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Clinical Advances in Cerebral Aneurysm 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 December 2023) | Viewed by 19783

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Prof. Dr. Ramazan Jabbarli

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Department of Neurosurgery & Spine Surgery, University Hospital Essen, 45147 Essen, Germany
Interests: cerebral aneurysms; subarachnoid hemorrhage; arteriovenous malformations; neuro-oncology; spine surgery

Special Issue Information

Dear Colleagues,

The prevalence of cerebral aneurysms (CA) in the healthy adult population is relatively low at 2–3%. At the same time, CA are of high clinicoepidemiological relevance, linked with the risk of hemorrhagic stroke in the case of CA rupture, affecting mostly individuals in their mid-fifties. The resulting subarachnoid hemorrhage (SAH) is known for its substantial morbidity and mortality. Despite considerable achievements in neurocritical care in recent decades, certain complications of SAH contribute to poor outcome in over half of diseased individuals. This circumstance necessitates further improvements in management and prevention of secondary complications of SAH, as well as timely identification and prophylactic treatment of individuals with rupture-prone CA. As interventional (endovascular or microsurgical) closure of CA is associated with certain treatment-related morbidity, proper risk–benefit assessment requires more precise knowledge on individual risk factors for CA rupture.

This Special Issue of the Journal of Clinical Medicine will cover the following important aspects of CA management prior and after CA rupture:

Prognostic factors for CA development, growth, and rupture;
Risk–benefit assessment for the treatment of unruptured CA;
Advances in conservative and invasive management of unruptured CA;
Initial severity of SAH and early complications after CA rupture;
Diagnosis and treatment of cerebral vasospasm and delayed cerebral ischemia;
Management of intracranial pressure after SAH;
Acute and chronic hydrocephalus after SAH;
Systemic complications during and neurocritical care management of SAH;
Treating CA in the era of digital technologies: the value of artificial intelligence for the optimization of CA treatment.

Prof. Dr. Ramazan Jabbarli
Guest Editor

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

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Keywords

cerebral aneurysms
subarachnoid hemorrhage
infarct, outcome
risk factors
coiling
clipping

Published Papers (11 papers)

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Editorial

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4 pages, 173 KiB

Open AccessEditorial

Addressing Challenges in Cerebral Aneurysm Management: Strategies to Enhance Patient Outcomes

by Ramazan Jabbarli

J. Clin. Med. 2024, 13(8), 2308; https://doi.org/10.3390/jcm13082308 - 16 Apr 2024

Viewed by 202

Abstract

We are pleased to present a Special Issue dedicated to addressing the current challenges in the management of cerebral aneurysms (CA) [...] Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

Research

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12 pages, 2394 KiB

Open AccessArticle

Retrospective Application of Risk Scores to Unruptured Anterior Communicating Artery Aneurysms

by Katarzyna Wójtowicz, Lukasz Przepiorka, Sławomir Kujawski, Edyta Maj, Andrzej Marchel and Przemysław Kunert

J. Clin. Med. 2024, 13(3), 789; https://doi.org/10.3390/jcm13030789 - 30 Jan 2024

Viewed by 579

Abstract

Background: Treatment decisions for unruptured intracranial aneurysms (UIAs) pose a challenge for neurosurgeons, prompting the development of clinical scales assessing hemorrhage risk to provide management guidance. This study compares recommendations from the PHASES and UIA treatment scores (UIATS) applied to anterior communicating artery (AComA) UIAs against real-world management. Methods: While UIATS recommends management, for PHASES, an aneurysm with score of 10 or more was considered “high-risk”. Analysis involved assessing the concordance in each group alongside comparison to real-word management. Results: Among 129 patients, 46.5% were observed and 53.5% were treated. PHASES scores were significantly higher in the treatment group (p = 0.00002), and UIATS recommendations correlated with real-world decisions (p < 0.001). We observed no difference in the frequencies of UIATS recommendations between high- and low-risk groups. When comparing the UIATS and PHASES, 33% of high-risk aneurysms received a UIATS conservative management recommendation. In 39% of high-risk aneurysms, the UIATS recommendation was not definitive. Conversely, 27% of low-risk aneurysms obtained a UIATS UIA repair recommendation. Overall, concordance between PHASES and UIATS was 32%. Conclusions: Significant discordance in therapeutic suggestions underscores the predominant influence of center experience and individual assessments. Future studies should refine and validate decision-making strategies, potentially exploring alternative applications or developing tailored scales. Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

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10 pages, 1102 KiB

Open AccessArticle

Unruptured Anterior Communicating Artery Aneurysms: Management Strategy and Results of a Single-Center Experience

by Katarzyna Wójtowicz, Lukasz Przepiorka, Sławomir Kujawski, Andrzej Marchel and Przemysław Kunert

J. Clin. Med. 2023, 12(14), 4619; https://doi.org/10.3390/jcm12144619 - 11 Jul 2023

Cited by 2 | Viewed by 1211

Abstract

Although anterior communicating artery (AComA) unruptured intracranial aneurysms (UIAs) comprise one of the largest aneurysm subgroups, their complex adjacent neurovasculature and increased risk of rupture impede optimal management. In the present study, we analyzed the results of our diverse strategy in AComA UIAs with the additional goal of assessing the risk of treatment and the incidence of hemorrhage. We analyzed 131 patients, of which each was assessed by a multidisciplinary neurovascular team and assigned to observation (45.8%), endovascular treatment (34.4%) or microsurgery (19.8%). Median aneurysm sizes were 3, 7.2 and 7.75 mm, respectively. In the observation group, four (7.1%) aneurysms (initially <5 mm) grew over a median time of 63.5 months and were treated endovascularly. We found that fewer patients in the observation group were smokers (p = 0.021). The aneurysm size ratio was different between the combined treatment versus the observation group (p < 0.0001). Noteworthily, there were no hemorrhages in the observational group. Mortality for all patients with available follow-up was 2.4% (3/124) and permanent morbidity was 1.6% (2/124) over a mean follow-up of 64.2 months. These compelling rates refer to a high-risk group with potentially devastating consequences in which we have decreased the annual risk of hemorrhage to 0.14%. Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

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17 pages, 3335 KiB

Open AccessArticle

Distal Flow Diversion with Anti-Thrombotically Coated and Bare Metal Low-Profile Flow Diverters—A Comparison

by Marie-Sophie Schüngel, Karl-Titus Hoffmann, Erik Weber, Jens Maybaum, Nikolaos Bailis, Maximilian Scheer, Ulf Nestler and Stefan Schob

J. Clin. Med. 2023, 12(7), 2700; https://doi.org/10.3390/jcm12072700 - 04 Apr 2023

Cited by 1 | Viewed by 2188

Abstract

Background and purpose: The establishment of low-profile flow diverting stents (FDS), for example, the Silk Vista Baby (SVB) and the p48MW, facilitated endovascular treatment of peripheral cerebral aneurysms. This study therefore aims to compare the performance and outcomes of the SVB with those of the p48MW HPC, with a special focus on hemodynamic aspects of peripheral segments and bifurcations. Materials and methods: The study cohort comprises 108 patients, who were either treated with the SVB or the p48MW HPC between June 2018 and April 2021. Results: Sixty patients received a SVB and forty-eight patients a p48MW HPC. The SVB was used predominantly in the AcomA-complex, and the p48MW HPC in the MCA bifurcation. Immediately after implantation, significant hemodynamic downgrading (OKM A2-A3, B1-B3, C3) was achieved in 60% in the SVB group vs. 75.1% in the p48MW HPC group. At the second follow-up, after an average of 8.8 and 10.9 months, respectively, OKM D1 was observed in 64.4% of the SVB group vs. 27.3% in the p48MW HPC group. Only 1.7% vs. 6.8% of the aneurysms remained morphologically unaltered (OKM A1). Adverse events with persisting neurologic sequalae at last follow-up were largely comparable in both groups (5.0% vs. 4.2%). Conclusion: Immediately after implantation, the p48MW HPC had a more profound hemodynamic impact than the SVB; however, early complete occlusions were achieved in a greater proportion of lesions after implantation of the uncoated SVB. Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

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12 pages, 1636 KiB

Open AccessArticle

Morphometric Study of the Initial Ventricular Indices to Predict the Complications and Outcome of Aneurysmal Subarachnoid Hemorrhage

by Maryam Said, Meltem Gümüs, Jan Rodemerk, Mehdi Chihi, Laurèl Rauschenbach, Thiemo F. Dinger, Marvin Darkwah Oppong, Yahya Ahmadipour, Philipp Dammann, Karsten H. Wrede, Ulrich Sure and Ramazan Jabbarli

J. Clin. Med. 2023, 12(7), 2585; https://doi.org/10.3390/jcm12072585 - 29 Mar 2023

Viewed by 1102

Abstract

Objective: Acute hydrocephalus is a common complication in patients with aneurysmal subarachnoid hemorrhage (SAH). Several ventricular indices have been introduced to enable measurements of ventricular morphology. Previously, researchers have showed their diagnostic value for various neurological disorders. In this study, we evaluated the association between ventricular indices and the clinical course, occurrence of complications and outcome of SAH. Methods: A total of 745 SAH patients with available early admission computed tomography scans were included in the analyses. Six ventricular indices (bifrontal, bicaudate, ventricular and third ventricle ratios and Evans’ and Huckman’s indices) were measured. Primary endpoints included the occurrence of cerebral infarctions, in-hospital mortality and a poor outcome at 6 months. Secondary endpoints included different adverse events in the course of SAH. Clinically relevant cut-offs for the indices were determined using receiver operating curves. Univariate analyses were performed. Multivariate analyses were conducted on significant findings in a stepwise backward regression model. Results: The higher the values of the ventricular indices were and the older the patient was, the higher the WFNS and Fisher’s scores were, and the lower the SEBES score was at admission. Patients with larger ventricles showed a shorter duration of intracranial pressure increase > 20 mmHg and required decompressive craniectomy less frequently. Ventricular indices were independently associated with the parameters of inflammatory response after SAH (C-reactive protein in serum and interleukin-6 in cerebrospinal fluid and fever). Finally, there were independent correlations between larger ventricles and all the primary endpoints. Conclusions: The lower risk of intracranial pressure increase and absence of an association with vasospasm or systemic infections during SAH, and the poorer outcome in individuals with larger ventricles might be related to a more pronounced neuroinflammatory response after aneurysmal bleeding. These observations might be helpful in the development of specific medical and surgical treatment strategies for SAH patients depending on the initial ventricle measurements. Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

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12 pages, 541 KiB

Open AccessArticle

Aneurysmal Subarachnoid Hemorrhage in Hospitalized Patients on Anticoagulants—A Two Center Matched Case-Control Study

by Michael Veldeman, Tobias Rossmann, Miriam Weiss, Catharina Conzen-Dilger, Miikka Korja, Anke Hoellig, Jyri J. Virta, Jarno Satopää, Teemu Luostarinen, Hans Clusmann, Mika Niemelä and Rahul Raj

J. Clin. Med. 2023, 12(4), 1476; https://doi.org/10.3390/jcm12041476 - 13 Feb 2023

Cited by 1 | Viewed by 1988

Abstract

Objective—Direct oral anticoagulants (DOAC) are replacing vitamin K antagonists (VKA) for the prevention of ischemic stroke and venous thromboembolism. We set out to assess the effect of prior treatment with DOAC and VKA in patients with aneurysmal subarachnoid hemorrhage (SAH). Methods—Consecutive SAH patients treated at two (Aachen, Germany and Helsinki, Finland) university hospitals were considered for inclusion. To assess the association between anticoagulant treatments on SAH severity measure by modified Fisher grading (mFisher) and outcome as measured by the Glasgow outcome scale (GOS, 6 months), DOAC- and VKA-treated patients were compared against age- and sex-matched SAH controls without anticoagulants. Results—During the inclusion timeframes, 964 SAH patients were treated in both centers. At the time point of aneurysm rupture, nine patients (0.93%) were on DOAC treatment, and 15 (1.6%) patients were on VKA. These were matched to 34 and 55 SAH age- and sex-matched controls, re-spectively. Overall, 55.6% of DOAC-treated patients suffered poor-grade (WFNS_4–5) SAH compared to 38.2% among their respective controls (p = 0.35); 53.3% of patients on VKA suffered poor-grade SAH compared to 36.4% in their respective controls (p = 0.23). Neither treatment with DOAC (aOR 2.70, 95%CI 0.30 to 24.23; p = 0.38), nor VKA (aOR 2.78, 95%CI 0.63 to 12.23; p = 0.18) were inde-pendently associated with unfavorable outcome (GOS_1–3) after 12 months. Conclusions—Iatrogenic coagulopathy caused by DOAC or VKA was not associated with more severe radiological or clinical subarachnoid hemorrhage or worse clinical outcome in hospitalized SAH patients. Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

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13 pages, 1282 KiB

Open AccessArticle

Impact of Anemia Severity on the Outcome of an Aneurysmal Subarachnoid Hemorrhage

by Maryam Said, Thiemo Florin Dinger, Meltem Gümüs, Laurèl Rauschenbach, Mehdi Chihi, Jan Rodemerk, Veronika Lenz, Marvin Darkwah Oppong, Anne-Kathrin Uerschels, Philipp Dammann, Karsten Henning Wrede, Ulrich Sure and Ramazan Jabbarli

J. Clin. Med. 2022, 11(21), 6258; https://doi.org/10.3390/jcm11216258 - 24 Oct 2022

Cited by 2 | Viewed by 1326

Abstract

Objective: Previous reports indicate a negative impact of anemia on the outcome of an aneurysmal subarachnoid hemorrhage (SAH). We aimed to identify the outcome-relevant severity of post-SAH anemia. Methods: SAH cases treated at our institution between 01/2005 and 06/2016 were included (n = 640). The onset, duration, and severity (nadir hemoglobin (nHB) level) of anemia during the initial hospital stay were recorded. Study endpoints were new cerebral infarctions, a poor outcome six months post-SAH (modified Rankin scale > 3), and in-hospital mortality. To assess independent associations with the study endpoints, different multivariable regression models were performed, adjusted for relevant patient and baseline SAH characteristics as well as anemia-associated clinical events during the SAH. Results: The rates of anemia were 83.3%, 67.7%, 40.0%, 15.9%, and 4.5% for an nHB < 11 g/dL, < 10 g/dL, < 9 g/dL, < 8 g/dL, and < 7 g/dL, respectively. The higher the anemia severity, the later was the onset (post-SAH days 2, 4, 5.4, 7.6 and 8, p < 0.0001) and the shorter the duration (8 days, 6 days, 4 days, 3 days, and 2 days, p < 0.0001) of anemia. In the final multivariable analysis, only an nHB < 9 g/dL was independently associated with all study endpoints: adjusted odds ratio 1.7/3.22/2.44 for cerebral infarctions/in-hospital mortality/poor outcome. The timing (post-SAH day 3.9 vs. 6, p = 0.001) and duration (3 vs. 5 days, p = 0.041) of anemia with an nHB < 9 g/dL showed inverse associations with the risk of in-hospital mortality, but not with other study endpoints. Conclusions: Anemia is very common in SAH patients affecting four of five individuals during their hospital stay. An nHB decline to < 9 g/dL was strongly associated with all study endpoints, independent of baseline characteristics and SAH-related clinical events. Our data encourage further prospective evaluations of the value of different transfusion strategies in the functional outcomes of SAH patients. Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

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8 pages, 853 KiB

Open AccessArticle

Invasive Diagnostic and Therapeutic Management of Cerebral VasoSpasm after Aneurysmal Subarachnoid Hemorrhage (IMCVS)—A Phase 2 Randomized Controlled Trial

by Hartmut Vatter, Erdem Güresir, Ralph König, Gregor Durner, Rolf Kalff, Patrick Schuss, Thomas E. Mayer, Jürgen Konczalla, Elke Hattingen, Volker Seifert and Joachim Berkefeld

J. Clin. Med. 2022, 11(20), 6197; https://doi.org/10.3390/jcm11206197 - 20 Oct 2022

Cited by 7 | Viewed by 4593

Abstract

Cerebral vasospasm (CVS) is associated with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH). The most frequently used form of rescue therapy for CVS is invasive endovascular therapy. Due to a lack of prospective data, we performed a prospective randomized multicenter trial (NCT01400360). A total of 34 patients in three centers were randomized to invasive endovascular treatment or conservative therapy at diagnosis of relevant CVS onset. Imaging data was assessed by a neuroradiologist blinded for treatment allocation. Primary outcome measure was development of DCI. Secondary endpoints included clinical outcome at 6 months after SAH. A total of 18 of the 34 patients were treated conservatively, and 16 patients were treated with invasive endovascular treatment for CVS. There was no statistical difference in the rate of cerebral infarctions either at initial or at the follow-up MRI between the groups. However, the outcome at 6 months was better in patients treated conservatively (mRs 2 ± 1.5 vs. 4 ± 1.8, p = 0.005). Invasive endovascular treatment for CVS does not lead to a lower rate of DCI but might lead to poorer outcomes compared to induced hypertension. The potential benefits of endovascular treatment for CVS need to be addressed in further studies, searching for a subgroup of patients who may benefit. Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

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7 pages, 215 KiB

Open AccessArticle

Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage: The Results of Induced Hypertension Only after the IMCVS Trial—A Prospective Cohort Study

by Erdem Güresir, Thomas Welchowski, Tim Lampmann, Simon Brandecker, Agi Güresir, Johannes Wach, Felix Lehmann, Franziska Dorn, Markus Velten and Hartmut Vatter

J. Clin. Med. 2022, 11(19), 5850; https://doi.org/10.3390/jcm11195850 - 02 Oct 2022

Cited by 5 | Viewed by 1687

Abstract

Delayed cerebral ischemia (DCI) is a predictor of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Treatment strategies vary and include induced hypertension and invasive endovascular treatment. After the IMCVS trial (NCT01400360), which failed to demonstrate a benefit of endovascular treatment for cerebral vasospasm (CVS) and resulted in a significantly worse outcome, we changed our treatment policy in patients with diagnosed CVS to induced hypertension only, and we present our prospective results in the subgroup of SAH patients meeting inclusion criteria of the IMCVS trial. All patients underwent screening for DIND when conscious and for CVS using CT-A/-P at day 6–8 after SAH. In the case of CVS, arterial hypertension was induced and continued until re-assessment. In total, 149 of 303 patients developed CVS. DCI developed in 35 patients (23.5%). In multivariate analyses, CVS was a predictor for the development of new infarctions. Poor admission status, re-bleeding before treatment, and DCI predicted poor outcome. The omittance of invasive endovascular rescue therapies in SAH patients with CVS, additional to induced hypertension, does not lead to a higher rate of DCI. Potential benefits of additional endovascular treatment for CVS need to be addressed in further studies searching for a subgroup of patients who may benefit. Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

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Review

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16 pages, 2176 KiB

Open AccessReview

Anti-Inflammatory Drug Therapy in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis of Prospective Randomized and Placebo-Controlled Trials

by Johannes Wach, Martin Vychopen, Agi Güresir and Erdem Güresir

J. Clin. Med. 2023, 12(12), 4165; https://doi.org/10.3390/jcm12124165 - 20 Jun 2023

Cited by 2 | Viewed by 1264

Abstract

Emerging evidence suggests that neuroinflammation may play a potential role in aneurysmal subarachnoid hemorrhage (aSAH). We aim to analyze the influence of anti-inflammatory therapy on survival and outcome in aSAH. Eligible randomized placebo-controlled prospective trials (RCTs) were searched in PubMed until March 2023. After screening the available studies for inclusion and exclusion criteria, we strictly extracted the main outcome measures. Dichotomous data were determined and extracted by odds ratio (OR) with 95% confidence intervals (CIs). Neurological outcome was graded using the modified Rankin Scale (mRS). We created funnel plots to analyze publication bias. From 967 articles identified during the initial screening, we included 14 RCTs in our meta-analysis. Our results illustrate that anti-inflammatory therapy yields an equivalent probability of survival compared to placebo or conventional management (OR: 0.81, 95% CI: 0.55–1.19, p = 0.28). Generally, anti-inflammatory therapy trended to be associated with a better neurologic outcome (mRS ≤ 2) compared to placebo or conventional treatment (OR: 1.48, 95% CI: 0.95–2.32, p = 0.08). Our meta-analysis showed no increased mortality form anti-inflammatory therapy. Anti-inflammatory therapy in aSAH patients tends to improve the neurological outcome. However, multicenter, rigorous, designed, prospective randomized studies are still needed to investigate the effect of fighting inflammation in improving neurological functioning after aSAH. Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

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17 pages, 2562 KiB

Open AccessEditor’s ChoiceReview

Pathophysiology of Early Brain Injury and Its Association with Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Review of Current Literature

by Diana L. Alsbrook, Mario Di Napoli, Kunal Bhatia, Masoom Desai, Archana Hinduja, Clio A. Rubinos, Gelsomina Mansueto, Puneetpal Singh, Gustavo G. Domeniconi, Asad Ikram, Sara Y. Sabbagh and Afshin A. Divani

J. Clin. Med. 2023, 12(3), 1015; https://doi.org/10.3390/jcm12031015 - 28 Jan 2023

Cited by 9 | Viewed by 2686

Abstract

Background: Delayed cerebral ischemia (DCI) is a common and serious complication of aneurysmal subarachnoid hemorrhage (aSAH). Though many clinical trials have looked at therapies for DCI and vasospasm in aSAH, along with reducing rebleeding risks, none have led to improving outcomes in this patient population. We present an up-to-date review of the pathophysiology of DCI and its association with early brain injury (EBI). Recent Findings: Recent studies have demonstrated that EBI, as opposed to delayed brain injury, is the main contributor to downstream pathophysiological mechanisms that play a role in the development of DCI. New predictive models, including advanced monitoring and neuroimaging techniques, can help detect EBI and improve the clinical management of aSAH patients. Summary: EBI, the severity of subarachnoid hemorrhage, and physiological/imaging markers can serve as indicators for potential early therapeutics in aSAH. The microcellular milieu and hemodynamic pathomechanisms should remain a focus of researchers and clinicians. With the advancement in understanding the pathophysiology of DCI, we are hopeful that we will make strides toward better outcomes for this unique patient population. Full article

(This article belongs to the Special Issue Clinical Advances in Cerebral Aneurysm Treatment)

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