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

Spontaneous thrombosis of a large unruptured intracranial aneurysm causing ischemic stroke due to occlusion of the parent artery: A case report and literature review

Spontaneous thrombosis of an unruptured large or giant saccular intracranial aneurysm is a well-known phenomenon and can cause ischemic stroke (IS), which is a rare event. The possible pathogenic mechanisms of IS include distal embolic occlusion secondary to migration of the intra-aneurysmal thrombus, occlusion of the parent artery lumen caused by the retrograde extension of the aneurysmal thrombosis, external compression of the parent artery due to the increased aneurysmal mass effect. Among these, IS due to simultaneous thromboses of the aneurysm and its parent artery is extremely rare, with only a few cases reported in the literature. Herein, we present a case of a 18-year-old woman who suffered an acute IS, attribute to spontaneous complete thrombosis of an unruptured large saccular aneurysm of the right middle cerebral artery with occlusion of the parent artery, and we review the literature simultaneously.

Microsurgical clipping versus endovascular therapy for treating patients with middle cerebral artery aneurysms presenting with neurological ischemic symptoms

Studies comparing different treatment methods in patients with middle cerebral artery (MCA) aneurysms in different subgroups of onset symptoms are lacking. It is necessary to explore the safety and efficacy of open surgical treatment and endovascular therapy in patients with MCA aneurysms in a specific population. This study aimed to compare microsurgical clipping versus endovascular therapy regarding complication rates and outcomes in patients with MCA aneurysms presenting with neurological ischemic symptoms. This was a retrospective cohort study in which 9656 patients with intracranial aneurysms were screened between January 2014 and July 2022. Further, 130 eligible patients were enrolled. The primary outcome was the incidence of serious adverse events (SAEs) within 30 days of treatment, whereas secondary outcomes included postprocedural target vessel-related stroke, disabling stroke or death, mortality, and aneurysm occlusion rate. Among the 130 included patients, 45 were treated with endovascular therapy and 85 with microsurgical clipping. The primary outcome of the incidence of SAEs within 30 days of treatment was significantly higher in the clipping group [clipping: 23.5%(20/85) vs endovascular: 8.9%(4/45), adjusted OR:4.05, 95% CI:1.20-13.70; P = 0.024]. The incidence of any neurological complications related to the treatment was significantly higher in the clipping group [clipping:32.9%(28/85) vs endovascular:15.6%(7/45); adjusted OR:3.49, 95%CI:1.18-10.26; P = 0.023]. Postprocedural target vessel-related stroke, disabling stroke or death, mortality rate, and complete occlusion rate did not differ significantly between the two groups. Endovascular therapy seemed to be safer in treating patients with MCA aneurysms presenting with neurological ischemic symptoms compared with microsurgical clipping, with a significantly lower incidence of SAEs within 30 days of treatment and any neurological complications related to the treatment during follow-up.

Treatment Strategy of Intracranial Anterior Circulation Aneurysm Presenting with Cerebral Ischemia: A Single-Center Experience

OBJECTIVE

To investigate the clinical characteristics and treatment strategy of anterior circulation aneurysm presenting with cerebral ischemia.

METHODS

We performed a retrospective review of patients with intracranial anterior circulation aneurysms presenting with cerebral ischemia examined in the Fifth Ward of the Neurosurgery Department of Tianjin Huanhu Hospital between September 2016 and September 2023. Data were reviewed for age, sex, presentation, type and size, location, treatment modalities, postoperative complications, clinical and imaging outcomes, and follow-up outcomes.

RESULTS

Among the 13 patients, there were 8 males and 5 females (1.6:1). Their presentations included ischemic stroke (69.23%, 9/13) and transient ischemic attack (TIA) (30.77%, 4/13). The aneurysms were dissecting (46.15%, 6/13), saccular (30.77%, 4/13), and saccular combined with thrombosis (23.08%, 3/13) in shape. There were 6 giant aneurysms, 4 large aneurysms, and 3 microaneurysms. Three (23.08%, 3/13) aneurysms were located at the internal carotid artery (ICA) and 10 (76.92%, 10/13) were located in the middle cerebral artery (MCA). A preoperative magnetic resonance perfusion (MRP) examination was performed in all patients, and 9 (69.23%, 9/13) patients showed hypoperfusion. Treatment modalities included stent-assisted embolization, direct clipping, clipping combined with bypass, resection combined with bypass, isolated combined with bypass, proximal occlusion combined with bypass, and the internal carotid artery constriction combined with bypass. Twelve (92.31%, 12/13) patients had no postoperative complications, and temporary complications occurred in 1 (7.69%, 1/13) patient. Aneurysms disappeared in 11 cases and shrank in 2 cases postoperatively. All patients were followed up for 1 to 72 months. We found no new cerebral infarction, no subarachnoid hemorrhage, and no recurrence or enlargement of aneurysms during the follow-up.

CONCLUSIONS

Intracranial anterior circulation aneurysm presenting with cerebral ischemia is rare. Saccular aneurysms with wide neck or thrombosis and dissected aneurysms of the anterior circulation may result in cerebral ischemic attack caused by distal vascular embolism. Individualized treatment should be performed, and cerebral revascularization is an effective treatment for patients with intracranial anterior circulation aneurysms presenting with cerebral ischemia.

Distal middle cerebral artery dissection with concurrent completely thrombosed aneurysm manifesting as cerebral ischemia. A case report and review of the literature

We report the case of a 70-year-old woman who presented with an acute ischemic stroke involving the left frontal operculum secondary to an M2 dissection and a concomitant completely thrombosed aneurysm of the left distal middle cerebral artery. Initial imaging work-up was inconclusive due to the lack of typical radiographic features and only repeated imaging studies pointed towards the presence of an arterial dissection combined with a completely thrombosed aneurysm. The aneurysm was partially clipped and wrapped with excellent clinical result at 1-year follow-up. The clinical, imaging and therapeutic challenges of this rare entity are discussed.

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.

Acute ischemic stroke due to unruptured small aneurysm of internal carotid artery: A case report

RATIONALE

Intracranial small aneurysm is a rare cause of ischemic stroke, and been described only in sparse case reports. The exact pathophysiology, treatment strategies, and prognosis remain incompletely understood.

PATIENT CONCERNS

A 42-year-old man presented with an acute onset weakness of the right limbs.

DIAGNOSES

Neuroimaging evaluation confirmed a diagnosis of acute ischemic stroke and left internal carotid artery (ICA) small aneurysm.

INTERVENTIONS

The patient underwent oral anti-platelet therapy (100 mg aspirin daily).

OUTCOMES

The patient recovered to normal status within 4 weeks following antiplatelet treatment. During a follow-up period of 1 year, he remained neurologically asymptomatic and led a virtually normal life.

LESSONS

It is crucial for clinicians to be aware of this entity, as cerebral infarction caused by small cerebral aneurysm is extremely rare.

INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS FOR EXUDATIVE RETINAL ARTERIAL MACROANEURYSMS

PURPOSE

There is no established therapy for exudative-hemorrhagic complications in primary retinal arteriolar macroaneurysm (RAM).

METHODS

Retrospective multicenter interventional study of anti-vascular endothelial growth factor in symptomatic RAMs. Central macular thickness in μm and best-corrected visual acuity in logMar were correlated with the RAM size and distance to the macula. Statistical analyses were performed using paired comparisons and Pearson correlation.

RESULTS

Thirty-two eyes (32 patients) were treated with a mean of 2.7 injections over a mean follow-up of 16.6 months. Initial best-corrected visual acuity correlated with the RAM size and distance to the macula (P = 0.02). Central macular thickness decreased by 131,180, and 211 μm at 1, 2, and 3 months after the first injection (P < 0.001). Best-corrected visual acuity improved by 0.47 and 0.38 Early Treatment Diabetic Retinopathy Study lines at 2 and 3 months (P = 0.005). Anti-vascular endothelial growth factor response correlated with the RAM size (P = 0.04) and the distance to the macula (P = 0.009).

CONCLUSION

Symptomatic RAMs can be treated successfully with anti-vascular endothelial growth factor injections, leading to a decrease in macular edema.

Thrombolysis in Acute Stroke Due to Thrombosed Aneurysm

We describe a case of a patient who presented with an acute stroke and thrombosed aneurysm of the same vessel. We review the literature on acute stroke management in the setting of an ischemic stroke caused by a thrombosed aneurysm, including intravenous thrombolysis and mechanical thrombectomy. We found that it is unclear whether thrombolysis is safe in these cases. Future case series may be helpful in answering the question.

Recurrent Embolic Stroke Caused by Large Cavernous Carotid Aneurysm: Stroke Recurrence Prevention with High-Flow Bypass Followed by Proximal Occlusion

Intracranial aneurysms may cause embolic stroke. Medical or surgical management is selected on an individual basis, as the optimal treatment strategy has not been established. A 79-year-old woman with a large cavernous carotid aneurysm suffered repeated embolic stroke after enlargement and partial thrombosis of the aneurysm, in spite of antiplatelet therapy. Coil embolization of the primitive trigeminal artery and ligation of the internal carotid artery (ICA) at the cervical portion followed by high-flow bypass from the cervical external carotid artery to the middle cerebral artery were performed. The aneurysm was thrombosed, and prevention of further stroke was achieved. Acute enlargement and thrombosis of large or giant cavernous carotid aneurysm may cause repeated embolic stroke, and requires emergent exclusion of the aneurysm from circulation by proximal ICA occlusion together with distal revascularization before devastating embolic stroke occurs.

Management of Unruptured Intracranial Aneurysms

Unruptured intracranial aneurysms (UIA) occur in approximately 2-3 % of the population. Most of these lesions are incidentally found, asymptomatic and typically carry a benign course. Although the risk of aneurysmal subarachnoid hemorrhage is low, this complication can result in significant morbidity and mortality, making assessment of this risk the cornerstone of UIA management. This article reviews important factors to consider when managing unruptured intracranial aneurysms including patient demographics, comorbidities, family history, symptom status, and aneurysm characteristics. It also addresses screening, monitoring, medical management and current surgical and endovascular therapies.

Partial thrombosis of an anterior communicating artery aneurysm prior to endovascular coiling, with intra-procedural distal thrombus embolization

Thromboembolic stroke from migration of thrombus formed in non-giant intracranial aneurysms is a recognized but rare event. We describe a case of partial thrombosis of a 7 mm anterior communicating artery aneurysm, which embolized to the right callosomarginal artery in the brief time interval between two sequential diagnostic angiograms performed as part of elective endovascular coiling, and before any instrumentation had been advanced into the intracranial circulation. To our knowledge, this is the first reported case of aneurysmal thrombus embolization observed angiographically in near real time.