Multiple aneurysms in subarachnoid hemorrhage - identification of the ruptured aneurysm, when the bleeding pattern is not self-explanatory - development of a novel prediction score

Challenges in identifying ruptured aneurysms in cases of multiple aneurysms: Utilizing MRI with contrast for surgical planning-A case report

Key Clinical Message

Accurately identifying the ruptured aneurysm in patients with subarachnoid hemorrhage and multiple aneurysms is critical to prevent rebleeding and optimize outcomes. Vessel wall MRI with contrast can aid in pinpointing the culprit aneurysm, informing a tailored surgical or endovascular management strategy for these complex cases. In patients with subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms, MRI with contrast and DSA are crucial for identifying the ruptured aneurysm, guiding a shift from endovascular to microsurgical clipping. Successful single-session treatment and absence of postsurgical deficits highlight the effectiveness of a multidisciplinary approach. Further research on optimal strategies is needed.

Abstract

Multiple intracranial aneurysms make up approximately 20% of cases of aneurysmal SAH. In patients with aneurysmal SAH and multiple intracranial aneurysms, definite treatment of the ruptured aneurysm causing SAH is of the highest priority. However, identifying the bleeding source can be challenging, and it may not be recognizable by the hemorrhage pattern. Misdiagnosis and mistreatment of a ruptured aneurysm in a patient with multiple aneurysms can lead to bleeding recurrence and an undesirable outcome. We report a 65-year-old woman who presented with severe sudden onset headache. Neuroimaging studies revealed diffuse SAH and concurrent PICA and ACom aneurysm with triplicate A2. However, the ruptured aneurysm responsible for the patient's symptoms was not obvious based on routine neuroimaging studies. Magnetic resonance imaging with contrast was performed, revealing circumferential enhancement of the PICA aneurysm. In this report, we demonstrate the real-world effect of vessel wall MRI with contrast on decision-making regarding identifying the ruptured aneurysm and surgical planning in cases of multiple aneurysms. Furthermore, we show that MRI and aneurysm wall enhancement could be a promising option in detecting ruptured aneurysms in cases of multiple aneurysms.

The clinical challenge of subarachnoid hemorrhage associated with multiple aneurysms when the bleeding source is not certainly identifiable

BACKGROUND

Multiple intracranial aneurysms (IAs) are encountered in 20-30% of the subarachnoid hemorrhages (SAH). Neuroimaging and clinical examination are usually sufficient to detect the bleeding source, but sometimes it can be misdiagnosed with catastrophic consequences.

METHODS

We reviewed our diagnostic work-up for all patients admitted from January 2016 to December 2020 for SAH with multiple IAs accounting for our rate of diagnostic failure. Then, we grouped the patients into 4 categories according to aneurysms topography and described our operative protocol in case of uncertain bleeding origin.

RESULTS

Sixty-two patients harboring 161 IAs were included. The bleeding source was identified in 56 patients (90.3%), who harbored other 81 bystander aneurysms. In 6 cases (9.7%) with a total of 24 aneurysms we failed the bleeding source identification. According to IAs topography, we grouped the IAs multiplicity in: 1) anterior plus posterior circulation IAs; 2) multiple posterior circulation IAs; 3) bilateral anterior circulation IAs; and 4) multiple ipsilateral anterior circulation IAs. In case of unidentified bleeding source, key-elements favoring the simultaneous multiple IAs treatment were their number, morphology, topography, clinicians' experience, and management modality as endovascular treatment allows a faster exclusion of multiple IAs distant one each other compared with surgery. MCA involvement represented the more frequent reason to prefer multiple clipping rather than multiple coiling.

CONCLUSIONS

In a small percentage of patients with SAH with multiple IAs, bleeding source identification can be difficult. Until the routinely availability of new tools such as vessel wall imaging or computational fluid dynamics, an experienced neurovascular team and strategies aiming to simultaneously exclude multiple IAs remain mandatory.

Effects of induced arterial hypertension for vasospasm on unruptured and unsecured cerebral aneurysms (growth and rupture). A retrospective case-control study

OBJECTIVES

Unruptured cerebral aneurysms (UCAs) often coexist with the ruptured one but are typically left unsecured during the weeks following aneurysmal subarachnoid hemorrhage (aSAH). We compared the rate of UCAs rupture or volume growth (≥5 mm3) between patients exposed to induced arterial hypertension (iHTN) for vasospasm and those not exposed (control group).

MATERIALS AND METHODS

From 2013 to 2021, we retrospectively included consecutive adult patients with aSAH who had ≥1 UCA. Custom software for digital subtraction angiography (DSA) image analysis characterized UCAs volume, going beyond merely considering UCAs long axis.

RESULTS

We analyzed 118 patients (180 UCAs): 45 in the iHTN group (64 UCAs) and 73 in the control group (116 UCAs). Systolic blood pressure in the iHTN group was significantly higher than in the control group for several days after aSAH. During the 107 day-monitoring period [interquartile range(IQR):92;128], no UCA rupture occurred in either group. UCA volume analysis was performed in 44 patients (60 UCAs): none of the UCAs in the iHTN group and 3 out of 42 (7%) in the control group had a >5 mm3 volume growth (p=0.55). Other morphologic parameters did not exhibit any variations that might indicate an increased risk of rupture in the iHTN group compared to the control group.

CONCLUSION

iHTN did not increase the risk of rupture or volume growth of UCAs within several weeks following aSAH. These reassuring results encourage not to refrain, because of the existence of UCAs, from iHTN as an option to prevent cerebral infarction during cerebral vasospasm.

Aneurysmal subarachnoid haemorrhage: Volumetric quantification of the blood distribution pattern to accurately predict the ruptured aneurysm location

BACKGROUND

In spontaneous subarachnoid haemorrhage (SAH) accurate determination of the bleeding source is paramount to guide treatment. Traditionally, the bleeding pattern has been used to predict the aneurysm location. Here, we have tested a software-based tool, which quantifies the volume of intracranial blood and stratifies it according to the regional distribution, to predict the location of the ruptured aneurysm.

METHODS

A consecutive series of SAH patients admitted to a single tertiary centre between 2012-2018, within 72 h of onset, harbouring a single intracranial aneurysm. A semi-automatized method of blood quantification, based on the relative density increase, was applied to initial non-contrast CTs. Five regions were used to define the bleeding patterns and to correlate them with aneurysm location: perimesencephalic, interhemispheric, right/left hemisphere and intraventricular.

RESULTS

68 patients were included for analysis. There was a strong association between the distribution of blood and the aneurysm location (p < 0.001). In particular: ACom and interhemispheric fissure (p < 0.001), MCA and ipsilateral hemisphere (p < 0.001), ICA and ipsilateral hemisphere and perimesencephalic cisterns (p < 0.001), PCom and hemispheric, perimesencephalic and intraventricular (p = 0.019), and PICA and perimesencephalic and intraventricular (p < 0.001). The internal diagnostic value was high (AUROC ≥ 0.900) for these locations.

CONCLUSION

Regional automatised volumetry seems a reliable and objective tool to quantify and describe the distribution of blood within the subarachnoid spaces. This tool accurately predicts the location of the ruptured aneurysm; its use may be prospectively considered in the emergency setting when speed and simplicity are attained.

Evaluation of unruptured aneurysm scoring systems and ratios in subarachnoid hemorrhage patients with multiple intracranial aneurysms

Background

This study aims to appraise aneurysm scores and ratios' ability to discriminate between ruptured aneurysms and unruptured intracranial aneurysms (UIAs) in subarachnoid hemorrhage (SAH) patients harboring multiple intracranial aneurysms (MICAs). We, then, investigate the most frequent risk factors associated with MICAs.

Methods

We retrospectively applied unruptured intracranial aneurysm treatment score (UIATS) and population hypertension age size of aneurysm earlier SAH from another aneurysm site of aneurysm (PHASES) score, aspect, and dome-to-neck ratio to the 59 consecutive spontaneous SAH patients with MICAs admitted between January 2000 and December 2015 to the Department of Neurosurgery of the University Hospital Center "Hôpital des Spécialités" of Rabat (Morocco). Patients with at least two intracranial aneurysms (IAs) confirmed on angiography were included in the study.

Results

Fifty-nine patients were harboring 128 IAs. The most frequent patient-level risk factors were arterial hypertension (AHT) 30.5 % (n = 18) and smoking status 22.0 % (n = 13). A PHASES score recommended treatment in 52 of 60 ruptured aneurysms and in six of 68 UIAs with a sensitivity of 31.67% and a specificity of 76.47%. UIATS recommended treatment in 26 of 62 ruptured aneurysms and in 35 of 55 UIAs with a sensitivity of 41.9% and a specificity of 63.6%. Aspect ratio recommended treatment in 60 of 60 ruptured aneurysms and in 63 of 68 UIAs with a sensitivity of 100% and a specificity of 88.24%. Dome-to-neck ratio recommended treatment in 45 of 60 ruptured aneurysms and in 48 of 68 UIAs with a sensitivity of 80% and a specificity of 63.24%. The aspect ratio (area under the curve [AUC] = 0.953) AUC > 0.8 has a higher discriminatory power between ruptured aneurysms and UIAs.

Conclusion

AHT and smoking status were the most common risk factors for intracranial multiple aneurysms and the aspect ratio and PHASES score were the most powerful discrimination tools between ruptured aneurysms and the UIAs.

Endovascular treatment of multiple intracranial aneurysms in patients with subarachnoid hemorrhage: one or multiple sessions?

Objective

This study aimed to compare the safety and efficacy of single- and multiple-stage endovascular treatment in aneurysmal subarachnoid hemorrhage (SAH) patients with multiple intracranial aneurysms.

Methods

We retrospectively analyzed the clinical and imaging data of 61 patients who harbored multiple aneurysms and presented to our institution with aneurysmal subarachnoid hemorrhage. Patients were grouped according to endovascular treatment strategy: one-stage or multiple-stage.

Result

The 61 study patients harbored 136 aneurysms. One aneurysm in each patient had ruptured. In the one-stage treatment group, all 66 aneurysms in 31 patients were treated in one session. The mean follow-up was 25.8 months (range, 12-47). At the last follow-up, the modified Rankin scale was ≤2 in 27 patients. In total, 10 complications occurred (cerebral vasospasm, six patients; cerebral hemorrhage, two patients; and thromboembolism, two patients). In the multiple-stage treatment group, only the ruptured aneurysm (30 in total) was treated at the time of presentation, and the remaining aneurysms (40 in total) were treated later. The mean follow-up was 26.3 months (range, 7-49). At the last follow-up, the modified Rankin scale score was ≤2 in 28 patients. In total, five complications occurred (cerebral vasospasm, four patients; and subarachnoid hemorrhage, one patient). During the follow-up period, there was one recurrence of aneurysm with subarachnoid hemorrhage in the single-stage treatment group and four recurrences in the multiple-stage treatment group.

Conclusion

Both single- and multiple-stage endovascular treatment is safe and effective in aneurysmal subarachnoid hemorrhage patients who harbor multiple aneurysms. However, multiple-stage treatment is associated with a lower rate of hemorrhagic and ischemic complications.

Identification of ruptured intracranial aneurysms using the aneurysm-specific prediction score in patients with multiple aneurysms with subarachnoid hemorrhages- a Chinese population based external validation study

Background

For patients with aneurysmal subarachnoid hemorrhages (SAHs) and multiple intracranial aneurysms (MIAs), a simple and fast imaging method that can identify ruptured intracranial aneurysms (RIAs) may have great clinical value. We sought to use the aneurysm-specific prediction score to identify RIAs in patients with MIAs and evaluate the aneurysm-specific prediction score.

Methods

Between May 2018 and May 2021, 134 patients with 290 MIAs were retrospectively analyzed. All patients had an SAH due to IA rupture. CT angiography (CTA) was used to assess the maximum diameter, shape, and location of IAs to calculate the aneurysm-specific prediction score. Then, the aneurysm-specific prediction score was applied to RIAs in patients with MIAs.

Results

The IAs with the highest aneurysm-specific prediction scores had not ruptured in 17 (12.7%) of the 134 patients with 290 MIAs. The sensitivity, specificity, false omission rate, diagnostic error rate, and diagnostic accuracy of the aneurysm-specific prediction score were higher than those of the maximum diameter, shape, and location of IAs.

Conclusions

The present study suggests that the aneurysm-specific prediction score has high diagnostic accuracy in identifying RIAs in patients with MIAs and SAH, but that it needs further evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02727-w.

Exploring the Unique Contrast Properties of Aptamer-Gadolinium Conjugates in Magnetic Resonance Imaging for Targeted Imaging of Thrombi

Objective: An important clinical question in the determination of the extent of thrombosis-related vascular conditions is the identification of blood clot location. Fibrin is a major molecular constituent of blood clots and can, therefore, be utilized in molecular imaging. In this proof-of-concept study, we sought to prepare a fibrin-targeting magnetic resonance imaging contrast agent, using a Gd(III)-loaded fibrinogen aptamer (FA) chelate conjugate (Gd(III)-NOTA-FA) (NOTA = 1,4,7-triazacyclononane-1,4,7-triacetic acid), to endow the ability to specifically accumulate at the location of blood clots, thereby enhancing contrast capabilities. Methods: The binding affinity of FA for fibrin was confirmed by fluorescence microscopy and microscale thermophoresis. The preparation and effective loading of the chelate-aptamer conjugates were confirmed by mass spectrometry and a xylenol orange colorimetric test. Longitudinal and transverse relaxivities and the effects of target binding were assessed using T1- and T2-map sequences at 7 T. T1- and T2-weighted images were acquired after blood clots were treated with Gd(III)-NOTA-FA. Collagen was used as the protein control, while an unrelated aptamer sequence, FB139, was used as the aptamer control. Results: FA demonstrated a high affinity and selectivity toward the polymeric protein, with a K_d of 16.6 nM, confirming an avidity over fibrinogen. The longitudinal (r1) and transverse (r2) relaxivities of Gd(III)-NOTA-FA demonstrated that conjugation to the long aptamer strand shortened T1 relaxation times and increased T2 relaxation times (3.04 and 38.7 mM^-1 s^-1, respectively). These effects were amplified by binding to the fibrin target (1.73 and 46.5 mM^-1 s^-1, respectively). In vitro studies with thrombin-polymerized human blood (clots) in whole blood showed an unexpected enhancement of signal intensity (hyperintense) produced exclusively at the location of the clot during the T2-weighted scan, while the presence of fibrinogen within a whole blood pool resulted in T1 signal intensity enhancement throughout the pool. This is advantageous, as simply reversing the type of a scan from a typical T1-weighted to a T2-weighted would allow to selectively highlight the location of blood clots. Conclusions: Gd(III)-NOTA-FA can be used for molecular imaging of thrombi, through fibrin-targeted delivery of contrast to the location of blood clots in T2-weighted scans.

Clinical Characteristics of Ruptured Intracranial Aneurysm in Patients with Multiple Intracranial Aneurysms

OBJECTIVE

It is difficult to correctly identify the ruptured aneurysm in patients with multiple intracranial aneurysms. Here, we investigated the clinical characteristics of ruptured intracranial aneurysms in such patients.

METHODS

We retrospectively analyzed 361 patients who underwent microsurgical clipping of ruptured intracranial aneurysms at our institution from 2012 to 2018. Patients' age, sex, Fisher group, World Federation of Neurosurgical Societies grade, size (neck width, depth, maximum diameter), location, and shape of intracranial aneurysm, and hemorrhage pattern on admission were reviewed.

RESULTS

In total, 266 patients (74%) had single intracranial aneurysms and 95 (26%) had multiple intracranial aneurysms. Eighty-nine of the 95 multiple intracranial aneurysms (94%) had irregular shape (P < 0.01). The median aspect ratios of ruptured and unruptured intracranial aneurysms were 2.2 ± 1.1 and 1.0 ± 0.4, respectively (P < 0.01). Twelve of 95 patients (13%) had ruptured intracranial aneurysms that were smaller than unruptured intracranial aneurysms. Among the 12 patients, the aspect ratios of ruptured intracranial aneurysms were greater than those of unruptured intracranial aneurysms (P < 0.01). Regarding morphologic characteristics, aspect ratio, maximum size, and irregular shape could be the useful predictive factors, but the greatest aspect ratio among patients with multiple aneurysms was the most predictive of an intracranial aneurysm rupture, after adjustment for aneurysmal size (adjusted odds ratio 217.82; 95% confidence interval 56.41-841.08).

CONCLUSIONS

The results of this study indicate that the aspect ratio is the most predictive factor of a ruptured intracranial aneurysm in patients with multiple intracranial aneurysms.

Risk factors and treatment approach for subarachnoid hemorrhage in a patient with nine intracranial aneurysms

Introduction. In about one-third of the patients with aneurysmal subarachnoid bleeding, multiple intracranial aneurysms are confirmed. Risk factors such as female gender, smoking, hypertension, and age over 60 tend to be associated with multiple aneurysms. In this paper, we also discuss family predisposition and the treatment approach for multiple cerebral aneurysms. Case outline. Here, we present a case of a female patient, 64-year-old, with spontaneous subarachnoid hemorrhage that had nine intracranial aneurysms. The patient was treated for hypertension for a longer period, excessive smoker, and two of her nearest members of the family died from intracranial bleeding. The patient was fully conscious, without any neurological impairment. Subarachnoid bleeding was diffuse and nor brain-computer tomography finding nor digital subtraction angiography couldn't suggest the source or location of bleeding among nine presented aneurisms. Magnet resonance imaging had to be done, and the T1W fast spin-echo sequence showed a 9 mm large ruptured an aneurysm at the basilar tip, after contrast application, beside others. Three days after insult endovascular embolization was done and two basilar aneurysms were excluded from the circulation, including the one that bled. Conclusion. The patient had the majority of risk factors for multiple intracranial aneurysms. Knowledge of the family predisposition of multiple intracranial aneurysms allowed us to make proper diagnostics of a patient's descendant and reveal a new patient.