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Segherlou ZH, Shakeri-Darzekonani M, Khavandegar A, Stephenson S, Ciccone K, Masheghati F, Hosseini Siyanaki MR, Lyerly M, Lucke-Wold B. Hormonal influences on cerebral aneurysms: unraveling the complex connections. Expert Rev Endocrinol Metab 2024; 19:207-215. [PMID: 38712738 DOI: 10.1080/17446651.2024.2347275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/22/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Intracranial aneurysms (IAs) occur in 3-5% of the general population and are characterized by localized structural deterioration of the arterial wall with loss of internal elastic lamina and disruption of the media. The risk of incidence and rupture of aneurysms depends on age, sex, ethnicity, and other different factors, indicating the influence of genetic and environmental factors. When an aneurysm ruptures, there is an estimated 20% mortality rate, along with an added 30-40% morbidity in survivors. The alterations in hormonal levels can influence IAs, while the rupture of an aneurysm can have various impacts on endocrine pathways and affect their outcome. AREA COVERED This review explores the reciprocal relationship between endocrinological changes (estrogen, growth hormone, and thyroid hormones) and IAs, as well as the effects of aneurysm ruptures on endocrine fluctuations. EXPERT OPINION Based on the data presented in this paper, we recommend further exploration into the influence of hormones on aneurysm formation and rupture. Additionally, we propose conducting endocrine assessments for patients who have experienced a rupture of IAs. Monitoring hormonal changes in patients with IAs could serve as a potential risk factor for rupture, leading to interventions in the approach to managing IAs.
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Affiliation(s)
| | | | - Armin Khavandegar
- College of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Stephenson
- Biotechnology Department, Krieger School of Arts and Sciences, John Hopkins University, Baltimore, MD, USA
| | - Kimberly Ciccone
- Department of Behavioral Neuroscience, College of Arts and Sciences, University of North Florida, Jacksonville, FL, USA
| | - Forough Masheghati
- College of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Mac Lyerly
- School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
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Ramirez-Velandia F, Young M, Alwakaa O, Han K, Ogilvy CS. Flow Diversion as a Definitive Treatment for Recurrently Ruptured A1-A2 Anterior Cerebral Artery Aneurysm Following Clipping and Coiling. Cureus 2024; 16:e57103. [PMID: 38681287 PMCID: PMC11054312 DOI: 10.7759/cureus.57103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
Even after clipping of intracranial aneurysms, patients may experience incomplete occlusion or the future recurrence of their treated aneurysm. This paper presents a distinctive case of a recurrent A1-A2 anterior cerebral artery aneurysm that underwent four interventions over 16 years. The aneurysm was treated with two clippings, subsequent coiling, and flow diversion for definitive treatment. The challenges encountered in managing bifurcation aneurysms are discussed, emphasizing the importance of considering hemodynamic factors, vessel geometry, and recurrence risk factors in treatment decisions. The case highlights the need for closer follow-up of ruptured bifurcation aneurysms due to the higher likelihood of recurrence. The role of flow diverters in reinforcing vessel anatomy and preventing recurrence is also highlighted.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurological Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Michael Young
- Neurological Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Omar Alwakaa
- Neurological Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Kimberly Han
- Neurological Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Christopher S Ogilvy
- Neurological Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
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3
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Boite Y, Suaiden Klein T, de Andrade Medronho R, Wajnberg E. Numerical simulation of flow-diverting stent: comparison between branches in bifurcation brain aneurysm. Biomech Model Mechanobiol 2023; 22:1801-1814. [PMID: 37335373 DOI: 10.1007/s10237-023-01733-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
The usage of flow-diverting stents in the treatment of intracranial aneurysms is widespread due to their high success and low complication rates. However, their use is still not officially recommended for bifurcation aneurysms, as there is a risk of generating ischemic complications due to the reduced blood flow to the jailed branch. Many works utilize computational fluid dynamics (CFD) to study how hemodynamic variables respond to flow diverter placement, but few seem to use it to verify flow variation between branches of bifurcation aneurysms and to aid in the choice of the best ramification for device placement. This investigation was performed in the present work, by comparing wall shear stress (WSS) and flowrates for a patient-specific scenario of a middle cerebral artery (MCA) aneurysm, considering device placement on each branch. A secondary objective was to follow a methodology that provides fast results, envisioning application to daily medical practice. The device was simplified as a homogeneous porous medium, and extreme porosity values were simulated for comparison. Results suggest that stent placement on either branch is both safe and effective, significantly reducing WSS and flow into the aneurysm while maintaining flow to the different ramifications within acceptable thresholds.
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Affiliation(s)
- Yasmin Boite
- Programa de Pós-Graduação em Engenharia de Processos Químicos e Bioquímicos da Escola de Química, UFRJ, LabCFD, Rua Moniz de Aragão, Bloco K, Rio de Janeiro, RJ, 21941972, Brazil.
| | - Tânia Suaiden Klein
- Programa de Pós-Graduação em Engenharia de Processos Químicos e Bioquímicos da Escola de Química, UFRJ, LabCFD, Rua Moniz de Aragão, Bloco K, Rio de Janeiro, RJ, 21941972, Brazil
| | - Ricardo de Andrade Medronho
- Programa de Pós-Graduação em Engenharia de Processos Químicos e Bioquímicos da Escola de Química, UFRJ, LabCFD, Rua Moniz de Aragão, Bloco K, Rio de Janeiro, RJ, 21941972, Brazil
| | - Eduardo Wajnberg
- Radiologia Intervencionista, Hospital Américas, Avenida Jorge Curi, 550, Rio de Janeiro, RJ, 22793334, Brazil
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Brambila-Solórzano A, Méndez-Lavielle F, Naude JL, Martínez-Sánchez GJ, García-Rebolledo A, Hernández B, Escobar-del Pozo C. Influence of Blood Rheology and Turbulence Models in the Numerical Simulation of Aneurysms. Bioengineering (Basel) 2023; 10:1170. [PMID: 37892900 PMCID: PMC10604493 DOI: 10.3390/bioengineering10101170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/18/2023] [Accepted: 09/30/2023] [Indexed: 10/29/2023] Open
Abstract
An aneurysm is a vascular malformation that can be classified according to its location (cerebral, aortic) or shape (saccular, fusiform, and mycotic). Recently, the study of blood flow interaction with aneurysms has gained attention from physicians and engineers. Shear stresses, oscillatory shear index (OSI), gradient oscillatory number (GON), and residence time have been used as variables to describe the hemodynamics as well as the origin and evolution of aneurysms. However, the causes and hemodynamic conditions that promote their growth are still under debate. The present work presents numerical simulations of three types of aneurysms: two aortic and one cerebral. Simulation results showed that the blood rheology is not relevant for aortic aneurysms. However, for the cerebral aneurysm case, blood rheology could play a relevant role in the hemodynamics. The evaluated turbulence models showed equivalent results in both cases. Lastly, a simulation considering the fluid-structure interaction (FSI) showed that this phenomenon is the dominant factor for aneurysm simulation.
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Affiliation(s)
- Alberto Brambila-Solórzano
- Thermofluids Department, Faculty of Engineering, UNAM, Coyoacan, Mexico City C.P. 04510, Mexico (F.M.-L.); (J.L.N.); (G.J.M.-S.)
| | - Federico Méndez-Lavielle
- Thermofluids Department, Faculty of Engineering, UNAM, Coyoacan, Mexico City C.P. 04510, Mexico (F.M.-L.); (J.L.N.); (G.J.M.-S.)
| | - Jorge Luis Naude
- Thermofluids Department, Faculty of Engineering, UNAM, Coyoacan, Mexico City C.P. 04510, Mexico (F.M.-L.); (J.L.N.); (G.J.M.-S.)
| | - Gregorio Josué Martínez-Sánchez
- Thermofluids Department, Faculty of Engineering, UNAM, Coyoacan, Mexico City C.P. 04510, Mexico (F.M.-L.); (J.L.N.); (G.J.M.-S.)
| | - Azael García-Rebolledo
- Faculty of Mechanical and Electrical Engineering, Carretera Km 9 Colima-Coquimatlan, Colima C.P. 28400, Mexico
| | - Benjamín Hernández
- Oak Ridge Leadership Computing Facility, Oak Ridge National Laboratory, Oak Ridge, TN 37830, USA;
| | - Carlos Escobar-del Pozo
- Faculty of Mechanical and Electrical Engineering, Carretera Km 9 Colima-Coquimatlan, Colima C.P. 28400, Mexico
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Li W, Wu X, Wang J, Huang T, Zhou L, Zhou Y, Tan Y, Zhong W, Zhou Z. A novel clinical-radscore nomogram for predicting ruptured intracranial aneurysm. Heliyon 2023; 9:e20718. [PMID: 37842571 PMCID: PMC10570585 DOI: 10.1016/j.heliyon.2023.e20718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023] Open
Abstract
Objectives Our study aims to find the more practical and powerful method to predict intracranial aneurysm (IA) rupture through verification of predictive power of different models. Methods Clinical and imaging data of 576 patients with IAs including 192 ruptured IAs and matched 384 unruptured IAs was retrospectively analyzed. Radiomics features derived from computed tomography angiography (CTA) images were selected by t-test and Elastic-Net regression. A radiomics score (radscore) was developed based on the optimal radiomics features. Inflammatory markers were selected by multivariate regression. And then 4 models including the radscore, inflammatory, clinical and clinical-radscore models (C-R model) were built. The receiver operating characteristic curve (ROC) was performed to evaluate the performance of each model, PHASES and ELAPSS. The nomogram visualizing the C-R model was constructed to predict the risk of IA rupture. Results Five inflammatory features, 2 radiological characteristics and 7 radiomics features were significantly associated with IA rupture. The areas under ROCs of the radscore, inflammatory, clinical and C-R models were 0.814, 0.935, 0.970 and 0.975 in the training cohort and 0.805, 0.927, 0.952 and 0.962 in the validation cohort, respectively. Conclusion The inflammatory model performs particularly well in predicting the risk of IA rupture, and its predictive power is further improved by combining with radiological and radiomics features and the C-R model performs the best. The C-R nomogram is a more stable and effective tool than PHASES and ELAPSS for individually predicting the risk of rupture for patients with IA.
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Affiliation(s)
| | | | - Jing Wang
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Tianxing Huang
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Lu Zhou
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yu Zhou
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yuanxin Tan
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Weijia Zhong
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Zhiming Zhou
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
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Delucchi M, Spinner GR, Scutari M, Bijlenga P, Morel S, Friedrich CM, Furrer R, Hirsch S. Bayesian network analysis reveals the interplay of intracranial aneurysm rupture risk factors. Comput Biol Med 2022; 147:105740. [DOI: 10.1016/j.compbiomed.2022.105740] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/24/2022] [Accepted: 06/11/2022] [Indexed: 11/24/2022]
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Wetzel-Yalelis A, Karadag C, Li L, Turowski B, Bostelmann R, Abusabha Y, Hofmann BB, Gousias K, Agrawal R, König M, Kaiser M, Mijderwijk HJ, Petridis AK. The rupture of an anterior communicating artery aneurysm does not associate with an asymmetry in the A1 or A2 arteries: a retrospective study of radiological features. Br J Neurosurg 2021:1-6. [PMID: 34933612 DOI: 10.1080/02688697.2021.2016624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 10/24/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Although the formation and rupture risk of an anterior communicating artery (ACoA) aneurysm has been the subject of many studies, no previous study has primarily searched for the relationship of the parent and daughter vessels and the impact of their size/diameter ratio on the potential rupture risk of an AcoA aneurysm. The objective of this study is to explore this link and to further analyse the surrounding vasculature of the anterior communicating artery aneurysm. MATERIALS AND METHODS We conducted a retrospective analysis of 434 patients: 284 patients with an ACoA aneurysm (121 unruptured and 162 ruptured) and 150 control patients without an ΑCoA aneurysm. Radiological angiography investigations were used to assess the diameter ratios of the parent vessels in addition to ACoA aneurysm morphology parameters. RESULTS When comparing the ruptured to the unruptured cases, we observed no significant difference in the parent or daughter vessel diameter ratios. Younger patient age (OR 0.96, p = 0.00) and a higher aneurysm size ratio (OR 1.10, p = 0.02) were of prognostic importance concerning the rupture risk of the aneurysm. The A1 diameter ratio and the A2 diameter were not statistically significant (OR 1.00, p = 0.99, and OR 3.38, p = 0.25 respectively). CONCLUSIONS In our study, we focused on asymmetry in the parent and daughter vessels as well as traditional ACoA aneurysm morphological characteristics. We were able to label younger patient age and a greater size ratio as independent prognostic factors for ACoA aneurysm rupture. We were unable to label parent and daughter vessel asymmetry as prognostic factors. To validate our findings, parent and daughter vessel asymmetry should be subjected to future prospective studies.
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Affiliation(s)
| | - Cihat Karadag
- Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Lan Li
- Department of Neurosurgery, Alfried Krupp Hospital, Essen, Germany
| | - Bernd Turowski
- Medical Faculty, Department of Diagnostic and Interventional Radiology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Richard Bostelmann
- Department of Neurosurgery, Christliches Krankenhaus Quakenbrück gemeinnützige GmbH, Quakenbrück, Germany
| | - Yousef Abusabha
- Medical Faculty, Department of Neurosurgery, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Björn B Hofmann
- Medical Faculty, Department of Neurosurgery, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | | | - Rachit Agrawal
- Department of Neurosurgery, St. Marien Hospital, Luenen, Germany
| | - Matthias König
- Department of Diagnostic and Interventional Radiology and Neuroradiology, St. Marien Hospital, Luenen, Germany
| | - Marga Kaiser
- Department of Diagnostic and Interventional Radiology and Neuroradiology, St. Marien Hospital, Luenen, Germany
| | - Hendrik-Jan Mijderwijk
- Medical Faculty, Department of Neurosurgery, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Athanasios K Petridis
- Medical Faculty, Department of Neurosurgery, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
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8
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Morel S, Bijlenga P, Kwak BR. Intracranial aneurysm wall (in)stability-current state of knowledge and clinical perspectives. Neurosurg Rev 2021; 45:1233-1253. [PMID: 34743248 PMCID: PMC8976821 DOI: 10.1007/s10143-021-01672-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/15/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022]
Abstract
Intracranial aneurysm (IA), a local outpouching of cerebral arteries, is present in 3 to 5% of the population. Once formed, an IA can remain stable, grow, or rupture. Determining the evolution of IAs is almost impossible. Rupture of an IA leads to subarachnoid hemorrhage and affects mostly young people with heavy consequences in terms of death, disabilities, and socioeconomic burden. Even if the large majority of IAs will never rupture, it is critical to determine which IA might be at risk of rupture. IA (in)stability is dependent on the composition of its wall and on its ability to repair. The biology of the IA wall is complex and not completely understood. Nowadays, the risk of rupture of an IA is estimated in clinics by using scores based on the characteristics of the IA itself and on the anamnesis of the patient. Classification and prediction using these scores are not satisfying and decisions whether a patient should be observed or treated need to be better informed by more reliable biomarkers. In the present review, the effects of known risk factors for rupture, as well as the effects of biomechanical forces on the IA wall composition, will be summarized. Moreover, recent advances in high-resolution vessel wall magnetic resonance imaging, which are promising tools to discriminate between stable and unstable IAs, will be described. Common data elements recently defined to improve IA disease knowledge and disease management will be presented. Finally, recent findings in genetics will be introduced and future directions in the field of IA will be exposed.
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Affiliation(s)
- Sandrine Morel
- Department of Pathology and Immunology, Faculty of Medicine, Centre Medical Universitaire, University of Geneva, Rue Michel-Servet 1, 1211, Geneva, Switzerland. .,Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
| | - Philippe Bijlenga
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Brenda R Kwak
- Department of Pathology and Immunology, Faculty of Medicine, Centre Medical Universitaire, University of Geneva, Rue Michel-Servet 1, 1211, Geneva, Switzerland
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9
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Morel S, Schilling S, Diagbouga MR, Delucchi M, Bochaton-Piallat ML, Lemeille S, Hirsch S, Kwak BR. Effects of Low and High Aneurysmal Wall Shear Stress on Endothelial Cell Behavior: Differences and Similarities. Front Physiol 2021; 12:727338. [PMID: 34721060 PMCID: PMC8551710 DOI: 10.3389/fphys.2021.727338] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/21/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Intracranial aneurysms (IAs) result from abnormal enlargement of the arterial lumen. IAs are mostly quiescent and asymptomatic, but their rupture leads to severe brain damage or death. As the evolution of IAs is hard to predict and intricates medical decision, it is essential to improve our understanding of their pathophysiology. Wall shear stress (WSS) is proposed to influence IA growth and rupture. In this study, we investigated the effects of low and supra-high aneurysmal WSS on endothelial cells (ECs). Methods: Porcine arterial ECs were exposed for 48 h to defined levels of shear stress (2, 30, or 80 dyne/cm2) using an Ibidi flow apparatus. Immunostaining for CD31 or γ-cytoplasmic actin was performed to outline cell borders or to determine cell architecture. Geometry measurements (cell orientation, area, circularity and aspect ratio) were performed on confocal microscopy images. mRNA was extracted for RNAseq analysis. Results: ECs exposed to low or supra-high aneurysmal WSS were more circular and had a lower aspect ratio than cells exposed to physiological flow. Furthermore, they lost the alignment in the direction of flow observed under physiological conditions. The effects of low WSS on differential gene expression were stronger than those of supra-high WSS. Gene set enrichment analysis highlighted that extracellular matrix proteins, cytoskeletal proteins and more particularly the actin protein family were among the protein classes the most affected by shear stress. Interestingly, most genes showed an opposite regulation under both types of aneurysmal WSS. Immunostainings for γ-cytoplasmic actin suggested a different organization of this cytoskeletal protein between ECs exposed to physiological and both types of aneurysmal WSS. Conclusion: Under both aneurysmal low and supra-high WSS the typical arterial EC morphology molds to a more spherical shape. Whereas low WSS down-regulates the expression of cytoskeletal-related proteins and up-regulates extracellular matrix proteins, supra-high WSS induces opposite changes in gene expression of these protein classes. The differential regulation in EC gene expression observed under various WSS translate into a different organization of the ECs’ architecture. This adaptation of ECs to different aneurysmal WSS conditions may affect vascular remodeling in IAs.
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Affiliation(s)
- Sandrine Morel
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Sabine Schilling
- Institute of Applied Simulation, Zurich University of Applied Sciences, Wädenswil, Switzerland.,Institute of Tourism and Mobility, Lucerne School of Business, Lucerne University of Applied Sciences and Arts, Lucerne, Switzerland
| | - Mannekomba R Diagbouga
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Matteo Delucchi
- Institute of Applied Simulation, Zurich University of Applied Sciences, Wädenswil, Switzerland
| | | | - Sylvain Lemeille
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sven Hirsch
- Institute of Applied Simulation, Zurich University of Applied Sciences, Wädenswil, Switzerland
| | - Brenda R Kwak
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Li G, Song X, Wang H, Liu S, Ji J, Guo Y, Qiao A, Liu Y, Wang X. Prediction of Cerebral Aneurysm Hemodynamics With Porous-Medium Models of Flow-Diverting Stents via Deep Learning. Front Physiol 2021; 12:733444. [PMID: 34603085 PMCID: PMC8484706 DOI: 10.3389/fphys.2021.733444] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/19/2021] [Indexed: 11/26/2022] Open
Abstract
The interventional treatment of cerebral aneurysm requires hemodynamics to provide proper guidance. Computational fluid dynamics (CFD) is gradually used in calculating cerebral aneurysm hemodynamics before and after flow-diverting (FD) stent placement. However, the complex operation (such as the construction and placement simulation of fully resolved or porous-medium FD stent) and high computational cost of CFD hinder its application. To solve these problems, we applied aneurysm hemodynamics point cloud data sets and a deep learning network with double input and sampling channels. The flexible point cloud format can represent the geometry and flow distribution of different aneurysms before and after FD stent (represented by porous medium layer) placement with high resolution. The proposed network can directly analyze the relationship between aneurysm geometry and internal hemodynamics, to further realize the flow field prediction and avoid the complex operation of CFD. Statistical analysis shows that the prediction results of hemodynamics by our deep learning method are consistent with the CFD method (error function <13%), but the calculation time is significantly reduced 1,800 times. This study develops a novel deep learning method that can accurately predict the hemodynamics of different cerebral aneurysms before and after FD stent placement with low computational cost and simple operation processes.
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Affiliation(s)
- Gaoyang Li
- Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Xiaorui Song
- Department of Radiology, Shandong First Medical University and Shandong Academy of Medical Sciences, Tai'an, China
| | - Haoran Wang
- Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Siwei Liu
- Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Jiayuan Ji
- Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Yuting Guo
- Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Aike Qiao
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Youjun Liu
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Xuezheng Wang
- Department of Radiology, Shandong First Medical University and Shandong Academy of Medical Sciences, Tai'an, China
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11
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Munarriz PM, Navarro-Main B, Alén JF, Jiménez-Roldán L, Castaño-Leon AM, Moreno-Gómez LM, Paredes I, García-Pérez D, Panero I, Eiriz C, Esteban-Sinovas O, Bárcena E, Gómez PA, Lagares A. The influence of aneurysm morphology on the volume of hemorrhage after rupture. J Neurosurg 2021; 136:1015-1023. [PMID: 34534958 DOI: 10.3171/2021.3.jns21293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Factors determining the risk of rupture of intracranial aneurysms have been extensively studied; however, little attention is paid to variables influencing the volume of bleeding after rupture. In this study the authors aimed to evaluate the impact of aneurysm morphological variables on the amount of hemorrhage. METHODS This was a retrospective cohort analysis of a prospectively collected data set of 116 patients presenting at a single center with subarachnoid hemorrhage due to aneurysmal rupture. A volumetric assessment of the total hemorrhage volume was performed from the initial noncontrast CT. Aneurysms were segmented and reproduced from the initial CT angiography study, and morphology indexes were calculated with a computer-assisted approach. Clinical and demographic characteristics of the patients were included in the study. Factors influencing the volume of hemorrhage were explored with univariate correlations, multiple linear regression analysis, and graphical probabilistic modeling. RESULTS The univariate analysis demonstrated that several of the morphological variables but only the patient's age from the clinical-demographic variables correlated (p < 0.05) with the volume of bleeding. Nine morphological variables correlated positively (absolute height, perpendicular height, maximum width, sac surface area, sac volume, size ratio, bottleneck factor, neck-to-vessel ratio, and width-to-vessel ratio) and two correlated negatively (parent vessel average diameter and the aneurysm angle). After multivariate analysis, only the aneurysm size ratio (p < 0.001) and the patient's age (p = 0.023) remained statistically significant. The graphical probabilistic model confirmed the size ratio and the patient's age as the variables most related to the total hemorrhage volume. CONCLUSIONS A greater aneurysm size ratio and an older patient age are likely to entail a greater volume of bleeding after subarachnoid hemorrhage.
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Affiliation(s)
- Pablo M Munarriz
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre.,2Universidad Complutense de Madrid
| | | | - Jose F Alén
- 2Universidad Complutense de Madrid.,3Department of Neurosurgery, Hospital Universitario La Princesa; and
| | | | | | | | - Igor Paredes
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | | | - Irene Panero
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | - Carla Eiriz
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | | | - Eduardo Bárcena
- 4Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pedro A Gómez
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre
| | - Alfonso Lagares
- 1Department of Neurosurgery, Hospital Universitario 12 de Octubre.,2Universidad Complutense de Madrid
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12
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Brunozzi D, See A, Rizko M, Choi J, Atwal G, Alaraj A. Impact of cerebral aneurysm size on distal intracranial hemodynamics and changes following flow diversion. Interv Neuroradiol 2021; 28:291-295. [PMID: 34425691 DOI: 10.1177/15910199211032467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The impact of cerebral aneurysm size on distal intracranial hemodynamics such as arterial pressure and Pulsatility Index is not completely understood, either before or after flow diversion. OBJECTIVE The aim of the study is to assess the impact of aneurysm size on distal Pulsatility Index and pressure before and after flow diversion. METHODS From December 2015, prospective measurement of middle cerebral artery pressure and Pulsatility Index was performed in consecutive patients with unruptured cerebral aneurysms in the cavernous to communicating segments of the internal carotid artery, which were treated with single flow diversion. Pressure and Pulsatility Index were recorded at the M1-segment ipsilateral to the cerebral aneurysm. Ratio of middle cerebral artery to radial arterial pressure (pressure ratio) was calculated to control for variations in systemic blood pressure. Correlations between aneurysm size and pressure ratio and Pulsatility Index were assessed before and after treatment. RESULTS A total of 28 aneurysms were treated. The mean aneurysm size was 7.2 mm. Aneurysm size correlated linearly with systolic pressure ratio (1% pressure ratio increase per mm aneurysm size increase, P = 0.002, r2 = 0.33), mean pressure ratio (0.6% per mm, P = 0.03, r2 = 0.17) and Pulsatility Index (5% Pulsatility Index increase per mm, P = 0.003, r2 = 0.43). After flow diversion, aneurysm size preserved a linear correlation with the systolic pressure ratio (1% per mm, P = 0.004, r2 = 0.28), but not with the mean pressure ratio (0.4% per mm, P = 0.15, r2 < 0.1) or Pulsatility Index (0.3% per mm, P = 0.78, r2 < 0.1). CONCLUSION Aneurysm size affects distal hemodynamics: patients with larger aneurysms have increased systolic and mean pressure ratio, and increased Pulsatility Index. After flow diversion, mean pressure ratio and Pulsatility Index no longer associate with the aneurysm size, suggesting an effect of the flow diversion also on distal intracranial hemodynamics.
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Affiliation(s)
- Denise Brunozzi
- Department of Neurosurgery, 14681University of Illinois at Chicago, USA
| | - Alfred See
- Department of Neurosurgery, 14681University of Illinois at Chicago, USA
| | - Mark Rizko
- Department of Neurosurgery, 14681University of Illinois at Chicago, USA
| | - Jason Choi
- Department of Neurosurgery, 14681University of Illinois at Chicago, USA
| | - Gursant Atwal
- Department of Neurosurgery, 14681University of Illinois at Chicago, USA
| | - Ali Alaraj
- Department of Neurosurgery, 14681University of Illinois at Chicago, USA.,12247Department of Bioengineering, 21725University of Illinois at Chicago, USA
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Hemodynamic factor evaluation using computational fluid dynamics analysis for de novo bleb formation in unruptured intracranial aneurysms. Neurol Sci 2021; 43:1849-1857. [PMID: 34331615 PMCID: PMC8860802 DOI: 10.1007/s10072-021-05482-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/08/2021] [Indexed: 11/25/2022]
Abstract
Background Although bleb formation increases the risk of rupture of intracranial aneurysms, previous computational fluid dynamic (CFD) studies have been unable to identify robust causative hemodynamic factors, due to the morphological differences of prebleb aneurysm models and a small number of aneurysms with de novo bleb formation. This study investigated the influences of differences in the aneurysm-models and identify causative hemodynamic factors for de novo bleb formation. Materials and methods CFD analysis was conducted on three aneurysm models, actual prebleb, postbleb, and virtual prebleb models of two unruptured aneurysms with de novo bleb formation. A new multipoint method was introduced in this study. We evenly distributed points with a 0.5-mm distance on the aneurysm surface of the actual prebleb models (146 and 152 points in the individual aneurysm, respectively), and we statistically compared hemodynamics at the points in the areas with and without bleb formation (19 and 279 points, respectively). Results Visually, blebs formed on an aneurysm surface area with similar hemodynamic characteristics in the actual and virtual prebleb models. Statistical analysis using the multipoint method revealed that the de novo bleb formation area was significantly correlated with high pressure (p < 0.001), low wall shear stress (WSS) (p < 0.001), and the center of divergent WSS vectors (p = 0.025). Conclusions De novo bleb formation in intracranial aneurysms may occur in areas associated with the combination of high pressure, low WSS, and the center of divergent WSS vectors. The multipoint method is useful for statistical analysis of hemodynamics in a limited number of aneurysms.
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Rutkowski DR, Roldán-Alzate A, Johnson KM. Enhancement of cerebrovascular 4D flow MRI velocity fields using machine learning and computational fluid dynamics simulation data. Sci Rep 2021; 11:10240. [PMID: 33986368 PMCID: PMC8119419 DOI: 10.1038/s41598-021-89636-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 04/29/2021] [Indexed: 12/12/2022] Open
Abstract
Blood flow metrics obtained with four-dimensional (4D) flow phase contrast (PC) magnetic resonance imaging (MRI) can be of great value in clinical and experimental cerebrovascular analysis. However, limitations in both quantitative and qualitative analyses can result from errors inherent to PC MRI. One method that excels in creating low-error, physics-based, velocity fields is computational fluid dynamics (CFD). Augmentation of cerebral 4D flow MRI data with CFD-informed neural networks may provide a method to produce highly accurate physiological flow fields. In this preliminary study, the potential utility of such a method was demonstrated by using high resolution patient-specific CFD data to train a convolutional neural network, and then using the trained network to enhance MRI-derived velocity fields in cerebral blood vessel data sets. Through testing on simulated images, phantom data, and cerebrovascular 4D flow data from 20 patients, the trained network successfully de-noised flow images, decreased velocity error, and enhanced near-vessel-wall velocity quantification and visualization. Such image enhancement can improve experimental and clinical qualitative and quantitative cerebrovascular PC MRI analysis.
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Affiliation(s)
- David R Rutkowski
- Mechanical Engineering, University of Wisconsin, Madison, WI, USA
- Radiology, University of Wisconsin, 1111 Highland Ave, Madison, WI, USA
| | - Alejandro Roldán-Alzate
- Mechanical Engineering, University of Wisconsin, Madison, WI, USA
- Radiology, University of Wisconsin, 1111 Highland Ave, Madison, WI, USA
| | - Kevin M Johnson
- Radiology, University of Wisconsin, 1111 Highland Ave, Madison, WI, USA.
- Medical Physics, University of Wisconsin, 1111 Highland Ave, Madison, WI, USA.
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15
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Wüstenhagen C, John K, Langner S, Brede M, Grundmann S, Bruschewski M. CFD validation using in-vitro MRI velocity data - Methods for data matching and CFD error quantification. Comput Biol Med 2021; 131:104230. [PMID: 33545507 DOI: 10.1016/j.compbiomed.2021.104230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 11/26/2022]
Abstract
Predicting blood flow velocities in patient-specific geometries with Computational Fluid Dynamics (CFD) can provide additional data for diagnosis and treatment planning but the solution can be inaccurate. Therefore, it is crucial to understand the simulation errors and calibrate the numerical model. In-vitro velocity-encoded MRI is a versatile tool to validate CFD. The comparison between CFD and in-vitro MRI velocity data, and the analysis of the simulation error are the objectives of this study. A three-step routine is presented to validate medical CFD data. First, a properly scaled model of the patient-specific geometry is fabricated to achieve high relative resolution in the MRI experiment. Second, the measured flow geometry is matched with the CFD data using one of two algorithms, Coherent Point Drift and Iterative Closest Point. The aligned data sets are then interpolated onto a common grid to enable a point-to-point comparison. Third, the global and local deviations between CFD and MRI velocity data are calculated using different algorithms to reliably estimate the simulation error. The routine is successfully tested with a patient-specific model of a cerebral aneurysm. In conclusion, the methods presented here provide a framework for CFD validation using in-vitro MRI velocity data.
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Affiliation(s)
- Carolin Wüstenhagen
- Institute of Fluid Mechanics, University of Rostock, Justus-von-Liebig-Weg 2, 18059, Rostock, Germany
| | - Kristine John
- Institute of Fluid Mechanics, University of Rostock, Justus-von-Liebig-Weg 2, 18059, Rostock, Germany
| | - Sönke Langner
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057, Rostock, Germany
| | - Martin Brede
- Institute of Fluid Mechanics, University of Rostock, Justus-von-Liebig-Weg 2, 18059, Rostock, Germany
| | - Sven Grundmann
- Institute of Fluid Mechanics, University of Rostock, Justus-von-Liebig-Weg 2, 18059, Rostock, Germany
| | - Martin Bruschewski
- Institute of Fluid Mechanics, University of Rostock, Justus-von-Liebig-Weg 2, 18059, Rostock, Germany.
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16
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Lyu L, Xu P, Ping J, Hu C, Xu K. Changes and significance of hydrodynamic parameters in Budd-Chiari syndrome with obstruction of the inferior vena cava prior to and after interventional therapy. Exp Ther Med 2021; 21:178. [PMID: 33488788 PMCID: PMC7812571 DOI: 10.3892/etm.2021.9609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/17/2020] [Indexed: 01/01/2023] Open
Abstract
In recent years, the role of computational fluid dynamics for Budd-Chiari syndrome evaluation has become the focus of certain studies. The purpose of the present study was to evaluate the role of computational fluid dynamics in Budd-Chiari syndrome with obstruction of the inferior vena cava (IVC). Magnetic resonance venous angiography was used to obtain original IVC and hepatic venous blood flow images from patients with Budd-Chiari syndrome. The computational fluid dynamics method was used to establish a three-dimensional model and simulate the blood flow velocity, wall shear stress and wall pressure. The results revealed that the hemodynamic parameters of Budd-Chiari syndrome were successfully simulated by computational fluid dynamics. The hemodynamic parameters of the IVC stenosis varied with the cardiac cycle. Vascular flow velocity (pre-operative, 1.64±0.10 m/sec; post-operative, 0.34±0.14 m/sec; t=34.97, P<0.001) and wall shear stress (pre-operative, 25.69±2.85 Pa; post-operative, 3.51±1.70 Pa; t=29.86, P<0.001) at the area of stenosis decreased after interventional therapy and the wall pressure increased (pre-operative, -119.33±251.50 Pa; post-operative, 1,128.42±207.70 Pa; t=17.10, P<0.001). In conclusion, the computational fluid dynamics method was able to effectively simulate the hemodynamic parameters of Budd-Chiari syndrome with obstruction of the IVC and may provide an effective quantitative method for the evaluation of vascular function post-treatment.
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Affiliation(s)
- Lulu Lyu
- The First School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China.,Department of CT and MRI, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
| | - Peng Xu
- Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, P.R. China
| | - Jie Ping
- Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, P.R. China
| | - Chunfeng Hu
- Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, P.R. China
| | - Kai Xu
- The First School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China.,Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, P.R. China
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17
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A review of hemodynamic parameters in cerebral aneurysm. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2020. [DOI: 10.1016/j.inat.2020.100716] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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18
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Numerical investigation of patient-specific thoracic aortic aneurysms and comparison with normal subject via computational fluid dynamics (CFD). Med Biol Eng Comput 2020; 59:71-84. [PMID: 33225424 DOI: 10.1007/s11517-020-02287-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
Vascular hemodynamics play an important role in cardiovascular diseases. This work aimed to investigate the effects of an increase in ascending aortic diameter (AAD) on hemodynamics throughout a cardiac cycle for real patients. In this study, two scans of thoracic aortic aneurysm (TAA) subject with different AADs (42.94 mm and 48.01 mm) and a scan of a normal subject (19.81 mm) were analyzed to assess the effects of hemodynamics on the progression of TAA with the same flow rate. Real-patient aortic geometries were scanned by computed tomography angiography (CTA), and steady and pulsatile flow conditions were used to simulate real patient aortic geometries. Aortic arches were obtained from routine clinical scans. Computational fluid dynamics (CFD) simulations were performed with in vivo boundary conditions, and 3D Navier-Stokes equations were solved by a UDF (user-defined function) code defining a real cardiac cycle of one patient using Fourier series (FS). Wall shear stress (WSS) and pressure distributions were presented from normal subject to TAA cases. The results show that during the peak systolic phase pressure load increased by 18.56% from normal subject to TAA case 1 and by 23.8% from normal subject to TAA case 2 in the aneurysm region. It is concluded that although overall WSS increased in aneurysm cases but was low in dilatation areas. As a result, abnormal changes in WSS and higher pressure load may lead to rupture and risk of further dilatation. CFD simulations were highly effective to guide clinical predictions and assess the progress of aneurysm regions in case of early surgical intervention. Graphical abstract.
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19
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Munarriz PM, Bárcena E, Alén JF, Castaño-Leon AM, Paredes I, Moreno-Gómez LM, García-Pérez D, Jiménez-Roldán L, Gómez PA, Lagares A. Reliability and accuracy assessment of morphometric measurements obtained with software for three-dimensional reconstruction of brain aneurysms relative to cerebral angiography measures. Interv Neuroradiol 2020; 27:191-199. [PMID: 32996346 DOI: 10.1177/1591019920961588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To analyze the reliability and accuracy of morphological measurements of software employed to three-dimensionally reconstruct aneurysms and vessels (VMTKlab, version 1.6.1,) with computed tomography angiography (CTA) as the source of images. Agreement with measurements from three-dimensional digital subtraction angiography (3 D-DSA) was evaluated. METHODS We evaluated 40 patients presenting with aneurysmal subarachnoid hemorrhage (aSAH). We analyzed four main variables of the aneurysm morphology: absolute height (size), neck (maximum neck width), perpendicular height, and maximum width. The CTA images were uploaded to the software and then segmented to reconstruct the aneurysm. This new method was compared to the current gold standard-3D reconstruction of pretreatment cerebral angiography. We used intraclass correlation coefficient (ICC) and Bland-Altman plot analyses to evaluate the agreement between these methods. RESULTS The ICCs obtained for absolute height, neck, perpendicular height, and maximum width were 0.85, 0.57, 0.85, and 0.89, respectively. This implied good agreement except for the neck of the aneurysm (moderate agreement). Bland-Altman plots are presented for the four indexes. The average of the differences was not significant in terms of absolute height, perpendicular height, and maximum width indicating good agreement. However, it was significant for the neck of the aneurysm. CONCLUSIONS We report good agreement between the values generated using VMTKlab and cerebral angiography for three of the four main variables. Discrepancies in neck diameter are not surprising and its underestimation with a traditional delineation from cerebral angiography has been reported before.
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Affiliation(s)
- Pablo M Munarriz
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación i±12, Madrid, Spain.,Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
| | - Eduardo Bárcena
- Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jose F Alén
- Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Department of Neurosurgery, Hospital Universitario La Princesa, Madrid, Spain
| | - Ana M Castaño-Leon
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación i±12, Madrid, Spain.,Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación i±12, Madrid, Spain.,Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
| | - Luis Miguel Moreno-Gómez
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación i±12, Madrid, Spain
| | - Daniel García-Pérez
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación i±12, Madrid, Spain
| | - Luis Jiménez-Roldán
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación i±12, Madrid, Spain.,Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
| | - Pedro A Gómez
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación i±12, Madrid, Spain.,Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación i±12, Madrid, Spain.,Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
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20
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Sun L, Wang J, Li M, Li M, Zhu Y. The contribution of wall shear stress insult to the growth of small unruptured cerebral aneurysms in longitudinal 3D-TOF-MRA. J Neurol Sci 2020; 413:116798. [DOI: 10.1016/j.jns.2020.116798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/11/2020] [Accepted: 03/20/2020] [Indexed: 12/23/2022]
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21
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Size-Dependent Distribution of Patient-Specific Hemodynamic Factors in Unruptured Cerebral Aneurysms Using Computational Fluid Dynamics. Diagnostics (Basel) 2020; 10:diagnostics10020064. [PMID: 31991621 PMCID: PMC7168895 DOI: 10.3390/diagnostics10020064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/17/2020] [Accepted: 01/23/2020] [Indexed: 12/26/2022] Open
Abstract
PURPOSE To analyze size-dependent hemodynamic factors [velocity, shear rate, blood viscosity, wall shear stress (WSS)] in unruptured cerebral aneurysms using computational fluid dynamics (CFD) based on the measured non-Newtonian model of viscosity. METHODS Twenty-one patients with unruptured aneurysms formed the study cohort. Patient-specific geometric models were reconstructed for CFD analyses. Aneurysms were divided into small and large groups based on a cutoff size of 5 mm. For comparison between small and large aneurysms, 5 morphologic variables were measured. Patient-specific non-Newtonian blood viscosity was applied for more detailed CFD simulation. Quantitative and qualitative analyses of velocity, shear rate, blood viscosity, and WSS were conducted to compare small and large aneurysms. RESULTS Complex flow patterns were found in large aneurysms. Large aneurysms had a significantly lower shear rate (235 ± 341 s-1)) than small aneurysms (915 ± 432 s-1) at peak-systole. Two times higher blood viscosity was observed in large aneurysms compared with small aneurysms. Lower WSS was found in large aneurysms (1.38 ± 1.36 Pa) than in small aneurysms (3.53 ± 1.22 Pa). All the differences in hemodynamic factors between small and large aneurysms were statistically significant. CONCLUSIONS Large aneurysms tended to have complex flow patterns, low shear rate, high blood viscosity, and low WSS. The hemodynamic factors that we analyzed might be useful for decision making before surgical treatment of aneurysms.
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Role of bioclimate conditions on cerebral aneurysm rupture in the Brittany region of France. Neurochirurgie 2019; 66:9-15. [PMID: 31836487 DOI: 10.1016/j.neuchi.2019.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 08/30/2019] [Accepted: 11/03/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Subarachnoid hemorrhage (SAH) from intracranial aneurysm rupture is an unpredictable event responsible for significant morbidity and mortality. Despite inconsistencies, some studies suggest a potential role of climate conditions in SAH onset. The purpose of this study was to determine the impact of climatic and lunar factors on onset of SAH in an oceanic climate such as that of Brittany, France. METHODS All adults with SAH admitted to the neurosurgery department and intensive care unit of the University Hospital of Rennes (France) between January 1st, 2011 and December 31st, 2012 were included. Meteorological variables, their variations, lunar phases and tidal coefficients were compared between days with and without SAH. RESULTS We retrospectively included 295 patients with SAH. Mean minimum temperature was significantly lower during days with SAH (7.7±4.7°C versus 8.3±4.6°C; P=0.039); temperature variation between 2 successive days was significantly greater for days with SAH (8.6±4.1°C versus 7.9±3.8°C; P<0.01). Multivariate analysis showed that a 2-day temperature drop greater than or equal to 8°C was associated with 35% increased risk of SAH (odds ratio 1.35 [1.03-1.77]). There were no significant effects of other meteorological variables, lunar phase or tidal coefficient on SAH occurrence. CONCLUSION Low temperature and sudden temperature drop were associated with increased occurrence of SAH in Brittany, France.
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Millesi M, Knosp E, Mach G, Hainfellner JA, Ricken G, Trattnig S, Gruber A. Focal irregularities in 7-Tesla MRI of unruptured intracranial aneurysms as an indicator for areas of altered blood-flow parameters. Neurosurg Focus 2019; 47:E7. [PMID: 31786557 DOI: 10.3171/2019.9.focus19489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/09/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In the last several decades, various factors have been studied for a better evaluation of the risk of rupture in incidentally discovered intracranial aneurysms (IAs). With advanced MRI, attempts were made to delineate the wall of IAs to identify weak areas prone to rupture. However, the field strength of the MRI investigations was insufficient for reasonable image resolution in many of these studies. Therefore, the aim of this study was to analyze findings of IAs in ultra-high field MRI at 7 Tesla (7 T). METHODS Patients with incidentally found IAs of at least 5 mm in diameter were included in this study and underwent MRI investigations at 7 T. At this field strength a hyperintense intravascular signal can be observed on nonenhanced images with a brighter "rim effect" along the vessel wall. Properties of this rim effect were evaluated and compared with computational fluid dynamics (CFD) analyses. RESULTS Overall, 23 aneurysms showed sufficient image quality for further evaluation. In 22 aneurysms focal irregularities were identified within this rim effect. Areas of such irregularities showed significantly higher values in wall shear stress and vorticity compared to areas with a clearly visible rim effect (p = 0.043 in both). CONCLUSIONS A hyperintense rim effect along the vessel wall was observed in most cases. Focal irregularities within this rim effect showed higher values of the mean wall shear stress and vorticity when compared by CFD analyses. Therefore, these findings indicate alterations in blood flow in IAs within these areas.
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Affiliation(s)
- Matthias Millesi
- 1Department of Neurosurgery.,3Cerebrovascular Research Group Vienna
| | | | | | | | | | - Siegfried Trattnig
- 5High Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna; and
| | - Andreas Gruber
- 1Department of Neurosurgery.,2Department of Neurosurgery, Johannes Kepler University Linz, Austria.,3Cerebrovascular Research Group Vienna
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Brunozzi D, Theiss P, Andrews A, Amin-Hanjani S, Charbel FT, Alaraj A. Correlation Between Laminar Wall Shear Stress and Growth of Unruptured Cerebral Aneurysms: In Vivo Assessment. World Neurosurg 2019; 131:e599-e605. [DOI: 10.1016/j.wneu.2019.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 10/26/2022]
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25
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Staarmann B, Smith M, Prestigiacomo CJ. Shear stress and aneurysms: a review. Neurosurg Focus 2019; 47:E2. [DOI: 10.3171/2019.4.focus19225] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/08/2019] [Indexed: 12/16/2022]
Abstract
Wall shear stress, the frictional force of blood flow tangential to an artery lumen, has been demonstrated in multiple studies to influence aneurysm formation and risk of rupture. In this article, the authors review the ways in which shear stress may influence aneurysm growth and rupture through changes in the vessel wall endothelial cells, smooth-muscle cells, and surrounding adventitia, and they discuss shear stress–induced pathways through which these changes occur.
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Affiliation(s)
| | - Matthew Smith
- 2Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio
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26
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Duan Y, Lagman C, Ems R, Bambakidis NC. Relationship between middle cerebral parent artery asymmetry and middle cerebral artery aneurysm rupture risk factors. J Neurosurg 2019; 132:1174-1181. [PMID: 30925467 DOI: 10.3171/2018.12.jns182951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 12/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The exact pathophysiological mechanisms underlying cerebral aneurysm formation remain unclear. Asymmetrical local vascular geometry may play a role in aneurysm formation and progression. The object of this study was to investigate the association between the geometric asymmetry of the middle cerebral artery (MCA) and the presence of MCA aneurysms and associated high-risk features. METHODS Using a retrospective case-control study design, the authors examined MCA anatomy in all patients who had been diagnosed with an MCA aneurysm in the period from 2008 to 2017 at the University Hospitals Cleveland Medical Center. Geometric features of the MCA ipsilateral to MCA aneurysms were compared with those of the unaffected contralateral side (secondary control group). Then, MCA geometry was compared between patients with MCA aneurysms and patients who had undergone CTA for suspected vascular pathology but were ultimately found to have normal intracranial vasculature (primary control group). Parent vessel and aneurysm morphological parameters were measured, calculated, and compared between case and control groups. Associations between geometric parameters and high-risk aneurysm features were identified. RESULTS The authors included 247 patients (158 cases and 89 controls) in the study. The aneurysm study group consisted of significantly more women and smokers than the primary control group. Patients with MCA bifurcation aneurysms had lower parent artery inflow angles (p = 0.01), lower parent artery tortuosity (p < 0.01), longer parent artery total length (p = 0.03), and a significantly greater length difference between ipsilateral and contralateral prebifurcation MCAs (p < 0.01) than those in primary controls. Type 2 MCA aneurysms (n = 89) were more likely to be associated with dome irregularity or a daughter sac and were more likely to have a higher cumulative total of high-risk features than type 1 MCA aneurysms (n = 69). CONCLUSIONS Data in this study demonstrated that a greater degree of parent artery asymmetry for MCA aneurysms is associated with high-risk features. The authors also found that the presence of a long and less tortuous parent artery upstream of an MCA aneurysm is a common phenotype that is associated with a higher risk profile. The aneurysm parameters are easily measurable and are novel radiographic biomarkers for aneurysm risk assessment.
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Affiliation(s)
- Yifei Duan
- 1University Hospitals Cleveland Medical Center; and
| | | | - Raleigh Ems
- 2School of Medicine, Case Western Reserve University, Cleveland, Ohio
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Choi HH, Cho YD, Yoo DH, Lee J, Mun JH, An SJ, Kang HS, Cho WS, Kim JE, Han MH. Intracranial Mirror Aneurysms: Anatomic Characteristics and Treatment Options. Korean J Radiol 2018; 19:849-858. [PMID: 30174473 PMCID: PMC6082764 DOI: 10.3348/kjr.2018.19.5.849] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 02/03/2018] [Indexed: 11/29/2022] Open
Abstract
Objective Mirror aneurysms are generally considered as a subset of multiple aneurysms, defined as aneurysms occurring bilaterally and symmetrically on the same-named vessels. Although not infrequent, the characteristics of mirror aneurysms are not well studied. This investigation was conducted to elucidate the anatomic features of such lesions and examine treatment options. Materials and Methods A retrospective review was conducted, aimed at 172 patients treated for 344 mirror aneurysms between January 2007 and December 2015. Aneurysms of similar nature but in asymmetric locations on the same-named vessels were excluded. All available records were examined and lesion characteristics, as well as treatment outcomes were assessed. Results In study subjects (n = 172), mirror aneurysms most often involved middle cerebral artery bifurcation (n = 83), followed by a paraclinoid internal carotid artery (n = 50) and posterior communicating artery (n = 21). Most of the lesions (95.3%) measured ≤ 10 mm, and in 126 patients (74.6%), the size ratios were > 50%. Of the 344 aneurysms studied, coil embolization was undertaken in 217, surgical clipping in 62, and observation alone (no treatment) in 65. Coil embolization and surgical clipping were done bilaterally in 83 and 12 patients, respectively. In 12 patients, combined coiling and clipping were implemented on each side. Single-stage coil embolization of both the aneurysms was performed in 73 patients, with excellent post-procedural (85.6%) and follow-up (86.8%) occlusive results. There was no procedure-related morbidity or mortality. Conclusion By adopting different treatment strategies to different configurations and vascular sources, mirror aneurysms can be safely and effectively treated. If feasible, single-stage coil embolization should be considered as a reasonable treatment option for mirror aneurysms.
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Affiliation(s)
- Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul 06974, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Dong Hyun Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jeongjun Lee
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Korea
| | - Jong Hyeon Mun
- Department of Neurosurgery, Kwangju Christian Hospital, Gwangju 61661, Korea
| | - Sang Joon An
- Department of Neurology, International St. Mary's Hospital, Catholic Kwandong University of Korea College of Medicine, Incheon 22711, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Moon Hee Han
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
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Huang Y, Zhou P, Wang Z, Han Q. Disappearance of Ruptured Posterior Cerebral Artery Aneurysm Associated with Internal Carotid Artery Occlusion After Superficial Temporal Artery-to-Middle Cerebral Artery Bypass. World Neurosurg 2018; 116:178-181. [PMID: 29803057 DOI: 10.1016/j.wneu.2018.05.096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/12/2018] [Accepted: 05/14/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Internal carotid artery (ICA) occlusion associated with posterior cerebral artery (PCA) aneurysms is regarded as a rare cerebrovascular disease. Common treatment of aneurysms-direct clipping or coiling-is not taken into consideration for this kind of cerebrovascular property. Combined surgical cerebrovascular reconstruction of the superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass offers a chance to downregulate the hemodynamic stress of aneurysm rupture. CASE DESCRIPTION A 46-year-old female presented with a fever and headache 1 month ago. An axial computed tomography scan showed a subarachnoid hemorrhage (SAH). Digital subtraction angiography (DSA) was conducted, and the patient received an STA-MCA bypass following medical treatment for 1 month in the local hospital. Computed tomography angiography and DSA demonstrated an aneurysm located on the right PCA and an occlusion of the right ICA in our hospital. Three days after admission, the right STA-MCA bypass was performed. The patient suffered no neurologic deterioration and lived a normal life. 6 months after the STA-MCA bypass, DSA of the right vertebral artery revealed disappearance of the aneurysm located on the right PCA (P2 segment). CONCLUSIONS Owing to ICA occlusion, the gap of hemodynamic stress between the posterior segment of the circle of Willis and anterior segment of the circle of Willis enlarged. This may lead to a ruptured PCA aneurysm. In this case, the aneurysm disappeared following an STA-MCA bypass. STA-MCA bypass may be one of the major reasons downregulating the gap, which can be regarded as an effective option concerning such aneurysms.
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Affiliation(s)
- Yabo Huang
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, P. R. China
| | - Peng Zhou
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, P. R. China
| | - Zhong Wang
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, P. R. China
| | - Qingdong Han
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, P. R. China.
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Microsurgical Clipping of Intracranial Aneurysms Assisted by Neurophysiological Monitoring, Microvascular Flow Probe, and ICG-VA: Outcomes and Intraoperative Data on a Multimodal Strategy. World Neurosurg 2018; 113:e336-e344. [DOI: 10.1016/j.wneu.2018.02.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/03/2018] [Accepted: 02/05/2018] [Indexed: 02/08/2023]
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Aguilar-Salinas P, Brasiliense LBC, Walter CM, Hanel RA, Dumont TM. Current Status of the PulseRider in the Treatment of Bifurcation Aneurysms: A Systematic Review. World Neurosurg 2018; 115:288-294. [PMID: 29698797 DOI: 10.1016/j.wneu.2018.04.102] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/13/2018] [Accepted: 04/16/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The PulseRider is an innovative stent-like device designed for the treatment of intracranial bifurcation aneurysms. The aim of this study was to assess the current evidence on safety and effectiveness of the PulseRider. METHODS A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched: PubMed, Ovid MEDLINE, and Scopus. The search strategy consisted of "pulserider," "bifurcation aneurysm," and "endovascular" in both AND and OR combinations. Studies included were original research articles in peer-reviewed journals. The manuscripts were thoroughly examined for study design, outcomes, and results. RESULTS Three studies were identified describing use of the PulseRider device in the treatment of 63 patients with 63 bifurcation aneurysms. We identified 2 multicenter case series and 1 single-arm clinical trial. The majority of aneurysms treated were located at the basilar tip (37, 58.7%). All devices were successfully deployed, and there were 5 intraoperative complications (7.9%), including 2 intraoperative aneurysm ruptures, 1 vessel dissection, and 2 thrombus formations. Immediate complete aneurysm occlusion was achieved in 61.9% (39/63) of cases and at the 6-month imaging follow-up, 66.7% (42/63) achieved complete aneurysm occlusion. One recanalization was reported in 1 of the multicenter case series within the 6-month follow-up. CONCLUSIONS The PulseRider is safe and probably effective for the treatment of intracranial bifurcation aneurysms, sometimes not amenable for stent-assisted coiling. However, current evidence is limited to a small sample and short follow-up. In addition, the device has not been compared with other treatment modalities.
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Affiliation(s)
| | | | | | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Travis M Dumont
- Division of Neurosurgery, University of Arizona, Tucson, Arizona, USA.
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Cheng D, Zhuang Y, Kou Q, Zhang M, Zhao Y, Han C, Li J, Wang Y, Xu K, Mo F, Zhang J. Numerical simulation of hemodynamics in membranous obstruction of the suprahepatic inferior vena cava based on a subject-specific Budd-Chiari syndrome model. Clin Biomech (Bristol, Avon) 2018; 52:20-24. [PMID: 29316476 DOI: 10.1016/j.clinbiomech.2017.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 12/26/2017] [Accepted: 12/29/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study was performed to determine the hemodynamic changes of Budd-Chiari syndrome when the inferior vena vein membrane is developing. METHODS A patient-specific Budd-Chiari syndrome vascular model was reconstructed based on magnetic resonance images using Mimics software and different degrees (16%, 37%, and 54%) of idealized membrane were built based on the Budd-Chiari syndrome vascular model using Geomagic software. Three membrane obstruction Budd-Chiari syndrome vascular models were established successfully and fluent software was used to simulate hemodynamic parameters, including blood velocity and wall shear stress. FINDINGS The simulation results showed that there is low velocity and a low wall shear stress region at the junction of the inferior vena cava and the branches of the hepatic veins, and swirl may occur in this area. As the membrane develops, the size of the low velocity and low wall shear stress regions enlarged and the wall shear stress was increased at the membrane region. There was a significant difference in the mean values of wall shear stress between the different obstruction membrane models (P<0.05). INTERPRETATION Hemodynamic parameters play an important role in vascular disease and there may be a correlation between inferior vena cava wall shear force changes and the slow development process of the inferior vena cava membrane.
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Affiliation(s)
- Deqiang Cheng
- School of Information and Control Engineering, China University of Mining and Technology, Xuzhou 221116, China
| | - Yinping Zhuang
- School of Information and Control Engineering, China University of Mining and Technology, Xuzhou 221116, China; School of Medical Imaging, Xuzhou Medical University, 84West Huai-hai Road, Xuzhou 221004, China.
| | - Qiqi Kou
- School of Information and Control Engineering, China University of Mining and Technology, Xuzhou 221116, China
| | - Min Zhang
- School of Medical Imaging, Xuzhou Medical University, 84West Huai-hai Road, Xuzhou 221004, China
| | - Yinghong Zhao
- School of Medical Imaging, Xuzhou Medical University, 84West Huai-hai Road, Xuzhou 221004, China
| | - Cuiping Han
- School of Medical Imaging, Xuzhou Medical University, 84West Huai-hai Road, Xuzhou 221004, China
| | - Jingjing Li
- School of Medical Imaging, Xuzhou Medical University, 84West Huai-hai Road, Xuzhou 221004, China
| | - Yong Wang
- School of Medical Imaging, Xuzhou Medical University, 84West Huai-hai Road, Xuzhou 221004, China
| | - Kai Xu
- School of Medical Imaging, Xuzhou Medical University, 84West Huai-hai Road, Xuzhou 221004, China
| | - Fei Mo
- School of Medical Imaging, Xuzhou Medical University, 84West Huai-hai Road, Xuzhou 221004, China
| | - Jiawei Zhang
- School of Medical Imaging, Xuzhou Medical University, 84West Huai-hai Road, Xuzhou 221004, China
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Senko I, Shatokhin A, Bishnoi I, Yamada Y, Tanaka R, Suyama D, Kawase T, Kato Y. Intraoperative Rupture Cerebral Aneurysm and Computational Flow Dynamics. Asian J Neurosurg 2018; 13:496-498. [PMID: 29682071 PMCID: PMC5898142 DOI: 10.4103/ajns.ajns_359_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Intraoperative aneurysmal rupture (IAR) is the most fearsome complication of aneurysm surgery. IAR associates with high morbidity and mortality. In recent years, we have many studies regarding using computational fluid dynamics (CFD) in aneurysm surgery. CFD helps in calculating the velocity of blood flowing in the aneurysm sac, the pressure in the aneurysm sac, and wall shear stress (WSS). CFD also helps in predicting nature of aneurysm wall and thus may warn about different intraoperative microscopy findings in aneurysms. Using its application, surgeon may become more careful in doing microsurgical sharp dissection. A 40-year-old female admitted with diagnosis of unruptured anterior communicating artery aneurysm. CFD analysis demonstrated high intra-aneurysmal pressure and divergent WSS in dome. During sharp dissection, there was intraoperative rupture aneurysm twice which was managed with cotton tamponade and glue and temporary clipping aneurysm. Indocyanine green video angiography showed working parent arteries and nonfunctioning aneurysm. After operation, the patient recovered fully and had a modified Rankin score of 1. This case demonstrated importance of preoperative planning of aneurysm surgery using CFD analysis. IAR is associated with an increased risk for an unfavorable outcome. Accurate preoperative planning with studying flow dynamics and structure of aneurysm may help in use sharp microsurgical dissection more cautiously.
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Affiliation(s)
- Ilya Senko
- Department of Neurosurgery, Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | - Anton Shatokhin
- Department of Neurosurgery, Stavropol Emergency Hospital, Stavropol, Russia
| | - Ishu Bishnoi
- Department of Neurosurgery, Maharaja Agarsen Medical College, Agroha, Haryana, India
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University Bambuntane Hotokukai Hospital, Nagoya, Japan
| | - Riki Tanaka
- Department of Neurosurgery, Fujita Health University Bambuntane Hotokukai Hospital, Nagoya, Japan
| | - Daisuke Suyama
- Department of Neurosurgery, Fujita Health University Bambuntane Hotokukai Hospital, Nagoya, Japan
| | - Tukasa Kawase
- Department of Neurosurgery, Fujita Health University Bambuntane Hotokukai Hospital, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bambuntane Hotokukai Hospital, Nagoya, Japan
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Yang F, Li H, Wu J, Li M, Chen X, Jiang P, Li Z, Cao Y, Wang S. Relationship of A1 Segment Hypoplasia with the Radiologic and Clinical Outcomes of Surgical Clipping of Anterior Communicating Artery Aneurysms. World Neurosurg 2017; 106:806-812. [DOI: 10.1016/j.wneu.2017.07.122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
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A Patient-Specific Three-Dimensional Hemodynamic Model of the Circle of Willis. Cardiovasc Eng Technol 2017; 8:495-504. [PMID: 28913763 DOI: 10.1007/s13239-017-0330-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 09/04/2017] [Indexed: 10/18/2022]
Abstract
Circle of Willis (CoW) is one of the most important cerebral arteries in the human body and various attempts have been made to study the hemodynamic of blood flow in this vital part of the brain. In the present study, blood flow in a patient specific CoW is numerically modeled to predict disease-prone regions of the CoW. Medical images and computer aided design software are used to construct a realistic three-dimensional model of the CoW for this particular case. The arteries are considered as elastic conduits and the interactions between arterial walls and the blood flow are taken into account. Mooney-Rivlin hyperelastic model is used to describe the behavior of arterial walls and blood is considered as a non-Newtonian fluid obeying the Carreau model. An available experimental-based pulsatile velocity profile is used at the entrance of the CoW. The finite element-based commercial software, ADINA, is used to solve the governing equations. Blood pressure and velocity and arterial wall shear stress are calculated in different regions of the CoW. A simplified form of the model is also compared with the available published data. Results affirmed that the proposed computational model has the potential to capture the hemodynamic characteristics of the CoW. The computational results can be used to determine disease-prone locations for a given CoW.
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Longo M, Granata F, Racchiusa S, Mormina E, Grasso G, Longo GM, Garufi G, Salpietro FM, Alafaci C. Role of Hemodynamic Forces in Unruptured Intracranial Aneurysms: An Overview of a Complex Scenario. World Neurosurg 2017; 105:632-642. [DOI: 10.1016/j.wneu.2017.06.035] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/04/2017] [Accepted: 06/05/2017] [Indexed: 12/16/2022]
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Abstract
BACKGROUND Intracranial saccular aneurysms are acquired lesions that often present with neuro-ophthalmologic symptoms and signs. Recent advances in neurosurgical techniques, endovascular treatments, and neurocritical care have improved the optimal management of symptomatic unruptured aneurysms, but whether the chosen treatment has an impact on neuro-ophthalmologic outcomes remains debated. EVIDENCE ACQUISITION A review of the literature focused on neuro-ophthalmic manifestations and treatment of intracranial aneurysms with specific relevance to neuro-ophthalmologic outcomes was conducted using Ovid MEDLINE and EMBASE databases. Cavernous sinus aneurysms were not included in this review. RESULTS Surgical clipping vs endovascular coiling for aneurysms causing third nerve palsies was compared in 13 retrospective studies representing 447 patients. Complete recovery was achieved in 78% of surgical patients compared with 44% of patients treated with endovascular coiling. However, the complication rate, hospital costs, and days spent in intensive care were reported as higher in surgically treated patients. Retrospective reviews of surgical clipping and endovascular coiling for all ocular motor nerve palsies (third, fourth, or sixth cranial nerves) revealed similar results of complete resolution in 76% and 49%, respectively. Improvement in visual deficits related to aneurysmal compression of the anterior visual pathways was also better among patients treated with clipping than with coiling. The time to treatment from onset of visual symptoms was a predictive factor of visual recovery in several studies. Few reports have specifically assessed the improvement of visual deficits after treatment with flow diverters. CONCLUSIONS Decisions regarding the choice of therapy for intracranial aneurysms causing neuro-ophthalmologic signs ideally should be made at high-volume centers with access to both surgical and endovascular treatments. The status of the patient, location of the aneurysm, and experience of the treating physicians are important factors to consider. Although a higher rate of visual recovery was reported with neurosurgical clipping, this must be weighed against the potentially longer intensive care stays and increased early morbidity.
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Yang ZL, Ni QQ, Schoepf UJ, De Cecco CN, Lin H, Duguay TM, Zhou CS, Zhao YE, Lu GM, Zhang LJ. Small Intracranial Aneurysms: Diagnostic Accuracy of CT Angiography. Radiology 2017; 285:941-952. [PMID: 28654338 DOI: 10.1148/radiol.2017162290] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Purpose To assess the accuracy of computed tomographic (CT) angiography for diagnosis of cerebral aneurysms 5 mm or smaller, with digital subtraction angiography (DSA) as the reference standard, in a large patient cohort Materials and Methods This retrospective study was approved by the local institutional review board with a waiver of written informed consent. A total of 1366 patients who underwent cerebral CT angiography followed by DSA were included. The performance of CT angiography for depiction of aneurysms was evaluated by two readers on a per-patient and per-aneurysm basis and based on size of aneurysm, location, and status of rupture. The performance of CT angiography for diagnosis of aneurysms of different size, location, and rupture status was compared by using χ2 test. κ statistic was used to assess interreader agreement for diagnosis of aneurysms. Results Of 1366 patients, 579 patients had 711 small aneurysms at DSA. By using DSA as the reference standard, the respective sensitivity, specificity, and accuracy of CT angiography for readers 1 and 2 for detection of small aneurysms on a per-patient basis were 97.1% (562 of 579) and 97.4% (564 of 579), 98.5% (451 of 458) and 99.1% (454 of 458), and 97.7% (1013 of 1037) and 98.2% (1018 of 1037) and those on a per-aneurysm basis were 95.2% (677 of 711) and 95.4% (678 of 711), 96.6% (451 of 467) and 97.0% (454 of 468), and 95.8% (1128 of 1178) and 96.0% (1132 of 1179). The sensitivities of CT angiography were lower for detection of aneurysms smaller than 3 mm and unruptured compared with aneurysms that were 3-5 mm and ruptured (P < .001). No difference existed for the sensitivities of CT angiography for diagnosis of aneurysms in the anterior versus posterior circulation (P > .0167). Excellent or good interreader agreement was found for detection of intracranial aneurysms on a per-patient (κ = 0.982) and per-aneurysm (κ = 0.748) basis. Conclusion This large cohort study demonstrated that CT angiography had high accuracy for detection of small cerebral aneurysms, including those smaller than 3 mm. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Zhen Lu Yang
- From the Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China (Z.L.Y., Q.Q.N., U.J.S., C.S.Z., Y.E.Z., G.M.L., L.J.Z.); and Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S., C.N.D.C., H.L., T.M.D.)
| | - Qian Qian Ni
- From the Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China (Z.L.Y., Q.Q.N., U.J.S., C.S.Z., Y.E.Z., G.M.L., L.J.Z.); and Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S., C.N.D.C., H.L., T.M.D.)
| | - U Joseph Schoepf
- From the Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China (Z.L.Y., Q.Q.N., U.J.S., C.S.Z., Y.E.Z., G.M.L., L.J.Z.); and Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S., C.N.D.C., H.L., T.M.D.)
| | - Carlo N De Cecco
- From the Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China (Z.L.Y., Q.Q.N., U.J.S., C.S.Z., Y.E.Z., G.M.L., L.J.Z.); and Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S., C.N.D.C., H.L., T.M.D.)
| | - Han Lin
- From the Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China (Z.L.Y., Q.Q.N., U.J.S., C.S.Z., Y.E.Z., G.M.L., L.J.Z.); and Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S., C.N.D.C., H.L., T.M.D.)
| | - Taylor M Duguay
- From the Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China (Z.L.Y., Q.Q.N., U.J.S., C.S.Z., Y.E.Z., G.M.L., L.J.Z.); and Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S., C.N.D.C., H.L., T.M.D.)
| | - Chang Sheng Zhou
- From the Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China (Z.L.Y., Q.Q.N., U.J.S., C.S.Z., Y.E.Z., G.M.L., L.J.Z.); and Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S., C.N.D.C., H.L., T.M.D.)
| | - Yan E Zhao
- From the Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China (Z.L.Y., Q.Q.N., U.J.S., C.S.Z., Y.E.Z., G.M.L., L.J.Z.); and Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S., C.N.D.C., H.L., T.M.D.)
| | - Guang Ming Lu
- From the Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China (Z.L.Y., Q.Q.N., U.J.S., C.S.Z., Y.E.Z., G.M.L., L.J.Z.); and Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S., C.N.D.C., H.L., T.M.D.)
| | - Long Jiang Zhang
- From the Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China (Z.L.Y., Q.Q.N., U.J.S., C.S.Z., Y.E.Z., G.M.L., L.J.Z.); and Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S., C.N.D.C., H.L., T.M.D.)
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Ferracci FX, Gilard V, Cebula H, Magne N, Lejeune JP, Langlois O, Proust F. Growth of giant intracranial aneurysms: An aneurysmal wall disorder? Neurochirurgie 2017; 63:6-12. [DOI: 10.1016/j.neuchi.2017.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 12/13/2016] [Accepted: 01/01/2017] [Indexed: 10/20/2022]
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Sénémaud J, Caligiuri G, Etienne H, Delbosc S, Michel JB, Coscas R. Translational Relevance and Recent Advances of Animal Models of Abdominal Aortic Aneurysm. Arterioscler Thromb Vasc Biol 2017; 37:401-410. [DOI: 10.1161/atvbaha.116.308534] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 12/21/2016] [Indexed: 01/11/2023]
Abstract
Human abdominal aortic aneurysm (AAA) pathophysiology is not yet completely understood. In conductance arteries, the insoluble extracellular matrix, synthesized by vascular smooth muscle cells, assumes the function of withstanding the intraluminal arterial blood pressure. Progressive loss of this function through extracellular matrix proteolysis is a main feature of AAAs. As most patients are now treated via endovascular approaches, surgical AAA specimens have become rare. Animal models provide valuable complementary insights into AAA pathophysiology. Current experimental AAA models involve induction of intraluminal dilation (nondissecting AAAs) or a contained intramural rupture (dissecting models). Although the ideal model should reproduce the histological characteristics and natural history of the human disease, none of the currently available animal models perfectly do so. Experimental models try to represent the main pathophysiological determinants of AAAs: genetic or acquired defects in extracellular matrix, loss of vascular smooth muscle cells, and innate or adaptive immune response. Nevertheless, most models are characterized by aneurysmal stabilization and healing after a few weeks because of cessation of the initial stimulus. Recent studies have focused on ways to optimize existing models to allow continuous aneurysmal growth. This review aims to discuss the relevance and recent advances of current animal AAA models.
Visual Overview—
An online visual overview is available for this article.
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Affiliation(s)
- Jean Sénémaud
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
| | - Giuseppina Caligiuri
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
| | - Harry Etienne
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
| | - Sandrine Delbosc
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
| | - Jean-Baptiste Michel
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
| | - Raphaël Coscas
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
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Daughter Sac Formation Related to Blood Inflow Jet in an Intracranial Aneurysm. World Neurosurg 2016; 96:396-402. [DOI: 10.1016/j.wneu.2016.09.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 09/08/2016] [Accepted: 09/08/2016] [Indexed: 10/21/2022]
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Rinaldo L, McCutcheon BA, Murphy ME, Bydon M, Rabinstein AA, Lanzino G. Relationship of A 1 segment hypoplasia to anterior communicating artery aneurysm morphology and risk factors for aneurysm formation. J Neurosurg 2016; 127:89-95. [PMID: 27689465 DOI: 10.3171/2016.7.jns16736] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hypoplasia of the A1 segment of the anterior cerebral artery is frequently observed in patients with anterior communicating artery (ACoA) aneurysms. The effect of this anatomical variant on ACoA aneurysm morphology is not well understood. METHODS Digital subtraction angiography images were reviewed for 204 patients presenting to the authors' institution with either a ruptured or an unruptured ACoA aneurysm. The ratio of the width of the larger A1 segment to the smaller A1 segment was calculated. Patients with an A1 ratio greater than 2 were categorized as having A1 segment hypoplasia. The relationship of A1 segment hypoplasia to both patient and aneurysm characteristics was then assessed. RESULTS Of 204 patients that presented with an ACoA aneurysm, 34 (16.7%) were found to have a hypoplastic A1. Patients with A1 segment hypoplasia were less likely to have a history of smoking (44.1% vs 62.9%, p = 0.0410). ACoA aneurysms occurring in the setting of a hypoplastic A1 were also found to have a larger maximum diameter (mean 7.7 vs 6.0 mm, p = 0.0084). When considered as a continuous variable, increasing A1 ratio was associated with decreasing aneurysm dome-to-neck ratio (p = 0.0289). There was no significant difference in the prevalence of A1 segment hypoplasia between ruptured and unruptured aneurysms (18.9% vs 10.7%; p = 0.1605). CONCLUSIONS Our results suggest that a hypoplastic A1 may affect the morphology of ACoA aneurysms. In addition, the relative lack of traditional risk factors for aneurysm formation in patients with A1 segment hypoplasia argues for the importance of hemodynamic factors in the formation of ACoA aneurysms in this anatomical setting.
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Affiliation(s)
| | | | | | | | | | - Giuseppe Lanzino
- Departments of 1 Neurosurgery.,Neurointerventional Radiology, Mayo Clinic, Rochester, Minnesota
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