies indicate higher rupture risk with aneurysm growth. However, few studies address patient adherence to follow-up recommendations. This study aims to identify compliance rates and factors influencing follow-up adherence. METHODS: Patients with a UIA were identified from our institution's database from 2011-2021. Follow-up imaging (CT/MR Angiogram) was advised at specific intervals. Patients were categorized into compliant and non-compliant groups based on first-year compliance. Factors contributing to compliance were assessed through multivariate logistic regression. Phone interviews were conducted with non-compliant patients to understand reasons for non-adherence. RESULTS: Among 923 UIA diagnosed patients, 337 were randomly selected for analysis. The median follow-up period was 1.4 years, with a 42% first-year compliance rate. The mean aneurysm size was 3.3 mm. Five patients had a rupture during follow-up, of which 4 died. Compared with patients consulting specialists at the initial diagnosis, those seen by non-specialists exhibited lower compliance (OR 0.25, p < 0.001). Loss to follow-up was greatest during transition from emergency service to specialist appointments. Patients who spoke languages other than English exhibited poorer compliance than those speaking English (OR 0.20, p = 0.01). CONCLUSIONS: Significant amounts of UIA patients at low rupture risk were lost to follow-up before seeing UIA specialists. Main non-compliance factors include inadequate comprehension of follow-up instructions, poor care transfer from non-specialists to specialist, and insurance barriers.

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BACKGROUND AND IMPORTANCE: Despite technological advances, ruptured wide-necked aneurysms continue to pose a challenge for endovascular management. Comaneci (Rapid Medical) is a relatively new temporary aneurysm neck bridging device to assist in coiling of wide-necked aneurysms without the need for dual antiplatelet therapy or parent vessel flow interruption. Y configuration is often necessary to prevent coil migration in cases of wide-necked aneurysms. Thus far, there have been no reports of using Comaneci device in Y configuration to aid anterior circulation aneurysm treatment. CLINICAL PRESENTATION: A 60-year-old man presented with a Hunt-Hess grade 5, modified Fisher grade 4 subarachnoid hemorrhage from a ruptured wide-necked anterior communicating artery aneurysm with a dome-to-neck ratio of 1:2. Two Comaneci devices were used in a Y configuration to prevent coil prolapse into the contralateral A2 branch. After successful coiling of the aneurysm, both Comaneci devices were collapsed and removed without incident; the coil catheter was also removed without incident. Follow-up angiogram demonstrated successful occlusion of the wide-necked anterior communicating artery aneurysm without the use of a permanent stent or balloon assistance. CONCLUSION: This case represents a first-time report of successfully using 2 Comaneci devices in a Y configuration for the treatment of a ruptured wide-necked anterior circulation aneurysm. This knowledge can potentially further expand the use of double Comaneci devices in Y configuration for the treatment of both anterior and posterior circulation aneurysms.

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BACKGROUND: Intracranial aneurysms (IAs) remain a challenging neurological diagnosis associated with significant morbidity and mortality. There is a plethora of microsurgical and endovascular techniques for the treatment of both ruptured and unruptured aneurysms. There is no definitive consensus as to the best treatment option for this cerebrovascular pathology. The Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts discussed best practices and the most promising approaches to improve the management of brain aneurysms. METHODS: A group of experts from academia, industry, and federal regulators convened to discuss updated clinical trials, scientific research on preclinical system models, management options, screening and monitoring, and promising novel device technologies, aiming to improve the outcomes of patients with IA. RESULTS: Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts suggested the incorporation of artificial intelligence to capture sequential aneurysm growth, identify predictors of rupture, and predict the risk of rupture to guide treatment options. The consensus strongly recommended nationwide systemic data collection of unruptured IA radiographic images for the analysis and development of machine learning algorithms for rupture risk. The consensus supported centers of excellence for preclinical multicenter trials in areas such as genetics, cellular composition, and radiogenomics. Optical coherence tomography and magnetic resonance imaging contrast-enhanced 3T vessel wall imaging are promising technologies; however, more data are needed to define their role in IA management. Ruptured aneurysms are best managed at large volume centers, which should include comprehensive patient management with expertise in microsurgery, endovascular surgery, neurology, and neurocritical care. CONCLUSIONS: Clinical and preclinical studies and scientific research on IA should engage high-volume centers and be conducted in multicenter collaborative efforts. The future of IA diagnosis and monitoring could be enhanced by the incorporation of artificial intelligence and national radiographic and biologic registries. A collaborative effort between academic centers, government regulators, and the device industry is paramount for the adequate management of IA and the advancement of the field.

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BACKGROUND: Extensive research has confirmed the safety and effectiveness of flow diverters in the treatment of unruptured intracranial aneurysms. However, their use in cases of acute rupture remains a subject of debate. METHODS: This study was conducted as a single-center retrospective investigation from January 2018 to January 2022 and included patients with acutely ruptured intracranial aneurysms (within three days of rupture) who were treated using the Pipeline Embolization Device with adjunctive coil embolization. Patient demographics, operative procedures, and outcomes were analyzed. Antiplatelet therapy included intra-arterial tirofiban and postoperative dual therapy with clopidogrel and aspirin. RESULTS: A total of 21 patients (5 males, 16 females) diagnosed with acutely ruptured intracranial aneurysms were included in this study. The aneurysm types included 7 blood blister-like aneurysms (30.0%), 3 dissecting (14.3%), and 1 fusiform aneurysm (4.8%). Perioperative complications occurred in 2 patients (9.5%), and both cases involved thrombogenesis. Nineteen patients completed digital subtraction angiography during follow-up, with an average follow-up time of 8.7 months (5 - 18 months). Results showed a complete embolization rate of 94.7% (18/19), with a partial aneurysm still present in 1 patient. A total of 90.4% (19/21) of patients had a favorable prognosis (modified Rankin Scale score = 0 - 2). CONCLUSIONS: The Pipeline Embolization Device with adjunctive coil embolization proved to be a viable option for managing acutely ruptured intracranial aneurysms, notwithstanding the potential for ischemic complications.

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