Search Results (15)

Background/Objectives: The fetal-type posterior cerebral artery (fetal PCA) is an anatomical variant that alters hemodynamics and may influence posterior communicating artery (PCoA) aneurysm rupture risk. Aneurysm shape and size irregularity are key rupture predictors. This study investigates the impact of fetal PCA on PCoA aneurysm morphology and rupture risk using a radiomics-based approach. Methods: We retrospectively analyzed 87 patients with PCoA aneurysms (39 ruptured, 48 unruptured) treated at a tertiary center (January 2017–December 2022). Seventeen morphological parameters and 18 radiomic features were extracted per aneurysm. Patients were grouped by fetal PCA presence. Logistic regression and receiver operating characteristic (ROC) analyses identified rupture predictors. Results: Of 87 aneurysms, 38 had fetal PCA (24 ruptured, 14 unruptured), and 49 did not (15 ruptured, 34 unruptured). Fetal PCA was significantly associated with rupture (odds ratio [OR]: 3.28, p = 0.018). A higher non-sphericity index (NSI) correlated with rupture risk (OR: 3.35, p = 0.016). In non-fetal PCA aneurysms, size-related parameters such as height (6.83 ± 3.54 vs. 4.88 ± 2.57 mm, p = 0.034) and area (190.84 ± 167.08 vs. 107.94 ± 103.10 mm², p = 0.046) were key rupture predictors. In fetal PCA aneurysms, flow-related parameters like vessel angle (55.78 ± 31.39 vs. 38.51 ± 24.71, p = 0.035) were more influential. ROC analysis showed good discriminatory power, with an area under the curve: 0.726 for fetal PCA and 0.706 for NSI. Conclusions: Fetal PCA influences PCoA aneurysm rupture risk and morphology. NSI is a reliable rupture marker. Integrating morphological and anatomical data may improve rupture risk assessment and clinical decision-making. Full article

Introduction: Aneurysms of brain vessels are life-threatening conditions with various adverse outcomes, some stemming from microsurgical intervention, particularly when major vessel perforators are inadequately protected. The use of endoscopes enhances the approach to aneurysms by providing closer visualization (180–360 degrees) of the local anatomy, potentially reducing accidental damage. To improve visualization and efficiency, a microscope-integrated 45-degree angled microinspection endoscopic tool (QEVO^®, Carl Zeiss, Oberkochen^TM) has been developed and employed in various neurosurgical procedures. Methods: Between 2021 and 2025, 27 brain aneurysms were treated with QEVO^® assistance at the Department of Neurosurgery, Clinical Center of the University of Sarajevo. The choice of the videos corresponds to the best image quality in videos and on the microscopic determination of adjacent vessel perforators, which were not adequately seen purely by the surgical microscope in specific cases. Exclusion criteria included cases without a need for QEVO^® assistance in perforator visualization, severe brain edema, intraoperative aneurysm rupture, posterior circulation, or low video quality. Results: Case 1 demonstrates an anterior choroidal artery (AchA) aneurysm; Case 2 presents an anterior communicating artery (AcommA) aneurysm; and Case 3 features contralateral middle cerebral artery (MCA) microsurgical clipping with QEVO^® assistance. Conclusions: The QEVO^® tool significantly improves the visualization of aneurysm–perforator relationships, increasing the likelihood of preserving perforators during standard microsurgical clipping. This innovative approach may reduce surgical complications and enhance patient outcomes, highlighting the tool’s potential as an adjunct in aneurysm microsurgery. Full article

Background: Arteriovenous malformations (AVMs) are high-risk cerebrovascular anomalies that can lead to devastating complications, especially when associated with intracranial aneurysms. Their coexistence poses unique challenges in diagnosis and management due to heightened hemodynamic stress and rupture risks. This case presents a 35-year-old woman with a giant unruptured left frontal AVM and a bilobed posterior communicating artery (PComA) aneurysm, highlighting the critical role of advanced imaging, meticulous surgical planning, and individualized care in addressing complex cerebrovascular conditions. Methods: The patient presented with a generalized tonic–clonic seizure, her first-ever neurological event. Advanced imaging, including digital subtraction angiography and 3D rotational imaging, revealed a 3–4 cm AVM supplied by the left middle and anterior cerebral arteries, with venous drainage into the superior sagittal sinus. Additionally, an unruptured bilobed PComA aneurysm was identified. Given the AVM’s large size, high-flow dynamics, and significant rupture risk, surgical resection was prioritized. The aneurysm, being stable and anatomically distinct, was managed conservatively. Microsurgical techniques were employed to ensure complete AVM resection while preserving critical vascular and neurological structures. Results: Postoperative angiography confirmed the complete removal of the AVM without residual nidus or abnormal vascular connections. The patient recovered without complications, achieving seizure freedom and preserved neurological function. At the three-month follow-up, imaging showed a stable resection cavity and a hemodynamically stable aneurysm. Conclusions: This case demonstrates the power of multidisciplinary care and advanced neurosurgical techniques in achieving curative outcomes for complex cerebrovascular anomalies. It underscores the importance of risk-prioritized strategies and highlights emerging directions for the field, including AI-integrated imaging, hybrid treatment approaches, and long-term studies on hemodynamic stability post-resection. This case contributes valuable insights into optimizing outcomes for patients with coexisting AVMs and aneurysms, offering hope for those facing similarly challenging diagnoses. Full article

We report an unusual case of pupil-involving third nerve palsy associated with Terson’s syndrome that resulted in the diagnosis of a right posterior communicating artery aneurysm. Interestingly, Terson’s syndrome presented with Roth spot-resembling features, accompanied by third nerve palsy in a patient without any disturbance of consciousness. To our knowledge, the association of Terson’s syndrome with third nerve palsy has not been described before in the absence of radiologically diagnosed subarachnoid haemorrhage. We present the case of a 48-year-old woman who presented in the Department of Emergencies of the University Hospital of Patras with right-sided complete-pupil-involving third nerve palsy combined with bilateral Terson’s syndrome. More precisely, fundoscopy revealed multiple scattered intra- and pre-retinal haemorrhages in both eyes, while some retinal haemorrhages had a white-centred pattern resembling Roth spots. Neurological examination revealed no nuchal rigidity or any other neurological signs. The Glasgow coma scale score was 15/15. A cerebral computed tomography angiography revealed a 5 mm aneurysm of the right posterior communicating artery and the patient underwent a microvascular clipping operation after craniotomy. The significant contribution of the ophthalmological consultation to the appropriate and timely diagnosis and management of a life-threatening condition is highlighted. Full article

Background: A relationship between the geometry and symmetry of Willis’ circle and intracranial aneurysms was reported for anterior communicating and posterior communicating (PCom) aneurysms. A similar association with the middle cerebral artery (MCA) aneurysms instead appeared weaker. Methods: We reviewed 432 patients from six Italian centers with unilateral MCA aneurysms, analyzing the relationship between the caliber and symmetry of Willis’ circle and the presence of ruptured and unruptured presentation. CT-angiograms were evaluated to assess Willis’ circle geometrical characteristics and the MCA aneurysm side, dimension and rupture status. Results: The hypoplasia of the first segment of the anterior cerebral artery (A1) was in approximately one-quarter of patients and PCom hypoplasia was in almost 40%. About 9% had a fetal PCom ipsilaterally to the aneurysm. By comparing the aneurysmal and healthy sides, only the PCom hypoplasia appeared significantly higher in the affected side. Finally, the caliber of the internal carotid artery (ICA) and the first segment of MCA (M1) caliber were significantly greater in patients with unruptured aneurysms, and PCom hypoplasia appeared related to the incidence of an ipsilateral MCA aneurysm and its risk of rupture. Conclusions: Although according to these findings asymmetries of Willis’ circle are shown to be a risk factor for MCA aneurysm formation and rupture, the indifferent association with ipsilateral or contralateral hypoplasia remains a datum of difficult hemodynamic interpretation, thereby raising the concern that this association may be more casual than causal. Full article

Traumatic intracranial aneurysms (TICAs) are rare, accounting for less than 1% of all intracranial aneurysms. However, they are associated with a mortality rate of over 50%. The case presented herein focuses on a posterior communicating artery TICA caused by violent aggression. A 41-year-old man with massive subarachnoid hemorrhage (SAH), on admission to hospital, had a CT angiography that showed a ruptured left posterior communicating artery aneurysm with continuous blood loss and underwent neurosurgical cooling. The CT scan also showed fractures of the mandible, mastoid and left styloid process, as well as brain contusions caused by blows and kicks. Despite medical treatment and surgery, after four days, he died. The assault dynamics were recorded by a camera in the bar. The damage was caused by kicks to the neck and head. The forensic neuropathological examination showed the primary injury (SAH, subdural hemorrhage, cerebral contusions, head–neck fractures), as well as secondary damage following the attack (cerebral infarcts, edema, supratentorial hernia, midbrain hemorrhage). The coil was intact and well positioned. In this case, circumstantial information, medical records, and the type of injury could shed light on the mechanism of the production of a TICA. In addition, the CT angiography and histological investigations helped to distinguish a recent and traumatic aneurysm from a pre-existing one. Following precise steps, the study of aneurysms can be helpful in clarifying their traumatic origin even when the victim was taking drugs. The aim of this study is also to share the diagnostic process that we used in the forensic field for the assessment of suspected traumatic aneurysms. Full article

Hemodynamic simulations are increasingly used to study vascular diseases such as Intracranial Aneurysms (IA) and to further develop treatment options. However, due to limited data, certain aspects must rely on heuristics, especially at the simulation’s distal ends. In the literature, Murray’s Law is often used to model the outflow split based on vessel cross-section area; however, this poses challenges for the communicating arteries in the Circle of Willis (CoW). In this study, we contribute by assessing the impact of Murray’s Law in patient-specific geometries featuring IA at the posterior communication. We simulate different domain extensions representing common modelling choices and establish Full CoW simulations as a baseline to evaluate the effect of these modelling assumptions on hemodynamic indicators, focusing on IA growth and rupture-related factors such as the Wall Shear Stress (WSS) and Oscillatory Shear Index (OSI). Our findings reveal qualitative alterations in hemodynamics when not modeling posterior communication. Comparisons between computing the anterior circulation and computing the whole Circle of Willis reveal that quantitative changes in WSS may reach up to 80%, highlighting the significance of modelling choices in assessing IA risks and treatment strategies. Full article

Post-traumatic vertebral arteriovenous fistula (vAVF) caused by motor vehicle accidents (MVA) is a rare condition in which there is abnormal communication between the vertebral artery and its adjacent veins. In a post-MVA setting, it is commonly associated with vertebral body fracture. In this paper, we report a case of a 19-year-old girl with a complete C2/C3 anterior and posterior ligament tear post MVA without any cervical bony injury. Initial plain computed tomography (CT) cervical scan showed a prevertebral hematoma. A CT angiogram (CTA) raised the suspicion of a pseudo-aneurysm at the right posterior C3 vertebral body. Further imaging with magnetic resonance imaging (MRI) demonstrated traumatic AVF at the C2/C3 level involving the V2/V3 right vertebral artery to the vertebral venous plexus. Digital Subtraction Angiography (DSA) further revealed a transected right vertebral artery at the C2/C3 level with an arteriovenous fistula and an enlarged vertebral venous plexus. The fistulous communication was successfully occluded with coils from a cranial and caudal approach to the transected segment right vertebral artery, with a total of eight coils. Post-MVA vertebral arteriovenous fistula (vAVF) is a rare sequela of vertebral bony injury at the cervical region, and is an even rarer association with an isolated ligamentous injury, whereby endovascular treatment with ipsilateral vertebral artery closure is a feasible treatment of vAVF. Full article

Purposes: A stent-assisted coil (SAC) is a safe and effective treatment modality for some complex intracranial aneurysms, especially for wide neck aneurysms. However, some wide neck aneurysms with a tough angle and located in the posterior communicating artery (PCoA) are challenging to treat with a SAC. This study aimed to examine and discuss the swinging-tail technique for treating wide neck aneurysms located in the PCoA using a SAC by Prof. Lv. Materials and Methods: We retrospectively reviewed our institutional clinical database and identified nine patients with neck aneurysms located in the PCoA, and these patients underwent the swinging-tail technique by Prof. Lv, which is a novel technique of releasing a stent, from June 2016 to September 2021. Results: In this study, nine patients underwent SAC treatment using the swinging-tail technique by Prof. Lv. Aneurysmal complete occlusion was observed in every patient without any complications, as shown by immediate postoperative angiography. Additionally, the modified Rankin scale was monitored for clinical outcomes in the follow-up. One patient died postoperatively due to severe SAH with an intraventricular hemorrhage. Four of nine patients underwent imaging follow-up, demonstrating the complete occlusion of aneurysms; eight patients underwent clinical follow-up and achieved a favorable clinical outcome (modified Rankin scale score: 0–2). Conclusion: The SAC treatment for wide neck aneurysms located in the PCoA can be challenging for operators because of the specific location, resulting in inadequate vessel wall apposition by antegrade stenting via the ipsilateral vessel. In this circumstance, the swinging-tail technique may be a feasible and effective choice. Full article

Background: patients with a subarachnoid hemorrhage (SAH) might need a flow diverter (FD) placement for complex acutely ruptured intracranial aneurysms (IAs). We conducted a meta-analysis and developed a prediction model to estimate the favorable clinical outcome after the FD treatment in acutely ruptured IAs. Methods: a systematic literature search was performed from 2010 to January 2021 in PubMed and Embase databases. Studies with more than five patients treated with FDs within fifteen days were included. In total, 1157 studies were identified. The primary outcome measure was the favorable clinical outcome (mRS 0–2). Secondary outcome measures were complete occlusion rates, aneurysm rebleeding, permanent neurologic deficit caused by procedure-related complications, and all-cause mortality. A prediction model was constructed using individual patient-level data. Results: 26 retrospective studies with 357 patients and 368 aneurysms were included. The pooled rates of the favorable clinical outcome, mortality, and complete aneurysm occlusion were 73.7% (95% CI 64.7–81.0), 17.1% (95% CI 13.3–21.8), and 85.6% (95% CI 80.4–89.6), respectively. Rebleeding occurred in 3% of aneurysms (11/368). The c-statistic of the final model was 0.83 (95% CI 0.76–0.89). All the studies provided a very low quality of evidence. Conclusions: FD treatment can be considered for complex ruptured IAs. Despite high complication rates, the pooled clinical outcomes seem favorable. The prediction model needs to be validated by larger prospective studies before clinical application. Full article

Introduction: Flow diverters such as the pipeline embolization device (PED) cause hemodynamic changes of the treated vessel segment. In posterior communicating artery (PcomA), aneurysms’ unique anatomic consideration have to be taken in account due to the connection between the anterior and posterior circulation. We hypothesize that in conjunction with PcomA remodeling, there will also be remodeling of the ipsilateral P1 segment of the posterior cerebral artery (PCA) after PED treatment for PcomA aneurysms. Methods: We retrospectively collected radiological as well as clinical data of PcomA aneurysm patients treated with PED including PcomA and P1 vessel diameters before and after treatment as well as patient and aneurysm characteristics. Results: Overall, 14 PcomA aneurysm patients were included for analysis and PED treatment was performed without complications in all patients. In 10 out of 14 patients (71%), a decrease in PcomA diameter was observed and there was a significant mean decrease of 0.78 mm in PcomA diameter on angiographic last follow-up (LFU) (p = 0.003). In the same patient population (10 out of 14 patients), there was meanwhile a significant mean increase of 0.43 mm in the ipsilateral P1 segment diameter observed (p = 0.015). These vessel remodeling effects were in direct correlation with aneurysm occlusion since all of these patients showed aneurysm occlusion at LFU while 29% showed only partial occlusion without vessel remodeling effects. A decrease in PcomA diameter was directly associated with aneurysm occlusion (p = 0.042). There were no neurologic complications on LFU. Conclusion: In the treatment of PcomA aneurysms with PED, the P1 segment of the PCA increases in diameter while the PcomA diameter decreases. Our results suggest that this remodeling effect is associated with aneurysm occlusion and decrease of PcomA is hemodynamically compensated for by an increase in the ipsilateral P1 diameter. Full article

Background: Treatment of intracranial aneurysms with flow diverters (FDs) showed promising results. However, a subset of patients treated for posterior communicating artery (PComA) aneurysms has variable occlusion rates. Especially the fetal type-associated PComA aneurysms seemed to respond differently to treatment. We analyze our series of fetal type PComA aneurysms treated with a FD. The literature on this subject is reviewed. Methods: Data from patients treated with FD for all PComA aneurysms at the RadboudUMC Nijmegen were retrospectively analysed. Primary end-point was complete aneurysm occlusion at six months. Secondary end-points were clinical outcome, treatment safety, and results of secondary treatment after non-closure. The results for the fetal PComA aneurysms were compared to the literature. Results: Nineteen consecutive patients harboring 21 PComA aneurysms were treated. Three aneurysms had ipsilateral fetal type PCA (14.3%). Overall, none of the fetal type PcomA aneurysm showed complete occlusion versus 77.8% of the others (p = 0.03). Mortality and permanent morbidity rates were respectively 5.3% and 0%. Conclusions: FD treatment for PComA aneurysm with fetal type circulation seemed to be less effective compared to other types of PComA aneurysms. Flow characteristics at the PComA bifurcation are thought to be causative Alternative strategies should be considered as first line treatment. Full article

We report diffusion tensor tractography (DTT) of the corticospinal tract (CST) in a patient with paresis of all four limbs following subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) after the rupture of an anterior communicating artery (ACoA) aneurysm rupture. The 73-year-old female was admitted to our emergency room in a semi-comatose mental state. After coil embolization—an acute SAH treatment—she was transferred to our rehabilitation department with motor weakness development, two weeks after SAH. Upon admission, she was alert but she complained of motor weakness (upper limbs: MRC 3/5, and lower limbs: MRC 1/5). Four weeks after onset, DTT showed that the bilateral CSTs failed to reach the cerebral cortex. The left CST demonstrated a wide spread of fibers within the corona radiata as well as significantly lower tract volume (TV) and higher fractional anisotropy (FA) as well as mean diffusivity (MD) compared to the controls. On the other hand, the right CST shifted to the posterior region at the corona radiata, and MD values of the right CST were significantly higher when compared to the controls. Changes in both CSTs were attributed to vasogenic edema and compression caused by untreated hydrocephalus. We demonstrate in this case, two different pathophysiological entitles, contributing to this patient’s motor weakness after SAH. Full article

Severe spontaneous subarachnoid hemorrhage (SAH) is predominantly caused by aneurysm rupture, with non-aneurysmal vascular lesions representing only a minority of possible causes. We present the case of a 58-year old lady with a coincidental posterior communicating artery (PCom) aneurysm and a high cervical spine arterio-venous fistula associated with a small ruptured aneurysm. After the emergency clipping of the PCom aneurysm, additional diagnostic procedures—repeated digital subtraction angiography and spinal magnetic resonance imaging, revealed the actual cause of the SAH, a type-A ventral intradural fistula at cervical level C2/3. The fistula was treated micro surgically via a ventral approach using C3 somatectomy and C2-4 stabilization after the initial failure of endovascular therapy. Furthermore, the patient was treated for complications associated with severe SAH, including acute hydrocephalus and meningitis. In cases where the SAH pattern and perioperative findings do not suggest an intracranial aneurysm as the source of SAH, further diagnostic investigation is warranted to discover the real cause. Patients with severe non-aneurysmal SAH require a similar algorithm in diagnosing the cause of the hemorrhage as well as complex conditions such as ruptured aneurysms. Full article

After aneurysmal subarachnoid hemorrhage, most center practices treatment modality selection based on size and geometry in computed tomographic angiography. However, the validity as compared to digital subtraction angiography (DSA) is not well studied. Twenty patients with ruptured internal carotid artery aneurysm were identified in a two-year period. Mean difference in measurements from 3D computed tomographic angiography (3D-CTA) and 3D-DSA were less than 1 mm and 3D-DSA measurement did not alter the decision to proceed for endovascular embolization. With modern multislice computed tomography technology, good quality 3D-CTA alone would be sufficient to make size and geometry assessment for treatment selection for patients with ruptured internal carotid artery aneurysm. Full article