Unruptured cerebral aneurysms presenting with ischemic events

Microsurgical Clipping of Carotid-Ophthalmic Tandem Aneurysms: Case Report and Surgical Nuances

Tandem intracranial aneurysms (TandIAs) are rare but inherently complex, and special technical considerations are required for their surgical management. The present case highlights the key surgical aspects of two carotid-ophthalmic TandIAs incidentally found in a 60-year-old female. Both the aneurysms were superiorly projecting, regular in size, and involved the left ophthalmic segment of the internal carotid artery (ICA). The minimum distance between the necks was 3 mm. The patient underwent microsurgery because of the reported major complications rate of the endovascular treatment in the case of a very short minimum distance between the TandIAs. After cervical ICA exposure, both the aneurysms were excluded through a pterional approach. Intradural anterior clinoidectomy and unroofing of the optic canal allowed the mobilization of the left optic nerve. The more distal aneurysm was clipped before the opening of the distal dural ring of the ICA. The proximal aneurysm was clipped with two straight clips stacked perpendicular to the ICA. A small remnant was intentionally left to avoid the stenosis of the ophthalmic artery. Postoperative angiography showed the exclusion of both the aneurysms with a small dog-ear of the more proximal one. The patient was discharged neurologically intact and, after one year, the remnant remained stable. Microsurgical clipping is a definitive and durable treatment for carotid-ophthalmic TandIAs. In the case of a very short minimum distance between the aneurysms, the distal one should be clipped first to make the anterior clinoidectomy, opening of the distal dural ring of the ICA, and clipping of the more proximal aneurysm easier.

Occlusion of the Anterior Cerebral Artery Mimicking a Cerebral Aneurysm: Clinical Presentation and Literature Review

BACKGROUND

 Intracranial aneurysms may be misdiagnosed with other vascular lesions such as vascular loops, infundibulum, or the stump of an occluded artery (very rare and reported compromising only the middle cerebral artery and the posterior circulation territory). Our aim was to describe a unique case of occlusion of an anterior cerebral artery mimicking a cerebral aneurysm in a probable moyamoya disease patient, and to highlight its clinical presentation, diagnosis, and management, and to perform an extensive literature review.

CASE

 A 67-year-old man suffering from recurrent dizziness for 3 months. Previous medical history was unremarkable. Brain magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) demonstrated occlusion of the right middle cerebral artery (MCA) associated with a "probable moyamoya disease" and an aneurysm-like shadow protruding lesion at the anterior communicating artery (AcomA). Perfusion images showed ischemia along the right temporo-occipital lobe. Due to MCA occlusion with perfusion deficits and unspecific symptoms, we offered a right side encephalo-duro-myo-synangiosis (EDMS) and clipping of the AcomA aneurysm in one session. Intraoperatively, there was no evidence of the AcomA aneurysm; instead, this finding corresponded to the stump of the occluded right anterior cerebral artery (A1 segment). This segment appeared to be of yellowish color due to atherosclerosis and lacked blood flow. The patient underwent as previously planned a right side EDMS and the perioperative course was uneventful without the presence of additional ischemic attacks.

CONCLUSION

 Arterial branch occlusions can sometimes present atypical angiographic characteristics that can mimic a saccular intracranial aneurysm. It is relevant to consider this radiographic differential diagnosis, especially when aneurysm treatment is planned.

Ischemic Stroke as a Warning Sign of Impending Aneurysmal Rupture: A Report of Two Cases

Ischemic stroke associated with intracranial aneurysm is rare but potentially happens because of emboli originating from aneurysm sac or aneurysmal thrombosis extension to the parent artery. We describe two patients who present subarachnoid hemorrhage (SAH) soon after ischemic stroke. Case 1. A 51-year-old woman with a history of multiple endovascular therapy for ruptured basilar top aneurysm presented with double vision. Magnetic resonance imaging (MRI) revealed infarcts in the right thalamus and left occipital cortex. Four days after ischemic stroke, she suffered from sudden onset headache, computed tomography (CT) showed diffuse SAH with intraventricular hemorrhage. Case 2. A 62-year-old man presented with right facial palsy and sensory disorder. MRI revealed an infarct in the left pons. Four days after ischemic stroke, he became comatose and CT showed diffuse SAH. Both cases develop ischemic stroke adjacent to the aneurysms and subsequently cause devasting aneurysm rupture, suggesting ischemic stroke as a warning sign of aneurysm rupture. In such cases, early treatment of the aneurysm should be considered.

Prevalence, predictors and prognosis of incidental intracranial aneurysms in patients with suspected TIA and minor stroke: a population-based study and systematic review

INTRODUCTION

Unruptured intracranial aneurysms (UIAs) are common incidental imaging findings, but there are few data in patients with transient ischaemic attack (TIA)/stroke. The frequency of UIA might be higher due to shared risk factors, but rupture risk might be reduced by intensive secondary prevention. We determined the prevalence and prognosis of UIA in patients with suspected TIA/minor stroke.

METHODS

All patients referred to the population-based Oxford Vascular Study (2011-2020) with suspected TIA/minor stroke and non-invasive angiography were included. We determined the prevalence of incidental asymptomatic UIA and the risk of subsequent subarachnoid haemorrhage (SAH) by follow-up on intensive medical treatment, with guideline-based monitoring/management. We also did a systematic review of UIA prevalence/prognosis in cohorts with TIA/stroke.

FINDINGS

Among 2013 eligible patients, 95 (4.7%) had 103 previously unknown asymptomatic UIA. Female sex (OR 2.3, 95% CI 1.5 to 3.7), smoking (2.1, 1.2 to 3.6) and hypertension (1.6, 1.0 to 2.5) were independently predictive of UIA, with a prevalence of 11.1% in those with all three risk factors. During mean follow-up of 4.5 years, only one SAH occurred: 2.3 (95% CI 0.3 to 16.6) per 1000 person-years. We identified 19 studies of UIA in TIA/stroke cohorts (n=12 781), all with either symptomatic carotid stenosis or major acute stroke. The pooled mean UIA prevalence in patients with TIA/stroke was 5.1% (95% CI 4.8 to 5.5) and the incidence of SAH was 4.6 (95% CI 1.9 to 11.0) per 1000 person-years.

INTERPRETATION

The 5% prevalence of UIA in patients with confirmed TIA/minor stroke is likely higher than that in the general population. However, the risk of SAH on intensive medical treatment and guideline-based management/monitoring is low.

Brain ischemia due to direct vascular compression associate with rapid enlargement of unruptured middle cerebral artery aneurysm: A case report

Background

Acute cerebral infarction is a rare complication resulting from an unruptured cerebral aneurysm (UCA). There is presently no consensus on the optimal strategy for the management of UCAs with cerebral infarctions.

Case Description

A 53-year-old man presented with transient dysarthria and left hemiparesis. Magnetic resonance imaging (MRI) demonstrated the presence of a 7 mm UCA originating from the middle cerebral artery bifurcation, and diffusion-weighted imaging showed no evidence of cerebral infarction. One month later, his transient left hemiparesis recurred, and the patient was admitted to our hospital. Computed tomography angiography showed enlargement of the aneurysm. His left hemiparesis worsened 3 days later. MRI showed cerebral infarction in the area of perforating arteries and further enlargement of the aneurysm with surrounding parenchymal edema. Therefore, the rupture risk was considered to be rarely high and dome clipping was performed immediately. Postoperatively, his neurological status improved without any recurrent brain ischemia.

Conclusion

We report a rare case of a rapidly enlarging aneurysm that presented with cerebral infarction. This is the first report describing aneurysmal sac enlargement that can lead to perforating artery obstruction and brain ischemia. The case illustrates the importance of performing close follow-up examinations to confirm findings that suggest a high rupture risk.

Complete spontaneous thrombosis in unruptured non-giant intracranial aneurysms: A case report and systematic review

BACKGROUND AND AIM

Spontaneous partial or complete thrombosis of saccular unruptured intracranial aneurysm (UIAs) is a known occurrence in giant aneurysms. However, spontaneous complete thrombosis of non-giant aneurysms is a rare event in the natural history of UIAs. The aim of this paper is to report on the cases from literature of complete spontaneous thrombosis with a view to identify possible factors associated with this phenomenon.

MATERIAL AND METHODS

We performed a systematic review of the current literature on spontaneous complete thrombosis of saccular, non-giant, unruptured UIAs, including a case that we treated at our institution. We analysed the possible risk factors for thrombosis, association with ischemic events, rupture and recanalization. We reviewed the possible management's strategies for this group of patients described in literature to date.

RESULTS

We identified 26 patients for a total of 27 thrombosed aneurysms from the literature review (including our case). Thrombosis was prevalent in women, in the anterior circulation and in larger aneurysms. Endovascular events in the parent artery, either spontaneous or iatrogenic, were associated with spontaneous thrombosis in 4 cases. In 47 % of cases an antiplatelet treatment (AP) was introduced. Rupture and recanalization of the aneurysm were observed in 14 % and 33 % respectively. A larger size was the only factor statistically associated with rupture (P = 0041). AP was not statistically associated with recanalization or rupture of the aneurysm.

CONCLUSION

Complete spontaneous thrombosis is not a curative event. Its natural history is associated with recanalization, rupture and ischemic stroke. Conservative treatment with a clinical-radiological follow up and treatment with AP is a safe option for small aneurysms. Definitive aneurysmal exclusion should be considered in medium and large aneurysms due to the significant risks associated with untreated aneurysms.

Recanalized Left Internal Carotid Artery Bifurcation Aneurysm with Adherent Thrombus at Aneurysm Neck and M1 Origin Diagnosed on 2-Dimensional Angiography-Cause of Embolic Stroke

We report a unique case of recanalized left internal carotid artery aneurysm with thrombus adherent to the aneurysm neck and M1 origin diagnosed on 2-dimensional angiography causing embolic stroke in a 66-year-old female who was successfully treated with stent-assisted coiling. This is important to recognize as a cause of embolic stroke.

Lateral Medullary Ischemic Infarct Caused by Posterior Inferior Cerebellar Artery Aneurysm

Posterior inferior cerebellar artery (PICA) aneurysms are rare. The most common complication of intracranial aneurysms is rupture causing subarachnoid hemorrhage. Ischemic infarct, although more common in giant thrombosed aneurysms, is a very rare manifestation of small intracranial aneurysms. Here we describe a patient who presented with lateral medullary acute infarction associated with an ipsilateral, small (4 × 3.5 mm), unruptured and non-thrombosed PICA aneurysm.

Endovascular management of symptomatic cerebral aneurysm thromboembolism due to pre-aneurysmal arterial stenosis

Background:

Pre-aneurysmal internal carotid steno-occlusive disease resulting in cerebral intra-aneurysmal thrombosis and subsequent embolic infarction has not been previously described.

Conclusion:

Antithrombotic treatment for dissolution of the thrombus and pre-aneurysmal stent angioplasty followed by Pipeline embolization flow diverter placement through the aneurysm is a safe and feasible management option.

Embolic stroke secondary to spontaneous thrombosis of unruptured intracranial aneurysm: Report of three cases

Intracranial aneurysms uncommonly present with ischemic stroke. Parent artery occlusion due to local extension of the luminal thrombus, aneurysms ejecting emboli to distal arteries, or increased mass effect have been described as possible pathogenic mechanisms. Guidelines for the management of these patients are absent. We present the clinical outcome and radiological characteristics of three patients with spontaneous thrombosis of intracranial aneurysms as a cause of ischemic stroke. This information is relevant given the possible benign history in terms of stroke recurrence and risk of bleeding.

Endovascular coiling vs. surgical clipping for unruptured intracranial aneurysm: A meta-analysis

BACKGROUND

With increasing use of high-resolution imaging of brain, unruptured aneurysms are more and more frequently detected. With the advances in treatment techniques, an increasing number of aneurysms are now occluded using endovascular coiling instead of conventional surgical clipping. However, the better modality for unruptured intracranial aneurysm has been poorly understood.

OBJECTIVE

The objective of this meta-analysis was to compare the outcomes between endovascular coiling and surgical clipping among patients with unruptured intracranial aneurysms.

METHODS

PubMed, Embase, Web of Science, CENTRAL, and SIGLE were electronically searched from January 1, 1990 to March 13, 2012 with no language restriction for randomized or nonrandomized clinical controlled trials. Article screening and data extraction were conducted in duplicate. Results were statistically pooled through Review Manager 5 and StatsDirect 2.7.9.

RESULTS

Seven studies met our inclusion criteria. The pooled risk ratios (coiling vs. clipping) were 0.59 (95% CI = 0.23-1.54) for death; 0.37 (95% CI = 0.10-1.41) for bleeding; 0.78 (95% CI = 0.38-1.58) for cerebral ischemia; 0.87 (95% CI = 0.70-1.08) for occlusion of aneurysm; 0.53 (95% CI = 0.18-1.52) for independence in daily activities. The pooled rates of death, bleeding, ischemia, occlusion of aneurysm, and mRS no less than 3 were 1% (95% CI = 0-2%), 2% (95% CI = 0-5%), 8% (95% CI = 4-13%), 82% (95% CI = 64-95%), and 5% (95% CI = 1-10%) for endovascular coiling, respectively, and 1% (95% CI = 0-2%), 6% (95% CI = 3-10%), 9% (95% CI = 5-15%), 95% (95% CI = 90-98%), and 8% (95% CI = 3-14%) for surgical clipping, respectively. We failed to evaluate quality of life and cognitive outcome due to insufficient data. Both meta-regression and sensitivity analysis showed consistent results. Furthermore, Begg's test and Egger's test failed to detect publication bias.

CONCLUSION

We suggest that endovascular coiling and surgical clipping bear similar risk ratios of death, bleeding, cerebral ischemia, occlusion of aneurysm, and independence in daily activities and encourage further studies on quality of life and cognitive outcome. However, albeit the results in this meta-analysis are robust, due to great clinical heterogeneity and low quality of studies, the results in this meta-analysis should be interpreted with caution.

Cerebral ischemia complicating intracranial aneurysm: a warning sign of imminent rupture?

BACKGROUND AND PURPOSE

Patients harboring nongiant cerebral aneurysms may rarely present with an ischemic infarct distal to the aneurysm. The aim of this case series was to report clinical and radiologic characteristics of these patients, their management, and outcome.

MATERIALS AND METHODS

We undertook a single-center retrospective analysis of consecutive patients admitted during an 8-year period with an acute ischemic stroke revealing an unruptured nongiant (<25 mm) sacciform intracranial aneurysm. Clinical, radiologic, therapeutic, and follow-up data were analyzed.

RESULTS

Nine patients were included. The mean size of aneurysms was 9.6 ± 6 mm, and 5 were partially or totally thrombosed. Two patients had a fatal SAH within 3 days after stroke-symptom onset, whereas asymptomatic meningeal bleeding was diagnosed or suspected in 2 others. Most of the patients with unthrombosed aneurysms were successfully treated by endovascular coiling in the acute phase. Thrombosed aneurysms were usually treated with antithrombotics, and most recanalized secondarily, requiring endovascular treatment or surgical obliteration. No recurrence of an ischemic event or SAH was observed during the 31 ± 12 months of follow-up (from 4 to 53 months).

CONCLUSIONS

In this single-center series, the frequency of early SAH in patients with ischemic stroke distal to an unruptured intracranial aneurysm was high. Acute management should be undertaken with care regarding antithrombotic use, and early endovascular coiling should be considered.

Magnetic resonance angiography of the circle of Willis in patients with symptomatic intracranial neuropathology: medicare LCD L25367(R4)

Patients with symptomatic intracranial neuropathology such as atherosclerotic occlusive disease or unruptured aneurysms face high risks for morbidity and mortality. Magnetic resonance angiography of the circle of Willis is an important tool used to detect and diagnose intracranial neuropathology; however, recent changes to the Medicare local coverage determinations for this procedure threaten to compromise the physician's ability to deliver this current standard of care. Physicians can assume an important role in advocating for this lifesaving procedure on behalf of this vulnerable patient population.

Partially thrombosed intracranial aneurysms: symptoms, evolution, and therapeutic management

BACKGROUND

Partially thrombosed intracranial aneurysms (PTIAs) are different from saccular or nonthrombosed giant or large aneurysms, as they are characterized by multiple intramural thrombotic phenomena related to recurrent vessel wall dissections.

METHODS

We retrospectively reviewed clinical and radiological files of 23 consecutive patients with PTIAs (mean age 49.3 years). Twenty-two lesions were studied by magnetic resonance imaging (MRI). Patients were managed by endovascular treatments, medically with steroids, or conservatively.

RESULTS

Thirteen patients presented with progressive neurological symptoms. Subarachnoid hemorrhage was suspected but not proven in three. At MRI, 90.9% of PTIAs caused mass effect; perilesional T2 hypersignal compatible with edema was evident in 13.6%. Aneurysmal wall enhancement was detectable in 63.2% of the PTIAs and considered a marker of inflammatory processes. Parent artery occlusion was performed in seven patients with clinical improvement in six. Selective coiling was proposed in three patients (one improved, one remained stable, and one experienced symptoms progression). Three patients were treated with steroids and improved. Ten patients were managed conservatively: eight because spontaneous thrombosis of the lesion had been diagnosed and two because of clinical and radiological stability.

CONCLUSIONS

The natural history of PTIAs is different from other aneurysms. They most commonly present with progressive neurological symptoms due to mass effect. MRI properly diagnoses PTIAs and allows precise follow-up, more accurately than angiography because it detects prominent "abluminal" features indicating inflammation and neovascularization. Spontaneous thrombosis is part of the natural history of PTIAs and it should be taken in consideration when discussing the therapeutic management.