• Microsurgical excision of a ruptured distal lenticulostriate aneurysm in a child
• A case of middle cerebral artery large circumferential aneurysm treated with bypass-assisted trapping surgery
• High-Flow Bypass and Clip Trapping of a Giant Fusiform Middle Cerebral Artery (M1) Aneurysm: Technical Case Instruction
• Middle Cerebral Artery and Lenticulostriate Artery Revascularization for Clipping of a Dolichoectatic Middle Cerebral Artery Aneurysm: The “Flow-Out” Principle: 2-Dimensional Operative Video
• Single-lane clipping technique for a ruptured aneurysm of A1 fenestration of the anterior cerebral artery: a case report and literature review
• Cerebral revascularization for complex middle cerebral artery aneurysms: surgical strategies and outcomes in a single center
• Parent artery occlusion for ruptured aneurysms in moyamoya vessels or on collaterals
• Charcot-Bouchard Aneurysm

Charcot-Bouchard aneurysms are minute aneurysms (microaneurysms) in the brain that occur in small penetrating blood vessels with a diameter that is less than 300 micrometers. The most common vessels involved are the lenticulostriate branches (LSA) of the middle cerebral artery (MCA). LSAs originate from the MCA just before its bifurcation, and they can vary between 2 to 12 in number (average 8.1). Most branches arise medially (99.2%), close to the internal carotid artery. They supply the basal ganglia, and more specifically, the putamen and caudate, followed by the thalamus, pons, and cerebellum.

Charcot-Bouchard aneurysms are named after the French physician Jean-Martin Charcot and his student Charles Joseph Bouchard. In the 19th century, Bouchard discovered these aneurysms during his research under Charcot. Cole and Yates strengthened Charcot and Bouchard’s work by demonstrating that aneurysms truly exist using microangiographic techniques in the 1960s. However, it has been a topic of lively debate if it is, in fact, the rupture of these aneurysms that are responsible for the intracerebral bleeds.

Individuals with chronic systemic hypertension are at high risk of developing atrophy of the outer muscular layer. With the loss of integrity of the vessel wall, microaneurysms develop in LSA, which are at high risk of rupture. Bleeding of aneurysms into the deep structures of the brain parenchyma is also referred to as intraparenchymal hemorrhage or, more broadly, as intracerebral hemorrhage. Clinically the deficits that present can point towards the location of the bleed. The first-line diagnostic modality for these patients is a non-contrast computed tomography (CT) of the head to visualize the bleed. Depending on the severity and location of the hemorrhage, the treatment options vary from observation to neurosurgical intervention ¹⁾

Aneurysms of lenticulostriate artery (LSA) perforators are uncommon. There are few data on their natural history, and opinions differ on the treatment strategies.

Aneurysms of the lenticulostriate artery (LSA) are rare lesions that are categorized into either proximal (at the junction of the middle cerebral artery trunk) or distal (within the basal ganglia).

Vargas et al, report a case series and summarize the most recent literature with current treatment recommendations, and propose an anatomical classification for these entities.

A retrospective review of all patients who were diagnosed with an LSA aneurysm on cerebral angiogram was performed. An extensive online literature search was performed to identify other studies reporting on the diagnosis and management of ruptured and unruptured lenticulostriate aneurysms.

48 cases were identified in the literature and reviewed: 27 patients were treated surgically; five cases were treated with endovascular therapy; two cases underwent gamma knife radiosurgery; and 13 cases were managed conservatively.

They classified these aneurysms into three types: type 1 describes aneurysms arising from the middle cerebral artery next to a perforating LSA; type 2 is an LSA aneurysm from which the perforating artery or arteries arise-the type 2A subtype is one in which the aneurysm neck incorporates the origin of the perforating arteries and the type 2B describes perforating arteries arising from the dome of the aneurysm; and type 3 describes a fusiform aneurysm beyond the first loop or turn of an LSA.

LSA aneurysms are rare entities that present several treatment challenges ²⁾.

These lesions have been reported against the background of a diverse array of pathologies including hypertension, vascular malformations, moyamoya disease, substance abuse, systemic lupus erythematosus, ventricular neurocytoma, and Sneddon syndrome; however, most cases are idiopathic.

The ruptured aneurysm has a high risk of re-bleeding with a consequent marked decreased risk of patient survival and functional independence, for proximal LSA aneurysm, neurosurgery has been the mainstay of treatment, but its efficacy remains controversial.

Development of devices and improved operator experience have rendered endovascular coiling an alternative and acceptable option for such patients ³⁾.

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature search was conducted in the PubMed, Cochrane, EBSCOhost, Scopus, Web of Science, and ProQuest search engines to identify reported studies of LSA aneurysms until July 1, 2020. A descriptive analysis was performed.

Results: A total of 71 studies with 112 cases of LSA aneurysms were included. Patient age ranged from 2 months to 83 years (median, 44.5 years). Male and female patients were affected similarly (49% and 51%, respectively). The most common presentation was aneurysmal rupture (78%), and headache was the most frequently reported symptom (36%). Overall, 48% of the patients had undergone underwent surgical treatment, 30% conservative management, 21% endovascular treatment, and 1% radiosurgery. Four patients died, all of whom had presented with aneurysmal rupture.

Hinojosa-Gonzalez et al. summarized the reported cases of LSA aneurysms, with their clinical presentation, management, and outcomes, for physicians who may be confronted with this diagnosis. Future studies that use available classification systems and include as much detail as possible should be encouraged to fully elucidate the optimal management strategy for these patients ⁴⁾.

An 81-year-old woman developed consciousness disturbance. Computed tomography revealed hemorrhage in the right caudate nucleus and lateral ventricles. Three-dimensional computed tomographic angiography demonstrated only an aneurysm at the basilar artery. On angiography, on the sixth day, an aneurysm at the right lenticulostriate artery was demonstrated. Then, the aneurysm disappeared on three-dimensional computed tomographic angiography on the 15th day. Subsequent radiological examinations revealed no vascular anomaly in the right lenticulostriate artery.

An aneurysm at this location can show dynamic changes based on radiological findings. Close radiological observation is necessary ⁵⁾.

Patients with moyamoya disease and LSA aneurysm rupture admitted to Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medicine School from October 2012 to March 2015 were analyzed retrospectively. They were followed up for 1 year. The modified Rankin Scale (mRS) was used to evaluate the outcomes, and 0-2 was defined as good outcome. The demographic characteristics, image anatomical features, treatment schemes, and outcomes of the patients were summarized. The Pubmed database was used to retrieve other similar studies, which combined with this group of cases for analysis. Results A total of 10 patients were enrolled, 2 males and 8 females, aged 29-72 years, with an average of 43. 6 years. All cases were intracranial hemorrhage, including 3 cases of cerebral hemorrhage, 6 cases of ventricular hemorrhage, and 1 case of subarachnoid hemorrhage. At the time of admission, 7 patients had disturbance of consciousness, and 3 patients underwent emergency extraventricular drainage. Among them, 5 patients received endovascular embolization, 4 had good outcome, 1 had mild neurological deficit (mRS score 3); 2 received surgical treatment, all had good outcome; 3 received conservative treatment, all had re-bleeding, 2 died, and 1 had severe disability (mRS score 4). Fourteen eligible articles were included, and a total of 18 patients were included in the analysis: surgical treatment in 7 cases, endovascular treatment in 6 cases, and conservative treatment in 5 cases (self-healing in 1 case). According to the data of this group of patients and literature reports, the good outcome rate of the patients with early interventional embolization or craniotomy clipping treatment was significantly higher than that of conservative treatment (70. 6％vs. 22. 2％; P = 0. 038). Conclusion There is a certain risk of conservative treatment of Moyamoya disease complicated with LSA aneurysm rupture and requires active treatment. Interventional embolization of the parent artery or surgically clipping of aneurysm can effectively improve the clinical outcome of such patients. Interventional embolization of the parent artery and aneurysm can be selected simultaneously if the condition of the parent artery is allowed. Surgery can be selected when the condition of parent artery is poor and the aneurysm is located in the superficial part ⁶⁾.

A case report of a child with a ruptured distal lenticulostriate artery aneurysm that required careful decision-making and preparation before microsurgical excision. MR angiography was performed in the planning phase and neuronavigation was used during surgery. The surgery was a success, with the patient suffering minimal postoperative focal deficit, which later turned out to be transient ⁷⁾.

A 42-year-old woman presented with a sudden onset of dysarthria and right hemiparesis. Putaminal hemorrhage from a ruptured aneurysm in the left LSA was detected. Angiographically, moyamoya vessels were revealed. The aneurysm in the left LSA was saccular type and seemed to be related to Moyamoya disease. As the aneurysm was successfully approached with a microcatheter, coil embolization without parent artery occlusion was performed. Rebleeding from the embolized aneurysm in the LSA did not occur. This is the first report of a ruptured LSA aneurysm embolized using coils through a flow-guiding microcatheter without parent artery occlusion in a case of Moyamoya disease ⁸⁾.

One case of ruptured LSA aneurysm is related to Moyamoya disease (MMD). Surgical treatment of this aneurysm is challenging because of its deep location and complex neural structures around the LSA. They report one case treated with endovascular Onyx embolization, successfully and review the LSA aneurysm associated with MMD ⁹⁾

A 49-year-old man who presented with a hemorrhage in the basal ganglia. An angiogram revealed a distal LSA aneurysm in the setting of moyamoya disease. The patient’s aneurysm was successfully embolized by the use of Onyx 18. In this report, we present the first case of onyx embolization of a LSA aneurysm and review all the previous cases that were managed with endovascular techniques.

Conclusion: Treatment of these lesions with either surgery or endovascular therapy is challenging and requires specialized expertise. Given the risks of surgery, we believe that LSA aneurysms are best treated by endovascular means, especially in the setting of moyamoya disease ¹⁰⁾.

• Embolization of unruptured wide-necked aneurysms at the MCA bifurcation using the Neuroform atlas stent-assisted coiling: a two-center retrospective study
• Microsurgical clipping and endovascular intervention for middle cerebral artery aneurysm: A meta-analysis
• Endovascular embolization with EVOH for the treatment of a Rasmussen aneurysm
• Concomitant valve surgery is associated with worse outcomes in surgical treatments of post-infarction ventricular aneurysm
• Case report: Isolated dissection of the left gastric artery: an unusual cause of acute abdominal pain
• Management of Intracranial Aneurysms that Do Not Occlude on Initial Follow-up After Treatment With the Pipeline Embolization Device
• Outcomes Associated With Intracranial Aneurysm Treatments Reported as Safe, Effective, or Durable: A Systematic Review and Meta-Analysis
• Surgical, endovascular, and hybrid treatment of deep femoral artery aneurysm: Three case reports

• Outcomes Associated With Intracranial Aneurysm Treatments Reported as Safe, Effective, or Durable: A Systematic Review and Meta-Analysis
• A novel flow diverter device (Tubridge) for the treatment of intracranial aneurysms: a systematic review and meta-analysis
• Does the use of oral contraceptives or hormone replacement therapy offer protection against the formation or rupture of intracranial aneurysms in women?: a systematic review and meta-analysis
• Flow diversion for the treatment of intracranial bifurcation aneurysms: a systematic review and meta-analysis
• Phenox HPC and Phenox flow modulation devices for the endovascular treatment of intracranial aneurysms: a systematic review and meta-analysis
• Endovascular Treatment and Microsurgical Clipping for the Management of Paraclinoid Intracranial Aneurysms: A Systematic Review and Meta-Analysis
• Anti-Inflammatory Drug Therapy in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis of Prospective Randomized and Placebo-Controlled Trials
• Long-term outcomes of the Woven EndoBridge device for treatment of intracranial aneurysms: A systematic review and meta-analysis

Volovici et al. reviewed and analyzed studies investigating devices and procedures used in intracranial aneurysm (IA) treatment for methods and completeness of reporting and to compare the results of studies with positive, uncertain, and negative conclusions.

Embase, MEDLINE, Web of Science, and The Cochrane Central Register of Clinical Trials were searched for studies on IA treatment published between January 1, 1995, and October 1, 2022. Grey literature was retrieved from Google Scholar.

All studies making any kind of claims of safety, effectiveness, or durability in the field of IA treatment were included.

Data extraction and synthesis: Using a predefined data dictionary and analysis plan, variables ranging from patient and aneurysm characteristics to the results of treatment were extracted, as were details pertaining to study methods and completeness of reporting. Extraction was performed by 10 independent reviewers. A blinded academic neuro-linguist without involvement in IA research evaluated the conclusion of each study as either positive, uncertain, or negative. The study followed Preferring Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Main outcomes and measures: The incidence of domain-specific outcomes between studies with positive, uncertain, or hostile conclusions regarding safety, effectiveness, or durability were compared. The number of studies that provided a definition of safety, effectiveness, or durability and the incidence of incomplete reporting of domain-specific outcomes were evaluated.

Overall, 12 954 studies were screened, and 1356 studies were included, comprising a total of 410 993 treated patients. There was no difference in the proportion of patients with poor outcomes or in-hospital mortality between studies claiming a technique was safe, uncertain, or not safe. Similarly, there was no difference in the proportion of IAs completely occluded at the last follow-up between studies claiming a technique was effective, uncertain, or ineffective. Less than 2% of studies provided any definition of safety, effectiveness, or durability, and only 1 of the 1356 studies provided a threshold under which the technique would be considered unsafe. Incomplete reporting was found in 546 reports (40%).

Conclusions and Relevance: In this systematic review and meta-analysis of IA treatment literature, studies claiming safety, effectiveness, or durability of IA treatment had methodological flaws and incomplete reporting of relevant outcomes supporting these claims ¹⁾.

see Unruptured intracranial aneurysm treatment.

see Ruptured intracranial aneurysm treatment.

The treatment of intracranial aneurysm aims for the complete elimination of the aneurysm from the circulation with neuroendovascular treatment or surgery.

The efficacy of intracranial aneurysm treatment (long-term success or effectiveness of the treatment) is measured by evidence of the aneurysm obliteration (failure to be demonstrated by conventional or noninvasive angiography), without evidence of aneurysm recanalization (any blood flow into the aneurysm) or aneurysm recurrence (reappearance).

Intracranial Aneurysms (IA) can be treated with microsurgery or by endovascular treatments (EVT). EVT has taken an increasingly important part in IA management; the ability of neurosurgical teams to perform such surgery as well as the quality of their training is being questioned.

The decision-making process and patient selection for ruptured aneurysms treatment has evolved more as an art than as a science, which is a consequence of the collaborative efforts occurring between all subspecialties involved, the availability of both techniques on a 24–48-h window of treatment, the anatomical factors of the aneurysm neck and sac, as well as local expertise and morbidity factors involved with both options of treatment.

Management of these patients depends upon a number of factors including aneurysmal, patient, institutional, and operator factors. The ultimate goal of treating patients with IAs is complete and permanent occlusion of the aneurysm sac in order to eliminate future hemorrhagic risk, while preserving or restoring the patient’s neurological function. The most common treatment approaches include microsurgical clipping and endovascular coiling, and multiple studies have compared these two techniques. To date, three large prospective, randomized studies have been done: a study from Finland, International Subarachnoid Aneurysm Trial (ISAT), and the Barrow Ruptured Aneurysm Trial (BRAT). Despite differences in methodology, the results were similar: in patients undergoing coiling, although rates of rebleeding and retreatment are higher, the overall rate of poor outcomes at 12 months was significantly lower. As minimally invasive procedures and devices continue to be refined, endovascular strategies are likely to increase in popularity. However, as long-term outcome studies become available, it is increasingly apparent that they are complementary treatment strategies, with patient selection of critical importance ²⁾.

Although each of these trials was not methodologically flawless, the combined results from all three suggest that endovascular treatment of ruptured aneurysms suitable for this treatment strategy results in quicker recovery and better functional outcomes at one year at the expenses of lower rates of complete aneurysm obliteration frequently requiring retreatment ³⁾.

The treatment of intracranial aneurysms is best performed at high volume centers that utilize a multidisciplinary, team-based approach ⁴⁾.

In a trained team, the multidisciplinary approach appears to be a valuable strategy in the management of intracranial aneurysms, to achieve good functional outcomes ⁵⁾.

Given the similar clinical results of both modalities, the patient should be advised on the necessity of repeated follow-ups and of possible technical failure and eventually repeated procedure which is more likely if an endovascular procedure is chosen ⁶⁾.

Intracranial aneurysm surgery.

Intracranial aneurysm embolization.

Intracranial Aneurysm Flow Diversion.

Intracranial Aneurysm treatment complications

European Stroke Organization Guidelines for the Management of Intracranial Aneurysms and Subarachnoid Haemorrhage – February 2013

http://www.karger.com/Article/FullText/346087

Intracranial Aneurysm Treatment Outcome.

Intracranial aneurysm treatment in France

• Stenting of the Common Carotid Artery Ostium: Balloon Catheter Lifting-Up Technique With a Gooseneck Snare
• Young Patients Undergoing Carotid Stenting Procedures Have an Increased Rate of Procedural Failure at One Year Follow-Up
• Corroded iron stent increases fibrin deposition and promotes endothelialization after stenting
• Commentary: Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video
• Preliminary experience with diffuse correlation spectroscopy in acute ischemic stroke neurointerventional procedures
• Internal carotid artery stenosis with repeated ischemic stroke recurrence due to mechanical stimulation by the hyoid bone and thyroid cartilage: a case report
• Endovascular Treatment for Spontaneous bilateral carotid artery dissection with acute ischemic stroke: A Case Report with automated postprocessing CT perfusion findings and Review of the Literature
• Sex-Related Outcomes in Asymptomatic Patients Undergoing Carotid Artery Stenting

Common carotid artery stenting is a medical procedure performed to treat carotid artery stenosis, which is the narrowing of the carotid arteries that supply blood to the brain. It is a less invasive alternative to carotid endarterectomy, a surgical procedure used for the same purpose.

During common carotid artery stenting, a thin, flexible tube called a catheter is inserted into an artery, usually in the groin, and guided up to the site of the carotid artery stenosis. Using X-ray guidance, the catheter is advanced to the affected area. Once in position, a small, expandable mesh tube called a stent is placed at the site of the stenosis. The stent is then expanded, pushing against the walls of the artery, and helps to keep the artery open.

The stent acts as a scaffold, improving blood flow through the carotid artery and reducing the risk of stroke. Some stents are designed with a filter or a protective device to capture any debris that may break loose during the procedure, preventing it from reaching the brain.

Common carotid artery stenting is typically performed under local anesthesia, meaning the patient is awake but the area being treated is numbed. It is often considered for patients who are at high risk for complications from carotid endarterectomy, such as those with previous neck surgery, radiation therapy, or significant medical comorbidities.

Like any medical procedure, common carotid artery stenting carries some risks, including the potential for blood vessel injury, stroke, infection, or allergic reactions to contrast dye used during the procedure. However, it is generally considered safe and effective when performed by experienced medical professionals.

Carotid artery stenting is indicated for the treatment of carotid artery stenosis, which is the narrowing of the carotid arteries that supply blood to the brain. The procedure may be recommended in certain situations, depending on the severity of the stenosis and the patient’s overall health. The main indications for carotid artery stenting include:

Symptomatic Carotid Artery Stenosis: Carotid artery stenting is commonly recommended for patients who have experienced symptoms related to carotid artery stenosis, such as a transient ischemic attack (TIA) or a minor stroke. These symptoms may include temporary vision loss, weakness or numbness on one side of the body, difficulty speaking, or dizziness. In such cases, carotid artery stenting aims to reduce the risk of future stroke by improving blood flow through the carotid arteries.

Asymptomatic Carotid Artery Stenosis: Carotid artery stenting may also be considered in certain cases of asymptomatic carotid artery stenosis, particularly when the stenosis is severe (greater than 70% narrowing). The decision to proceed with stenting in asymptomatic cases is often based on factors such as the patient’s age, overall health, life expectancy, and the presence of other risk factors for stroke.

High-Risk Candidates for Carotid Endarterectomy (CEA): Carotid artery stenting is sometimes recommended for patients who are at high risk for complications from carotid endarterectomy, which is a surgical procedure used to treat carotid artery stenosis. High-risk factors may include previous neck surgery, radiation therapy to the neck, severe heart or lung disease, or advanced age. Carotid artery stenting is considered a less invasive alternative for these patients.

It is important to note that the decision to undergo carotid artery stenting should be made on an individual basis, taking into consideration the patient’s specific medical condition, overall health, and the expertise of the healthcare team. A thorough evaluation by a vascular specialist or a neurologist is typically conducted to determine the most appropriate treatment approach for each patient.

Carotid artery angioplasty and stenting (CAS) has experienced an astonishing rate of development, becoming a viable alternative to carotid endarterectomy (CEA) in the management of carotid artery stenosis. Many trials have attempted to compare both treatment modalities and establish indications for each, depending on clinical and anatomic features.

Eller et al. review the historical evolution of carotid stenting; its main technical aspects, indications, and contraindications; as well as the most important clinical trials comparing CAS and CEA ¹⁾.

Primary carotid stenting, performed using self-expanding stents alone without deliberate use of embolic protection devices and balloon angioplasty, has been shown to be effective and faster, cheaper, and potentially safer than conventional techniques.

see also Bilateral carotid artery stenting.

Carotid artery stenting (CAS) is a neuroendovascular treatment where a stent is deployed within the lumen of the carotid artery to prevent a stroke by treating carotid artery stenosis.

It has emerged as an alternative to carotid endarterectomy. In randomised trials comparing stenting with endarterectomy for symptomatic carotid artery stenosis, stenting was associated with a higher risk of procedure-related stroke, particularly in elderly patients, but with lower risks of myocardial infarction, cranial nerve palsy, and access site haematoma ^{2) 3) 4) 5)}.

A systematic review showed that the increase in procedure-related risk was driven by non-disabling stroke, with no evidence for a difference in rates of major or disabling stroke or death between the treatments ⁶⁾.

see Carotid artery stenting complications.

see International Carotid Stenting Study.

A study investigated the effect of residual stenosis after carotid artery stenting (CAS) on periprocedural and long-term outcomes.

Patients treated with CAS for symptomatic or asymptomatic carotid arterial stenosis were consecutively enrolled. Residual stenosis was estimated from post-procedure angiography findings. The effects of residual stenosis on 30-day periprocedural outcome and times to restenosis and clinical outcome were analyzed using logistic regression models and Wei-Lin-Weissfeld models, respectively.

A total of 412 patients (age, 64.7 ± 17.0 years; male, 82.0%) were enrolled. The median baseline stenosis was 80% (interquartile range [IQR], 70-90%), which improved to 10% (0-30%) for residual stenosis. Residual stenosis was significantly associated with periprocedural outcome (adjusted odds ratio, 0.983; 95% confidence interval [CI], 0.965-0.999, P = 0.01) after adjustment for baseline stenosis, age, hypertension, symptomaticity, and statin use. Over the 5-year observation period, residual stenosis did not increase the global hazard for restenosis and clinical outcome (adjusted hazard ratio, 1.011; 95% CI, 0.997-1.025. In the event-specific model, residual stenosis increased the hazard for restenosis (adjusted hazard ratio, 1.041; 1.012-1.072) but not for clinical outcome (adjusted hazard ratio, 1.011; 0.997-1.025).

Residual stenosis after carotid artery stenting may be useful to predict periprocedural outcome and restenosis ⁷⁾.

see Carotid artery stenting case series.

Endovascular revascularization of a stenotic lesion requires appropriate stent positioning. In particular, stenting of the common carotid artery (CCA) ostium makes it difficult to avoid proptosis into the aorta. Furthermore, the guiding catheter may become unstable during the stenting because of its position under the aortic arch. To resolve these problems, Terakado et al. performed antegrade stenting for a patient with a symptomatic stenotic left CCA ostium that was treated by lifting a balloon-guiding catheter with a gooseneck snare. A patient was a 74-year-old man who presented to the hospital with main complaints of right hemiparesis and motor aphasia. A left cerebral infarction due to severe stenotic left CCA ostium was diagnosed. A CT perfusion study showed decreased cerebral blood flow in the left hemisphere. Stenting of the stenotic left CCA ostium was performed using an antegrade approach. A balloon-guiding catheter positioned under the aortic arch was inflated and lifted from the right brachiocephalic artery using a gooseneck snare. The guiding catheter was stabilized during stenting. This method is highly effective for stenting CCA ostium ⁸⁾

A 68-year-old man was admitted. Neurological examination revealed severe left-sided motor weakness. Magnetic resonance imaging showed no cerebral infarction, but magnetic resonance angiography revealed complete occlusion of the right internal carotid artery. Systemic intravenous injection of recombinant tissue plasminogen activator was performed within 4h after the onset. But, magnetic resonance angiography still revealed complete occlusion. Revascularization of the right cervical internal carotid artery was performed via endovascular surgery. The occluded artery was successfully recanalized using the Penumbra System® and stent placement at the origin of the internal carotid artery. Immediately after surgery, dual antiplatelet therapy (aspirin and clopidogrel) was initiated, and then cilostazol was added on the following day. Carotid ultrasonography and three-dimensional computed tomographic angiography at 14days revealed no further obstruction to flow.

When trying to perform emergency carotid artery stenting within 24h after intravenous recombinant tissue plasminogen activator administration, several issues require attention, such as the decisions regarding the type of stent and embolic protection device, the selection of antiplatelet therapy and the methods of preventing hyperperfusion syndrome.

Emergency carotid artery stenting for the acute internal carotid artery occlusion may be considered a safe procedure in preventing early stroke recurrence in selected patients ⁹⁾.

• Association Between Chronic Hypertension and the Risk of 12 Cardiovascular Diseases Among Parous Women: The Role of Adverse Pregnancy Outcomes
• Prompt closure versus gradual weaning of external ventricular drainage for hydrocephalus following aneurysmal subarachnoid haemorrhage: Protocol for the DRAIN randomised clinical trial
• Hemodynamic Management in the Prevention and Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage
• Lower initial Red Blood Cell Count in Cerebrospinal Fluid predicts Good Functional Outcome in Patients with Spontaneous Subarachnoid Hemorrhage
• Nutritional intervention improves prognosis of subarachnoid hemorrhage patients undergoing aneurysmal clipping : a retrospective study
• Preoperative prognostic nutrition index can independently predict the 6-month prognosis of elderly patients undergoing neurosurgical clipping for aneurysmal subarachnoid hemorrhage
• Clinical Response following Hypertension-Induction for clinical Delayed Cerebral Ischemia following Subarachnoid Haemorrhage – a retrospective multicentre cohort study
• A comprehensive assessment of self-reported symptoms among patients harboring an unruptured intracranial aneurysm

Aneurysmal subarachnoid hemorrhage (aSAH) is a complex neurovascular syndrome with profound systemic effects, associated with high rates of disability and mortality.

see also Subarachnoid hemorrhage outcome.

Aneurysmal subarachnoid hemorrhage complications.

Quality of life after aneurysmal subarachnoid hemorrhage.

Aneurysmal Subarachnoid Hemorrhage Outcome in Elderly Patients.

Cognitive outcome after aneurysmal subarachnoid hemorrhage.

Obesity in aneurysmal subarachnoid hemorrhage.

Several studies have investigated the changes in CSF metabolomics that occur after aSAH. These studies have identified alterations in various metabolites and metabolic pathways, including those involved in energy metabolism, amino acid metabolism, and lipid metabolism.

One study found that levels of lactate, a marker of anaerobic metabolism, were significantly increased in the CSF of aSAH patients compared to controls. This suggests that there is a shift towards anaerobic metabolism in the brain following aSAH, possibly due to decreased oxygen delivery and increased metabolic demand.

Other studies have reported alterations in amino acid metabolism, particularly involving glutamate and gamma-aminobutyric acid (GABA). Glutamate is an excitatory neurotransmitter that can lead to neuronal damage when present in excess, while GABA is an inhibitory neurotransmitter that can protect against excitotoxicity. Studies have shown that CSF levels of glutamate are increased and GABA levels are decreased in aSAH patients, which may contribute to the pathophysiology of the disease.

Alterations in lipid metabolism have also been reported in aSAH patients, with decreased levels of sphingomyelins and phosphatidylcholines in the CSF. These lipids play important roles in cellular membrane structure and function, and their depletion may contribute to neuronal damage and inflammation.

Overall, the findings of metabolomics studies suggest that aSAH leads to widespread metabolic alterations in the brain, involving multiple metabolic pathways. These alterations may contribute to the pathophysiology of the disease and represent potential targets for therapeutic intervention.

There is increasing evidence suggesting that biomarkers can give insight into the aneurysmal subarachnoid hemorrhage pathogenesis and can serve as an outcome predictor ¹⁾

NFE2L2 SNP, rs10183914, is significantly associated with aneurysmal subarachnoid hemorrhage outcome. This is consistent with a clinically relevant pathophysiological role for oxidative and inflammatory brain injury due to blood and its breakdown products in aSAH. Furthermore, the findings support NRF2 as a potential therapeutic target following aSAH and other forms of intracranial hemorrhage ²⁾

In a study by Hammer et al. from the Paracelsus Medical University, complications like pneumonia (β = 5.11; 95% CI = 1.75-8.46; p = 0.0031), sepsis (β = 9.54; 95% CI = 3.27-15.82; p = 0.0031), hydrocephalus (β = 4.63; 95% CI = 1.82-7.45; p = 0.0014), and delayed cerebral ischemia (DCI) (β = 3.38; 95% CI = 0.19-6.56; p = 0.038) were critical factors depending on the LOS in intensive care as well as decompressive craniectomy (β = 5.02; 95% CI = 1.35-8.70; p = 0.0077). All analyzed comorbidities such as hypertension, diabetes, hypothyroidism, cholesterolemia, and smoking history had no significant impact on the LOS in intensive care. LOS in intensive care (OR = 1.09; 95% CI = 1.03-1.15; p = 0.0023), as well as World Federation of Neurosurgical Societies grading for subarachnoid hemorrhage (OR = 3.72; 95% CI = 2.23-6.21; p < 0.0001) and age (OR = 1.06; 95% CI = 1.02-1.10; p = 0.0061), were significant factors that had an impact on the outcome after 1 year. Complications in intensive care but not comorbidities are associated with higher LOS in intensive care. LOS in intensive care is a modest but significant predictor of outcomes after subarachnoid hemorrhage ³⁾.

Aneurysmal subarachnoid hemorrhage (aSAH) occurs in about 5% of all strokes and has still a mortality of 50% and a significant morbidity in survivors ⁴⁾.

The second cause of disability after the initial hemorrhage is cerebral vasospasm and the delayed cerebral ischemia which occurs in 50–70% of patients ⁵⁾.

These two pathological entities seem to have different pathophysiological etiologies and cannot be detected by the same techniques. Vasospasms of the vessels of the circle of Willis can be detected by transcranial Doppler ultrasonography (TCD), whereas microcirculation disturbances can be detected by perfusion imaging techniques. Digital subtraction angiography (DSA) remains until now the gold standard of imaging vasospasms, but it is invasive, and it is proven to be associated with the risk of mild neurological deficit as well as ischemic insults ⁶⁾.

As angiographic vasospasm is strongly associated with delayed cerebral ischemia (DCI) and clinical outcome, clinical trials in the last few decades focused on prevention of these angiographic spasms. Despite all efforts, no new pharmacological agents have shown to improve patient outcome. As such, it has become clear that our understanding of the pathophysiology of SAH is incomplete and we need to reevaluate our concepts on the complex pathophysiological process following SAH. Angiographic vasospasm is probably important.

The case fatality in aneurysmal subarachnoid hemorrhage (aSAH) is 50% due to the initial hemorrhage or subsequent complications like aneurysm rebleeding or delayed cerebral ischemia (DCI).

One factor that might influence the initial brain damage or subsequent complications is the use of antiplatelet medication before the initial hemorrhage.

Improvements in multidisciciplinary neurocritical care and advancements in medical and surgical treatment have contributed to a decline in the case fatality rate of aneurysmal subarachnoid hemorrhage ⁷⁾.

A greater proportion of patients, therefore, are surviving their initial hemorrhagic event but remain at increased risk of a number of complications.

see Aneurysmal subarachnoid hemorrhage complications.

The case fatality after aneurysmal haemorrhage is 50%; one in eight patients with subarachnoid haemorrhage dies outside hospital. Rebleeding is the most imminent danger; a first aim is therefore occlusion of the aneurysm ⁸⁾.

Prothrombotic states of early brain injury (EBI) and delayed cerebral ischemia (DCI) after aSAH determine morbidity and mortality.

The outcome depends on their condition on arrival at the hospital. However, a small number of patients recover from an initially poor condition.

Associated with intracerebral hematoma (ICH) typically has a poor outcome. SAH with ICH tends to have a worse prognosis than SAH alone.

It has a high socioeconomic impact as it tends to affect younger patients. The NCEPOD study looking into management of aSAH has recommended that neurovascular units in the United Kingdom should aim to secure cerebral aneurysms within 48 h and that delays because of weekend admissions can increase the mortality and morbidity attributed to aSAH.

A study provides important data showing excess in-Hospital mortality of patients with SAH on weekend admissions served by the United Kingdom’s National Health Service.; However, there were no effects of weekend admission on long-term outcomes ⁹⁾.

Clinical prediction models were developed with individual patient data from 10 936 patients and validated with data from 3355 patients after development of the model. In the validation cohort, a core model including patient age, premorbid hypertension, and neurological grade on admission to predict risk of functional outcome had good discrimination, with an area under the receiver operator characteristics curve (AUC) of 0.80 (95% confidence interval 0.78 to 0.82). When the core model was extended to a “neuroimaging model,” with inclusion of clot volume, aneurysm size, and location, the AUC improved to 0.81 (0.79 to 0.84). A full model that extended the neuroimaging model by including treatment modality had AUC of 0.81 (0.79 to 0.83). Discrimination was lower for a similar set of models to predict risk of mortality (AUC for full model 0.76, 0.69 to 0.82). All models showed satisfactory calibration in the validation cohort.

The prediction models reliably estimate the outcome of patients who were managed in various settings for ruptured intracranial aneurysms that caused subarachnoid haemorrhage. The predictor items are readily derived at hospital admission. The web based SAHIT prognostic calculator (http://sahitscore.com) and the related app could be adjunctive tools to support management of patients ¹⁰⁾.

National Institute of Health Stroke Scale

Barthel Index

Extended Glasgow Outcome Scale.

Modified Rankin Scale

Systematic reviews for clinical prognostic factors and clinical prediction tools in aneurysmal subarachnoid hemorrhage (aSAH) face a number of methodological challenges. These include within and between study patient heterogeneity, regional variations in treatment protocols, patient referral biases, and differences in treatment, and prognosis viewpoints across different cultures ¹¹⁾.

It is critical to determine the neural basis for executive deficits in aSAH, in order to better understand and improve patient outcomes.

In a tertiary care center in India, despite recent advances in the treatment of patients with aSAH, the morbidity and mortality rates have failed to improve significantly in unselected patients and natural cohorts. This may be attributed to the natural history of aSAH, and calls for new strategies to diagnose and treat such patients before the catastrophe ¹²⁾.

In the series of Nieuwkamp et al., despite an increase in the mean age of patients with SAH, case-fatality rates have decreased by 17% between 1973 and 2002 and show potentially important regional differences. This decrease coincides with the introduction of improved management strategies ¹³⁾.

The case fatality after aneurysmal haemorrhage is 50%; one in eight patients with subarachnoid haemorrhage dies outside hospital.

Mortality is 10% within first few days

30-day mortality rate was 46% in one series, and in others over half the patients died within 2 weeks of their SAH.

overall mortality is 45% (range: 32—67%)

causes of mortality

neurogenic stunned myocardium

about 8% die from progressive deterioration from the initial hemorrhage

of those reaching neurosurgical care, vasospasm kills 7%, and causes severe deficit in another 7%.

about 30% of survivors have moderate to severe disability.

about 66 % of those who hove successful aneurysm clipping never return to the same quality of life as before the SAH.

With the limitation of an explorative cohort study the results indicate that routine transcranial doppler (TCD) studies do not improve the overall outcome of patients after aSAH ¹⁴⁾.

Quantitative imaging indicators of ventricular hemorrhage (standard deviation of third ventricular hemorrhage density, minimum density of fourth ventricular hemorrhage, and left ventricular sphericity) are helpful to predict the poor prognosis of patients with aSAH with ventricular hemorrhage. The dimensional fusion model has greater value in predicting the poor prognosis of patients ¹⁵⁾

Quantitative estimation of the hemorrhage volume associated with aneurysm rupture is a tool of assessing prognosis.

A prospective cohort of 206 patients consecutively admitted with the diagnosis of aneurysmal subarachnoid hemorrhage to Hospital 12 de Octubre were included in the study. Subarachnoid, intraventricular, intracerebral, and total bleeding volumes were calculated using analytic software. For assessing factors related to prognosis, univariate and multivariate analysis (logistic regression) were performed. The relative importance of factors in determining prognosis was established by calculating their proportion of explained variation. Maximum Youden index was calculated to determine the optimal cut point for subarachnoid and total bleeding volume.

Variables independently related to prognosis were clinical grade at admission, age, and the different bleeding volumes. The proportion of variance explained is higher for subarachnoid bleeding. The optimal cut point related to poor prognosis is a volume of 20 mL both for subarachnoid and total bleeding.

Volumetric measurement of subarachnoid or total bleeding volume are both independent prognostic factors in patients with aneurysmal subarachnoid hemorrhage. A volume of more than 20 mL of blood in the initial noncontrast computed tomography is related to a clear increase in poor outcome risk ¹⁶⁾.

Acute lung injury or acute respiratory distress syndrome (ALI/ARDS) is a common complication after aneurysmal subarachnoid hemorrhage (aSAH), and is associated with worse neurologic outcomes and longer hospitalization. However, the effect of ALI/ARDS in SAH has not been well elucidated. The purpose of this study was to determine the incidence of ALI/ARDS in a cohort of patients with SAH and to determine the risk factors for ALI/ARDS and their impact on patient prognosis. We performed a retrospective analysis of 167 consecutive patients with aSAH enrolled. ALI/ARDS patients were rigorously adjudicated using North American-European Consensus Conference definition. Regression analyses were used to test the risk factors for ALI/ARDS in patients with SAH. A total of 167 patients fulfilled the inclusion criteria, and 27% patients (45 of 167) developed ALI. Among all 45 ALI patients, 33 (20%, 33 of 167) patients met criteria for ARDS. On multivariate analysis, elderly patients, lower glasgow coma scale (GCS), higher Hunt-Hess grade, higher simplified acute physiology score (SAPS) II score, pre-existing pneumonia, gastric aspiration, hypoxemia, and tachypnea were the strongest risk factor for ALI/ARDS. Patients with ALI/ARDS showed worse clinical outcomes measured at 30 days. Development of ALI/ARDS was associated with a statistically significant increasing the odds of tracheostomy and hospital complications, and increasing duration of mechanical ventilation, intensive care unit (ICU) length and hospitalization stay. Development of ALI/ARDS is a severe complication of SAH and is associated with a poor clinical outcome, and further studies should focus on both prevention and management strategies specific to SAH-associated ALI/ARDS ¹⁷⁾.

see C-reactive protein for aneurysmal subarachnoid hemorrhage outcome.

Higher early IL6 serum levels after aSAH are associated with poor outcome at discharge. In addition, involvement of leukemia inhibitory factor (LIF) in the early inflammatory reaction after aSAH has been demonstrated ¹⁸⁾.

The APOΕε4 polymorphism was analysed in 147 patients with aSAH. Allele and genotype frequencies were compared to those found in a gender- and area-matched control group of healthy individuals (n = 211). Early cerebral vasospasm (CVS) was identified and treated according to neurointensive care unit (NICU) guidelines. Neurological deficit(s) at admittance and at 1-year follow-up visit was recorded. Neurological outcome was assessed by the National Institute of Health Stroke Scale, Barthel Index and the Extended Glasgow Outcome Scale.

APOEε4 and non-APOEε4 allele frequencies were similar in aSAH patients and healthy individuals. The presence of APOEε4 was not associated with the development of early CVS. We could not find an influence of the APOE polymorphism on 1-year neurological outcome between groups. Subgroup analyses of patients treated with surgical clipping vs endovascular coiling did not reveal any associations.

For Csajbok et al. APOEε4 polymorphism has no major influence on risk of aSAH, the occurrence of CVS or long-term neurological outcome after aSAH ¹⁹⁾.

For Cheng et al., Apolipoprotein E (APOEε4) may induce cerebral perfusion impairment in the early phase, contributing to early brain injury (EBI) following aneurysmal subarachnoid hemorrhage (aSAH), and assessment of APOE genotypes could serve as a useful tool in the prognostic evaluation and therapeutic management of aSAH ²⁰⁾.

Iatrogenic coagulopathy caused by Direct oral anticoagulants or vitamin K antagonists was not associated with more severe radiological or clinical subarachnoid hemorrhage or worse clinical outcomes in hospitalized SAH patients ²¹⁾.

Brain edema in aneurysmal subarachnoid hemorrhage

Myosteatosis was found to be associated with poor physical condition directly after the onset of aSAH. Skeletal muscle atrophy and myosteatosis were however irrelevant to outcome in the Western-European aSAH patient. Future studies are needed to validate these finding ²²⁾.

Aneurysmal subarachnoid hemorrhage length of stay.

A low PbtO2 value is associated with a worse prognosis, and an increase in the PbtO2 value in response to treatment is a marker of a good outcome ²³⁾.

The inverse correlation between mean arterial pressure and mean transit time (MTT) in early perfusion computed tomography, increasing with the severity of aSAH, suggests an increasing disturbance of cerebral autoregulation with the severity of early brain injury. The results emphasize the importance of maintaining physiological blood pressure values in the early phase of aSAH and preventing hypotension, especially in patients with poor-grade aSAH ²⁴⁾