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Intracranial Aneurysms: Diagnostics and Current Treatment

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: closed (25 March 2026) | Viewed by 10327

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Special Issue Editors

Dr. Vincenzo Antonelli

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Guest Editor

Department of Neurosurgery, Hospital M. Bufalini—AUSL della Romagna, Cesena, Italy
Interests: neurosurgery; vascular suregry; brain injury; neuroncology, cranial base

Dr. Roberto Colasanti

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Guest Editor

Department of Neurosurgery, Hospital M. Bufalini—AUSL della Romagna, Cesena, Italy
Interests: neurosurgery; vascular suregry; brain Injury; neuroncology; cranial base
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Special Issue Information

Dear Colleagues,

Neurovascular diseases remain one of the leading causes of global morbidity and mortality, thus representing a major public health threat. In the last few decades, various advancements have progressively improved the diagnosis of intracranial aneurysms, as well as their clinical and surgical management. In addition, advancements in artificial intelligence and related technologies could optimize early and precise detection methodologies and enhance treatment algorithms. However, challenges still remain.

The aim of this Special Issue is to highlight the current research and progress for every aspect of the management of intracranial aneurysms (primary and secondary prevention, when possible, diagnostic imaging, acute inpatient care, endovascular and/or surgical treatment, complication management, rehabilitation and recovery, as well as progress in translational science). Our goal is to provide a detailed overview of key discoveries, novel diagnostic and innovative treatment methods and improved application of established approaches, while shedding light on emerging research areas and future perspectives.

We eagerly anticipate contributions on ruptured and un-ruptured aneurysms (e.g., diagnosis, treatment algorithms, current endovascular and surgical management, intensive care, clinical prevention and treatment of vasospasm and other potential complications, postoperative rehabilitation, etc.). In addition, we encourage interdisciplinary collaborations, inviting contributions from neurosurgeons, neuroradiologists, neurologists, neurorehabilitation specialists, and other allied healthcare professionals.

Dr. Vincenzo Antonelli
Dr. Roberto Colasanti
Guest Editors

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Keywords

neurovascular diseases
aneurysms
vascular malformations
diagnostic imaging
minimally invasive approaches
surgical techniques
endovascular interventions
treatment algorithms
subarachnoid hemorrhage
neurorehabiltation

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Published Papers (8 papers)

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Research

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13 pages, 1280 KB

Open AccessArticle

Association of A1 Segment Morphology with the Rupture Risk and Morphology of Anterior Communicating Artery Aneurysms: A Retrospective, Single-Center Study

by Ilhan Aydin, Neslihan Cavusoglu, Berkay Kef, Asya Gokceli, Efecan Cekic, Sahin Hanalioglu, Egemen Gok, Murad Asilturk and Bulent Timur Demirgil

J. Clin. Med. 2026, 15(4), 1376; https://doi.org/10.3390/jcm15041376 - 10 Feb 2026

Viewed by 482

Abstract

Background/Objectives: A1 segment asymmetry, including hypoplasia and aplasia, is a well-recognized anatomical variation associated with altered hemodynamic stress and anterior communicating artery (ACoA) aneurysm formation. However, its influence on subsequent aneurysm rupture risk remains controversial. This study aimed to evaluate the relationship between A1 segment morphology and aneurysm rupture risk, as well as its association with aneurysm size and morphological complexity. Methods: A retrospective single-institution analysis was conducted on 211 patients treated for ACoA aneurysms between June 2016 and March 2025. A1 segment morphology was assessed using digital subtraction angiography and categorized as symmetric, hypoplastic (diameter < 1 mm or <50% of the contralateral vessel), or aplastic. Demographic, clinical, and radiological variables were recorded. Statistical analyses included univariate comparisons with Bonferroni correction for multiple testing and multivariable logistic regression to identify independent predictors of aneurysm rupture. Results: The study population had a mean age of 54.72 ± 10.97 years, with a male-to-female ratio of 1.24:1 (55.5% male, 44.5% female). Symmetric A1 segments were observed in 49.3% of patients, hypoplastic segments in 31.3%, and aplastic segments in 19.4%. No statistically significant association was identified between A1 morphology and aneurysm rupture rates (p = 0.251) or mean aneurysm diameter (p = 0.996). Univariate analysis demonstrated that younger age (p = 0.006), male sex (p = 0.016), and smoking (p = 0.033) were associated with rupture. However, none of these factors, including A1 morphology, remained independent predictors of rupture in the multivariable logistic regression model. Conclusions: Although A1 segment asymmetry is common in patients with ACoA aneurysms, it does not independently influence rupture risk or aneurysm morphology. Our findings suggest that rupture behavior is driven primarily by dynamic hemodynamic factors rather than static anatomical variations. Full article

(This article belongs to the Special Issue Intracranial Aneurysms: Diagnostics and Current Treatment)

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18 pages, 1698 KB

Open AccessArticle

Pitfalls in Intracranial Aneurysm Clipping: How to Avoid and How to Get out of Them

by Lara Brunasso, Biagia La Pira, Rina Di Bonaventura, Carmelo Lucio Sturiale, Enrico Marchese, Giovanni Sabatino and Alessio Albanese

J. Clin. Med. 2025, 14(24), 8794; https://doi.org/10.3390/jcm14248794 - 12 Dec 2025

Cited by 2 | Viewed by 1403

Abstract

Background/Objectives: Surgical clipping remains a fundamental treatment modality for intracranial aneurysms, particularly in complex cases and those not amenable to endovascular approaches. However, it is associated with several technical challenges and potential complications that may compromise patient outcomes. This study aims to identify and analyze the most frequent and critical intraoperative pitfalls encountered during microsurgical clipping. We discuss experience-based strategies for avoiding these complications as well as practical solutions for managing them effectively when they occur. Methods: A retrospective review of our institutional experience with surgically treated intracranial aneurysms is reported. The study includes a comprehensive analysis of complications encountered across a defined series of cases, along with representative clinical cases. Results: Several categories of complications were identified, including aneurysm rupture, incomplete clipping and aneurysm remnant, vessel stenosis and brain ischemia, and new-onset seizures. Specific microsurgical techniques, intraoperative tools (e.g., indocyanine-green angiography, neurophysiological monitoring, micro-Doppler flowmetry evaluation), and decision-making algorithms are discussed to help mitigate these risks. For each scenario, tailored rescue strategies are outlined based on both the literature evidence and our clinical experience. Conclusions: Awareness of the potential pitfalls in aneurysm clipping and a structured approach to their prevention and management are crucial for optimizing surgical outcomes, and for preparing young vascular neurosurgeons. Through a combination of technical refinement and scenario-based preparedness, many complications can be anticipated and effectively addressed. Full article

(This article belongs to the Special Issue Intracranial Aneurysms: Diagnostics and Current Treatment)

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9 pages, 457 KB

Open AccessArticle

Could MR Angio Replace Digital Subtraction Angiography for Verification of Occlusion Rate of Cerebral Aneurysms?

by Rasmus Moldt Holmager, Jonas Jensen, Troels Halfeld Nielsen and Sune Munthe

J. Clin. Med. 2025, 14(22), 8221; https://doi.org/10.3390/jcm14228221 - 20 Nov 2025

Viewed by 822

Abstract

Background/Objectives: Cerebral aneurysms affect 3–5% of the population and carry a risk of rupture. Post-treatment imaging is essential to detect residual or recurrent filling. Digital subtraction angiography (DSA) is the gold standard, but it is invasive and can have complications. Magnetic resonance angiography (MRA) is a non-invasive alternative, but its reliability in follow-up remains debated. This study evaluated the diagnostic performance of MRA compared to DSA in detecting residual flow after endovascular treatment of intracranial aneurysms. Primary outcomes were MRA’s sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) and its potential to reduce or replace DSA in follow-up. Methods: A retrospective single-center study included patients ≥ 18 years treated endovascularly for ruptured or unruptured intracranial aneurysms during 2018–2021. Each follow-up case with both DSA and MRA was independently assessed by neuroradiologists, using DSA as the reference standard. Diagnostic performance metrics were calculated. Results: Of 400 screened cases, 198 were included. MRA and DSA findings agreed in 78.3% of cases. MRA showed 69.7% sensitivity and 80.0% specificity. PPV was 41.1%, and NPV was 93.0%. There were 33 false positives and 10 false negatives. Only one false negative led to retreatment, and none of the false positives required intervention. Conclusions: MRA shows high reliability in ruling out residual aneurysm flow due to its strong NPV. Despite limitations in confirming recurrence, MRA might be a useful first-line follow-up tool, with DSA reserved for inconclusive, unclear, or artifact cases. Full article

(This article belongs to the Special Issue Intracranial Aneurysms: Diagnostics and Current Treatment)

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Review

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12 pages, 424 KB

Open AccessReview

Pharmacokinetic and Pharmacodynamic Profiles of Intravenous and Enteral Nimodipine in Patients with Aneurysmal Subarachnoid Hemorrhage: A Scoping Review

by Marco Sanvitti, Giada Iafrate and Federico Bilotta

J. Clin. Med. 2026, 15(9), 3425; https://doi.org/10.3390/jcm15093425 - 30 Apr 2026

Viewed by 247

Abstract

Background: Nimodipine is routinely used in aneurysmal subarachnoid hemorrhage (aSAH), but the optimal route of administration remains uncertain. Intravenous and enteral delivery differ in pharmacokinetics, yet the clinical relevance of these differences is unclear. This scoping review aimed to map evidence on the pharmacokinetics (PK) and pharmacodynamics (PD) of intravenous and enteral nimodipine and their relationship with clinical outcomes. Methods: A scoping review was conducted following PRISMA-ScR guidelines. PubMed, Scopus, and Web of Science were searched from 1982 to March 2026. Studies in adult aSAH patients reporting PK and/or PD outcomes after intravenous or enteral nimodipine were included. Data were synthesized qualitatively. Results: Twenty studies were included. Intravenous administration provided higher and more consistent systemic exposure, whereas enteral administration showed low and highly variable bioavailability, particularly via nasogastric tubes. Despite these differences, pharmacodynamic effects were not clearly related to systemic concentrations, and hypotension occurred similarly across routes. Evidence on cerebral physiology was limited. Randomized studies showed no significant differences in delayed cerebral ischemia, infarction, or functional outcomes between routes. Conclusions: Pharmacokinetic advantages of intravenous nimodipine do not consistently translate into pharmacodynamic or clinical benefits, although available evidence is limited and heterogeneous. The PK–PD relationship appears weak, and further research is needed to guide optimized administration strategies. Full article

(This article belongs to the Special Issue Intracranial Aneurysms: Diagnostics and Current Treatment)

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14 pages, 1338 KB

Open AccessReview

Mechanisms of Intracranial Aneurysm Rupture: An Integrative Review of Experimental and Clinical Evidence

by Masahiko Itani and Tomohiro Aoki

J. Clin. Med. 2025, 14(22), 8256; https://doi.org/10.3390/jcm14228256 - 20 Nov 2025

Cited by 2 | Viewed by 2796

Abstract

Background: Intracranial aneurysm (IA) rupture is a devastating event in neurosurgery and a leading cause of subarachnoid hemorrhage. Although aneurysm size has been traditionally emphasized, recent research has highlighted multifactorial mechanisms involving hemodynamic stress, wall degeneration, inflammation, and genetic predisposition. Methods: Evidence from animal models, human pathological studies, computational fluid dynamics analyses, genetic association studies, and advanced imaging research was reviewed to provide an integrated view of rupture mechanisms. Results: Morphological and hemodynamic studies have shown that high aspect and size ratios, coupled with low wall shear stress and an elevated oscillatory shear index, contribute to focal wall weakening. Histopathological analyses of ruptured aneurysms consistently reveal endothelial loss, smooth-muscle-cell depletion, extracellular matrix degradation, and intense inflammatory cell infiltration, with patterns such as extremely thin, hypocellular, thrombosis-lined walls. Experimental studies have identified active inflammatory pathways, including neutrophil-driven cascades via CXCL1 signaling and complement C5a–C5aR1 activation, as direct triggers of wall failure. High-resolution vessel-wall magnetic resonance imaging correlates contrast enhancement with histological evidence of inflammation and neovascularization, suggesting its utility as a biomarker of instability. Conclusions: IA rupture is driven by a dynamic interplay between adverse hemodynamic environments, inflammatory degeneration, genetic susceptibility, and pathological vascular remodeling. Integrating these mechanistic insights may improve risk stratification and guide the development of targeted preventive strategies. Full article

(This article belongs to the Special Issue Intracranial Aneurysms: Diagnostics and Current Treatment)

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17 pages, 4644 KB

Open AccessReview

Fibromuscular Dysplasia and Intracranial Aneurysms: A Narrative Review of a Dangerous and Underestimated Association

by Marialuisa Zedde, Maria Simona Stoenoiu, Alexandre Persu and Rosario Pascarella

J. Clin. Med. 2025, 14(22), 8080; https://doi.org/10.3390/jcm14228080 - 14 Nov 2025

Viewed by 1356

Abstract

Background: Fibromuscular dysplasia (FMD) is a non-inflammatory vascular disorder that affects medium and large arteries, with a notable association with intracranial aneurysms (IAs). This review aims to assess the prevalence, characteristics, and implications of IAs in patients with FMD, highlighting gaps in current knowledge and the need for further research. Methods: A comprehensive literature search was conducted on PubMed using keywords related to FMD and intracranial aneurysms. The search focused on studies published over the last 28 years, identifying relevant data on the prevalence and morphological features of IAs in FMD patients. Due to the limited quality and availability of information, a narrative review format was adopted to synthesize findings. Results: The review found that the prevalence of IAs in FMD patients is significantly higher than in the general population, with estimates varying widely (4.7–21.7%). The majority of patients identified with IAs were female, and the age range of affected individuals varied significantly. Key risk factors for aneurysm formation included hypertension, smoking, and the presence of multifocal or multisite FMD. Notably, the study indicated that routine screening for IAs in FMD patients has to be weighted with the relatively low prevalence of asymptomatic IAs and the risk-to-benefit ratio of treatment in older patients. Conclusions: The association between FMD and intracranial aneurysms is significant, and timely detection of these aneurysms may allow preventing subarachnoid hemorrhage, whose fatality rate is high. Identification of subgroups where the screening may be cost-effective, also considering the impact of the awareness to have an IA without treatment proposal, is warranted. Further research is essential to clarify the relationship between FMD and IAs, optimize screening protocols, and improve outcomes for affected patients. The findings underscore the importance of ongoing registries to enhance understanding of the natural history and treatment of IAs in the context of FMD. Full article

(This article belongs to the Special Issue Intracranial Aneurysms: Diagnostics and Current Treatment)

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Other

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20 pages, 1829 KB

Open AccessSystematic Review

Inter-Rater Reliability of Subarachnoid Hemorrhage Radiological Grading Scales: A Systematic Review and Meta-Analysis

by Daria Dmitrievna Dolotova, Tatyana Alexandrovna Solominova, Natalia Alexeevna Polunina, Evgenia Romanovna Blagosklonova, Natalya Sergeevna Plyusova, Ganipa Ramazanovich Ramazanov, Rustam Shakhismailovich Muslimov, Maxim Vladimirovich Solominov and Andrey Vasilevich Gavrilov

J. Clin. Med. 2026, 15(8), 2899; https://doi.org/10.3390/jcm15082899 - 10 Apr 2026

Viewed by 385

Abstract

Background: Subarachnoid hemorrhage (SAH) has high mortality and disability rates. The timely and precise assessment of SAH severity is of critical importance in predicting life-threatening complications. Several CT-based radiological grading systems have been proposed, but a comprehensive meta-analysis of their inter-rater reliability (IRR) has not been conducted. Methods: This study followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two authors performed a systematic search of original articles in the PubMed database. Methodological quality of the studies was assessed using the Quality Appraisal of Reliability Studies (QAREL). Meta-analyses of Cohen’s kappa and intra-class correlation coefficient (ICC) were performed using R packages “metafor” and “meta”. Results: A systematic literature analysis was performed for twenty articles that met the inclusion criteria. The methodological quality was moderate in 14 of 20 studies; five studies were of low quality. Only eight articles were suitable for meta-analysis. Cohen’s kappa of the binarized Fisher scale was 0.85 (95% CI 0.70–0.93), though it was based on only two studies and 109 patients. The Hijdra scale had an ICC of 0.75 (95% CI 0.29–0.93). The original and modified Graeb scales proposed for the assessment of concomitant intra-ventricular hemorrhage demonstrated ICC of 0.83 (95% CI 0.59–0.94) and 0.93 (95% CI 0.84–0.97), respectively. For other scales, meta-analysis was not possible due to incomplete reporting or single evaluations. Conclusions: The current evidence on IRR of radiological grading scales for SAH is limited, emphasizing the need for further high-quality research to validate their reliability and clinical applicability. Full article

(This article belongs to the Special Issue Intracranial Aneurysms: Diagnostics and Current Treatment)

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16 pages, 4980 KB

Open AccessCase Report

Complex Anatomy, Advanced Techniques: Microsurgical Clipping of a Ruptured Hypophyseal Artery Aneurysm

by Corneliu Toader, Matei Serban, Nicolaie Dobrin, Razvan-Adrian Covache-Busuioc, Mugurel Petrinel Radoi, Alexandru Vlad Ciurea and Octavian Munteanu

J. Clin. Med. 2025, 14(7), 2361; https://doi.org/10.3390/jcm14072361 - 29 Mar 2025

Cited by 11 | Viewed by 2116

Abstract

Background: Ruptured intracranial aneurysms remain the subject of debate in their management, but the management of lesions located at high-risk locations, such as the hypophyseal artery, continue to prove to be a challenge in anatomical orientation and proximity to vascular structures. While endovascular therapies have changed the treatment paradigms, microsurgical clipping is the gold standard for wide-necked aneurysms for which endovascular techniques may be suboptimal. The successful treatment of a ruptured hypophyseal artery aneurysm in an elderly patient is described in this report, which highlights the importance of advanced imaging, careful technique, and new understanding of personalized aneurysm management. Methods: An 82-year-old woman was admitted with a thunderclap headache, alteration of consciousness and meningeal signs, suggestive of subarachnoid hemorrhage (SAH). A non-contrast computed tomography (CT) and digital subtraction angiography (DSA) confirmed a saccular 12 × 10 mm aneurysm with a broad 3.13 mm neck arising from the hypophyseal artery. The location and morphology of the aneurysm required microsurgical clipping, which was performed through a right pterional craniotomy. Results: Correct clip placement, complete exclusion of the aneurysm, and resorption of the subarachnoid blood were both observed on postoperative imaging. The neurological examination was completely normal, with no complications. Follow-up imaging at three months demonstrated stable, marked cerebral atrophy with compensatory ventricular enlargement without evidence of recurrence. Conclusions: This case illustrates the important role of micro-surgical clipping in anatomically complex aneurysms and its sustainable outcome and accuracy in cases where endovascular practices would have limitations. Advanced imaging, like three-dimensional DSA and intraoperative tools, have revolutionized precision surgery, allowing achievement of optimal outcomes, even for more-complicated cases. With an evolving, dynamic field and exciting new technologies coming to the fore—such as artificial intelligence to predict rupture risk and augmented reality navigation—decision-making and treatment of complex aneurysms will be optimized along secure pathways towards tailored, high-resolution treatment in the sense of personalized and yet high-precision care. Full article

(This article belongs to the Special Issue Intracranial Aneurysms: Diagnostics and Current Treatment)

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