Could Phosphorous MR Spectroscopy Help Predict the Severity of Vasospasm? A Pilot Study

One of the main causes of the dismal prognosis in patients who survive the initial bleeding after aneurysmal subarachnoidal hemorrhage is the delayed cerebral ischaemia caused by vasospasm. Studies suggest that cerebral magnesium and pH may potentially play a role in the pathophysiology of this adverse event. Using phosphorous magnetic resonance spectrocopy (31P-MRS), we calculated the cerebral magnesium (Mg) and pH levels in 13 patients who suffered from aSAH. The values between the group that developed clinically significant vasospasm (n = 7) and the group that did not (n = 6) were compared. The results of this study show significantly lower cerebral Mg levels (p = 0.019) and higher pH levels (p < 0.001) in the cumulative group (all brain voxels together) in patients who developed clinically significant vasospasm. Further clinical studies on a larger group of carefully selected patients are needed in order to predict clinically significant vasospasm.

Microsurgery for brain aneurysms in an accessory A2 and basilar arteries: a rare case presentation and surgical video

We present the case of a 58-year-old male with a 3-day history of sudden onset headache, loss of consciousness, and uncontrolled vomiting. The patient had 3/5 quadriparesis and a Glasgow coma scale (GCS) score of 8, which merited neurocritical intensive care. Brain imaging suggested the presence of two lesions: (i) a fusiform aneurysm of 12 × 7 mm in an accessory A2 artery of the anterior cerebral artery and (ii) an unruptured saccular aneurysm of 3.3 × 2.8 mm in the distal segment of the basilar artery. He was deemed a candidate for microsurgical management. Postoperatively, he had 4/5 quadriparesis, paresis of the right oculomotor nerve, and a GCS score of 13. A 3-month follow-up showed a significant improvement in neurological function with a score of 2 on the modified Rankin scale. The presented case illustrates the relevance of a nuanced acquaintance to operate in diseased anatomical variants and complex pathologies of narrow corridors.

Incidental cerebral aneurysm after takotsubo cardiomyopathy: A case report

Takotsubo syndrome (TS) is an acute heart disease that mimics the typical features of acute coronary syndrome (ACS). TS is generally reported after subarachnoid hemorrhage (SAH) due to a ruptured aneurysm, and has an incidence rate of 0.8 (17%). Here, we report a rare case of TS with unruptured intracranial aneurism. A 54-year-old woman had a history of systemic arterial hypertension and migraine. She went to a secondary hospital 2 h after sudden-onset chest pain, which irradiated to the left upper limb and back. The initial electrocardiogram (ECG) was normal but showed a troponin curve, which led us to suspect acute non-ST elevation myocardial infarction. Serial ECG showed dynamic changes in ST-segment elevation in DIII, AvF, V5, and V6. Emergency cardiac catheterisation was performed and did not show any obstructive lesions. However, ventriculography revealed hypokinesia of the inferoapical wall. During hospitalization, the patient had a severe refractory headache. Computed tomography (CT) and CT angiography were performed, which identified "mirror" saccular aneurysms. A supraclinoid internal carotid artery aneurysm was embolized with two stents. The patient's condition progressed satisfactorily. The association between takotsubo syndrome and aneurysmal SAH with some populations has already been reported. Due to this prior knowledge, and severe headache, it was necessary to perform screening for SAH and the discovery of an unruptured aneurysm in this case report. The present case report differs from most reported cases of takotsubo syndrome described in the literature because it presents unruptured mirror aneurysms, while most cases are diagnosed after intracranial hemorrhage.

Evaluation of External Trigeminal Nerve Stimulation to Prevent Cerebral Vasospasm after Subarachnoid Hemorrhage Due to Aneurysmal Rupture: A Randomized, Double-Blind Proof-of-Concept Pilot Trial (TRIVASOSTIM Study)

Cerebral vasospasm remains the most frequent and devastating complication after subarachnoid aneurysmal hemorrhage because of secondary cerebral ischemia and its sequelae. The underlying pathophysiology involves vasodilator peptide release (such as CGRP) and nitric oxide depletion at the level of the precapillary sphincters of the cerebral (internal carotid artery network) and dural (external carotid artery network) arteries, which are both innervated by craniofacial autonomic afferents and tightly connected to the trigeminal nerve and trigemino-cervical nucleus complex. We hypothesized that trigeminal nerve modulation could influence the cerebral flow of this vascular network through a sympatholytic effect and decrease the occurrence of vasospasm and its consequences. We conducted a prospective double-blind, randomized controlled pilot trial to compare the effect of 10 days of transcutaneous electrical trigeminal nerve stimulation vs. sham stimulation on cerebral infarction occurrence at 3 months. Sixty patients treated for aneurysmal SAH (World Federation of Neurosurgical Societies scale between 1 and 4) were included. We compared the radiological incidence of delayed cerebral ischemia (DCI) on magnetic resonance imaging (MRI) at 3 months in moderate and severe vasospasm patients receiving trigeminal nerve stimulation (TNS group) vs. sham stimulation (sham group). Our primary endpoint (the infarction rate at the 3-month follow-up) did not significantly differ between the two groups (p = 0.99). Vasospasm-related infarctions were present in seven patients (23%) in the TNS group and eight patients (27%) in the sham group. Ultimately, we were not able to show that TNS can decrease the rate of cerebral infarction secondary to vasospasm occurrence. As a result, it would be premature to promote trigeminal system neurostimulation in this context. This concept should be the subject of further research.

Torque Teno virus DNA is found in the intracranial aneurysm wall-Is there a causative role?

Objective

Torque Teno virus (TTV) is a recently discovered virus with high prevalence worldwide, that has been associated with vascular diseases. The aim of this study is to investigate the prevalence of TTV molecular DNA in the intracranial aneurysm (IA) artery walls.

Method

Samples of IA walls were collected after microsurgical clipping from 35 patients with IA (22 ruptured/13 unruptured cases). The samples were submitted to molecular DNA extraction using the EasyMag automatized extractor and performed with Qiagen DNA extraction Minikit 250. The samples underwent PCR examination with primers for β-globin as internal control using the Nanodrop ^® 2000 spectrophotometer. A quantitative (real-time) PCR with TTV-specific primers was performed. Clinical and radiological data of patients included was collected.

Results

TTV was detected in 15 (42.85%) cases, being 10 (45.4%) ruptured and 5 (38.4%) unruptured (p = 0.732) lesions. Multiple IAs accounted for 14 (40%) cases. Five cases (17.2%) had TTV+ and multiple aneurysms (p = 0.73). Association between presence of virus and aneurysm rupture was not statistically significant (p = 0.96).

Conclusion

This study demonstrated a relatively high prevalence of viral DNA in the walls of IAs. This is the first study to identify the presence of TTV DNA in IA's samples, which was found more often in ruptured lesions. This is an exploratory study, therefore, larger studies are required to clarify the relationships between inflammation, viral infection, IA formation and rupture.

Flow Diverter Devices in the Treatment of Anterior Communicating Artery Region Aneurysms: Would the Regional Anatomy and the Aneurysm Location Affect the Outcomes?

BACKGROUND

In this study, the authors evaluated the efficacy and the safety of flow diverter devices (FDD) in anterior communicating artery (ACoA) region aneurysms, focusing on anatomical factors that could affect the outcome, such as the location of the aneurysm along the ACoA (centered on ACoA or decentered on the A1-A2 junction) and the anatomy of the ACoA region.

METHODS

Clinical, procedural and follow-up data were analyzed. Aneurysms were classified according to the location along the ACoA (centered or decentered on the A1-A2 junction) and on the basis of the anatomical configuration of the ACoA region. Safety was assessed by recording intraprocedural, periprocedural and delayed complications to determine the morbidity and mortality rates. The functional outcome was evaluated with the modified Rankin scale (mRS) prior to and after the endovascular procedure. To assess the efficacy, midterm and long-term clinical, angiographic and cross-sectional imaging follow-ups were recorded. Subgroup analysis according to the different ACoA regional anatomical configurations and the ACoA aneurysm locations were performed.

RESULTS

33 patients (17 males; 16 females) with ACoA region aneurysms were treated with FDDs. 27 aneurysms were located at the A1-A2 junction (82%) while the remaining six aneurysms were centered on the ACoA. No mortality was recorded. The overall morbidity rate was 6% (2/33 procedures). Major complications occurred in 33% (2/6) of ACoA aneurysms and in the 0% of A1-A2 junction aneurysms. Mid-term and long-term neuroimaging follow-ups showed the occlusion of the aneurysm in 28/33 cases (85%). Complete occlusion rates were 93% in the A1-A2 junction aneurysms and 50% in ACoA aneurysms.

CONCLUSIONS

The FDD is a safe and effective tool that can be used in the treatment of selected cases of ACoA region aneurysms. The location of the aneurysm along the ACoA and the regional anatomy of the ACoA complex could affect the efficacy and safety.

Ruptured brain aneurysm-induced subarachnoid hemorrhage with concurrent myocardial infarction in a rhesus monkey (Macaca mulatta)

Brain aneurysm ruptured subarachnoid hemorrhages (SAH) are extremely rare except in humans. This study described a SAH caused by a ruptured anterior communication artery aneurysm and concurrent myocardial infarction, along with pneumonia and intestinal obstruction in a rhesus monkey, which is rather rare in animal experiments.

Standalone Flow Diversion Therapy Effectively Controls Rebleeding of Acutely Ruptured Internal Carotid Artery Trunk (Nonbranching) Microaneurysms

Flow diversion is a promising option in selected patients with acutely ruptured microaneurysms. In this article, we reviewed our experience. Patients with acute spontaneous subarachnoid hemorrhage (SAH) after rupture of a blister-like or saccular microaneurysm (≤2 mm maximal diameter) at a nonbranching ICA site treated from January 2016 to June 2019 using flow diversion as standalone therapy were included in this study. An EVD was usually placed preventively. Antiplatelet effects of pre-procedure DAPT were evaluated (target PRU, 80–160). After the intervention, DAPT was continued for ≥6 months, aspirin—indefinitely. Angiographic controls were obtained. Fifteen patients (12 female; mean age, 46.4 years) with 15 ruptured ICA microaneurysms (mean diameter, 1.8 mm) were included. An EVD was placed in 12 patients (75%) before DAPT administration and stenting. PRU values immediately before FDS were 1–134 (mean, 72.1). One patient died 27 days after flow diversion due to a suspected fulminant pulmonary embolism. Aneurysms were completely occluded at the 6–12-month angiographic follow-up in 14/14 surviving patients, with no rebleeding at a mean of 14 months. Late mRS was 0–2 in 13/14 patients and 3 in one due to sequelae of the original hemorrhage. Flow diversion provided robust aneurysm rebleeding control. Angiographic follow-up confirmed complete aneurysm occlusion in all the cases.

YouTube as a source of patient information on brain aneurysms: a content-quality and audience engagement analysis

INTRODUCTION

The internet allows patients to access a vast amount of health information. We aimed to evaluate the credibility of YouTube videos that members of the public are accessing on brain aneurysms, and to evaluate what characteristics drive audience engagement.

MATERIAL AND METHODS

The first 50 videos for each of the following search terms were taken for analysis: 'brain aneurysm', 'cerebral aneurysm' and 'intracranial aneurysm'. The quality of each video was evaluated by two neurosurgeons and two medical students independently using the Journal of the American Medical Association (JAMA) and the DISCERN instruments. Qualitative and quantitative video data was analysed for quality and audience engagement. Inter-rater agreement was ascertained.

RESULTS

Out of a total of 150 videos, 70 met the inclusion criteria. The mean total DISCERN score was 36.5 ± 8.4 (out of 75 points), indicating that the videos were of poor quality. The mean JAMA score was 2.7 ± 0.7 (out of 4 points). Inter-rater agreement between the four raters was excellent (intraclass correlation coefficient 0.90 for DISCERN and 0.93 for JAMA). Most videos were uploaded by hospitals (50%) or educational health channels (30%). Videos had a higher number of average daily views when they included animation (P = 0.0093) and diagrams (P = 0.0422).

CONCLUSIONS

YouTube is a poor source of patient information on brain aneurysms. Our quality and audience engagement analysis may help content creators (i.e. hospital staff and physicians) to create more holistic, educational and engaging medical videos concerning brain aneurysms. Physicians could usefully refer their patients to the highest quality videos that we have found.

[Completeness of brain aneurysm exclusion according to CT angiography]

OBJECTIVE

To develop a classification of the completeness of brain aneurysm exclusion according to CT angiography for determining further diagnostic and curative strategy.

MATERIAL AND METHODS

The study included 138 patients who had 164 brain aneurysms. Clipping was carried out at the Burdenko Neurosurgery Center in 2013-2017. Titanium clips were used in 111 cases, cobalt clips - in 53 patients.

RESULTS

Completeness of brain aneurysm exclusion was assessed in 149 cases using CT angiography. In 15 cases, artifacts from cobalt clips impaired assessment. Total exclusion was achieved in 136 (91.3%) cases, subtotal (a remainder of residual neck) - in 10 (6.7%) cases, complete exclusion of the body and bottom (patent neck) - 2 (1.3%) patients, partial exclusion (partially patent bottom) - 1 patient (0.7%). In this series, a clip prevented complete contrast enhancement of brain aneurysm bottom in all cases.

CONCLUSION

CTA is a reliable method for assessing the quality of exclusion of brain aneurysm in patients with implanted titanium clips. In case of cobalt clips, stratification depending on severity of CT artifacts should be performed for data interpretation. In some cases, artifacts impair visualization of the vessels adjacent to the clips. In these patients, direct cerebral angiography or dual-energy computed tomography scanners with metal artifact suppression programs should be recommended.

Follow-up is recommended for patients with remnants of residual cervix. Redo surgery is indicated for completely patent neck, as well as partial or complete contrast enhancement of aneurysm bottom.

Clinical Context-Aware Biomedical Text Summarization Using Deep Neural Network: Model Development and Validation

Background

Automatic text summarization (ATS) enables users to retrieve meaningful evidence from big data of biomedical repositories to make complex clinical decisions. Deep neural and recurrent networks outperform traditional machine-learning techniques in areas of natural language processing and computer vision; however, they are yet to be explored in the ATS domain, particularly for medical text summarization.

Objective

Traditional approaches in ATS for biomedical text suffer from fundamental issues such as an inability to capture clinical context, quality of evidence, and purpose-driven selection of passages for the summary. We aimed to circumvent these limitations through achieving precise, succinct, and coherent information extraction from credible published biomedical resources, and to construct a simplified summary containing the most informative content that can offer a review particular to clinical needs.

Methods

In our proposed approach, we introduce a novel framework, termed Biomed-Summarizer, that provides quality-aware Patient/Problem, Intervention, Comparison, and Outcome (PICO)-based intelligent and context-enabled summarization of biomedical text. Biomed-Summarizer integrates the prognosis quality recognition model with a clinical context–aware model to locate text sequences in the body of a biomedical article for use in the final summary. First, we developed a deep neural network binary classifier for quality recognition to acquire scientifically sound studies and filter out others. Second, we developed a bidirectional long-short term memory recurrent neural network as a clinical context–aware classifier, which was trained on semantically enriched features generated using a word-embedding tokenizer for identification of meaningful sentences representing PICO text sequences. Third, we calculated the similarity between query and PICO text sequences using Jaccard similarity with semantic enrichments, where the semantic enrichments are obtained using medical ontologies. Last, we generated a representative summary from the high-scoring PICO sequences aggregated by study type, publication credibility, and freshness score.

Results

Evaluation of the prognosis quality recognition model using a large dataset of biomedical literature related to intracranial aneurysm showed an accuracy of 95.41% (2562/2686) in terms of recognizing quality articles. The clinical context–aware multiclass classifier outperformed the traditional machine-learning algorithms, including support vector machine, gradient boosted tree, linear regression, K-nearest neighbor, and naïve Bayes, by achieving 93% (16127/17341) accuracy for classifying five categories: aim, population, intervention, results, and outcome. The semantic similarity algorithm achieved a significant Pearson correlation coefficient of 0.61 (0-1 scale) on a well-known BIOSSES dataset (with 100 pair sentences) after semantic enrichment, representing an improvement of 8.9% over baseline Jaccard similarity. Finally, we found a highly positive correlation among the evaluations performed by three domain experts concerning different metrics, suggesting that the automated summarization is satisfactory.

Conclusions

By employing the proposed method Biomed-Summarizer, high accuracy in ATS was achieved, enabling seamless curation of research evidence from the biomedical literature to use for clinical decision-making.

Treatment of Recurrent Wide Neck Bifurcation Aneurysm With the Barrel Vascular Reconstruction Device

We present a case of successful embolization of a recurrent wide neck bifurcation aneurysm with a Barrel vascular reconstruction device (VRD). The unique properties of this novel device allowed optimal aneurysm neck coverage during third consecutive re-treatment, ultimately resulting in complete aneurysm obliteration. The parent vessel anatomy and the neck morphology of the aneurysm, in combination with a presence of a large pre-existing coil mass, were ideal for Barrel stent placement. The expanded portion of the device conformed perfectly to the recanalized aneurysm neck, providing optimal support for additional coil embolization. This case illustrates the advantages of Barrel VRD for definitive embolization of large, recurrent, and previously coiled wide-neck bifurcation aneurysm as a reasonable alternative to other traditional treatment modalities, such as flow diversion or Y and X stenting.

The First Awake Clipping of a Brain Aneurysm in Malaysia and in ASEAN: Achieving International Standards

World-renowned neurosurgeon, Professor Saleem Abdulrauf, has been featured in several medical journals for his successful "Awake Brain Aneurysm Surgery". Regarded as a "world first", this surgery, involves clipping un-ruptured brain aneurysms while patients are awake. Only one or two neurosurgery centres worldwide are capable of this. Performing the surgery while the patient is awake lowers risks of brain ischemia with neurological deficits and ventilator associated morbidities. The technique has been viewed as the start of a new era in brain surgery. Physicians from the Universiti Sains Malaysia (USM) School of Medical Sciences, at the Health Campus in Kelantan, headed by Professor Dr Zamzuri Idris (neurosurgeon) and Dr Wan Mohd Nazaruddin Wan Hassan (neuroanaesthetist), recently performed a similar procedure, the first such surgery in Malaysia and Southeast Asia. The USM team can therefore be considered to be among the first few to have done this brain surgery and achieved successful patient outcomes.

Contrast Enhancement of Aneurysm Sac Post-Pipeline Treatment Interpreted as Recanalization

Multiple imaging modalities are available to evaluate aneurysms post-flow diverter (FD) placement. Though digital subtraction angiography (DSA) is the gold standard imaging modality post-FD placement, it is not perfect, and neither are other techniques, including contrast-enhanced magnetic resonance angiography (CE-MRA) and magnetic resonance imaging (MRI). We present a case of a 73-year-old woman with a right internal carotid artery (ICA) aneurysm treated with a pipeline embolization device (PED). Initial follow-up post-PED placement by three-dimensional time-of-flight (3D-TOF) MRA demonstrated aneurysm occlusion, which was confirmed by computed tomography angiography (CTA) and CE-MRA in subsequent follow-up appointments. However, repeat CE-MRA two years later suggested recanalization of the aneurysm. After discussion with neuroradiologists and follow-up with a dynamic MRA, this finding was determined to be false. These findings shed light on the potential pitfall of using CE-MRA alone or any single imaging modality in the assessment of aneurysms post-PED placement. Our case report explores various imaging modalities used in the assessment of aneurysms post-PED placement and highlights the need to use multiple techniques for an accurate assessment.

An analysis of malpractice litigation related to the management of brain aneurysms

OBJECTIVE Given the highly complex and demanding clinical environment in which neurosurgeons operate, the probability of facing a medical malpractice claim is high. Recent emphasis on tort reform within the political sphere has brought this issue to the forefront of medical literature. Despite the widespread fear of litigation in the medical community, few studies have provided an analysis of malpractice litigation in the field. Here, the authors attempt to delineate the medicolegal factors that impel plaintiffs to file medical malpractice claims related to the management of brain aneurysms, and to better characterize the nature of these lawsuits. METHODS The online legal database WestLawNext was searched to find all medical malpractice cases related to brain aneurysms across a 30-year period. All state and federal jury verdicts and settlements relevant to the search criterion were considered. RESULTS Sixty-six cases were obtained. The average age of the patient was 46.7 years. Seventy-one percent were female. The cases were distributed across 16 states. The jury found in favor of the plaintiff in 40.9% of cases, with a mean payout of $8,765,405, and in favor of the defendant in 28.8% of the cases. A failure to diagnose and/or a failure to treat in a timely manner were the 2 most commonly alleged causes of malpractice. Settlements, which were reached in 25.8% of the cases, had a mean payout of $1,818,250. Neurosurgeons accounted for 6.7% of all defendants. CONCLUSIONS Unlike other medical specialties, a majority of the verdicts were not in the defendant's favor. The mean payouts were nearly 5-fold less in cases in which a settlement was reached, as opposed to a summary judgment. Neurosurgeons accounted for a small percentage of all codefendants.

Feasibility of Magnetoencephalography after Endovascular Treatment of Ruptured Intracranial Aneurysms

Objective

Among good outcome survivors of aneurysmal subarachnoid hemorrhage (aSAH), only 23% have normal neurocognitive performance, despite imaging that is often normal. The aim of this work is to explore the use of magnetoencephalography (MEG) after endovascular treatment of ruptured aneurysms.

Methods

Good outcome aSAH patients treated with coiling and matched controls were recruited. Clinical assessments and resting-state MEG and anatomical MRI images were obtained. Brain space was normalized to standard Montreal Neurological Institute (MNI) brain. Areas of interest were identified with Automated Anatomical Labeling (AAL) and “electrodes” reconstructed using vector beamformer. Spectral power density estimates for each location was averaged across the brain to derive mean signal power. Virtual-sensor data closest to the coil was assessed for signal quality.

Results

Thirteen aSAH patients and 13 matched controls were recruited. Mean age was 54.5 years (SD = 9.9) for controls and 56.8 years (SD = 11.8) for aSAH. The majority of aneurysms (62%) were in the midline. Mean time from aSAH to MEG was 18.8 months (2.4–67.5; SD = 19). Data quality was comparable in both groups, including the virtual-sensors close to the coil mass. Mean signal power showed no significant spectral alterations in the aSAH group.

Conclusion

MEG is feasible in aSAH patients after endovascular treatment. Our results suggest that the signal quality and strength is good, and the presence of coils does not interfere with testing. Considering the common neurocognitive complaints of aSAH survivors MEG could be developed to diagnose, quantify, and monitor neurocognitive problems after aSAH.

Mechanical Thrombectomy in the Treatment of Distal Occlusions during Coil Embolization of Ruptured Intracranial Aneurysms

The experience in the management of thromboembolic complications of distal vessels during coil embolization using stent-retrievers in the setting of subarachnoid hemorrhage (SAH) is still limited. We report a case of 58-year-old woman with a ruptured small anterior communicating aneurysm who experienced during coil embolization a thromboembolic occlusion of the upper post-bifurcation branch of the middle cerebral artery. Mechanical thrombectomy with a stent-retriever (Solitaire, Covidien, Neurovascular) resulted in complete recanalization of the occluded branch with no ischemic complication. This case should encourage the use of the Solitaire device as an effective rescue strategy in the treatment of distal artery occlusions in the setting of SAH.

Endovascular treatment of cerebral aneurysms using flow-diverter devices: A systematic review

BACKGROUND

Flow-diverter devices (FDDs) are new-generation stents placed in the parent artery at the level of the aneurysm neck to disrupt the intra-aneurysmal flow thus favoring intra-aneurysmal thrombosis.

OBJECTIVE

The objective of this review article is to define the indication and results of the treatment of intracranial aneurysms by FDD, reviewing 18 studies of endovascular treatment by FDDs for a total of 1704 aneurysms in 1483 patients.

METHODS

The medical literature on FDDs for intracranial aneurysms was reviewed from 2009 to December 2014. The keywords used were: "intracranial aneurysms," "brain aneurysms," "flow diverter," "pipeline embolization device," "silk flow diverter," "surpass flow diverter" and "FRED flow diverter."

RESULTS

The use of these stents is advisable mainly for unruptured aneurysms, particularly those located at the internal carotid artery or vertebral and basilar arteries, for fusiform and dissecting aneurysms and for saccular aneurysms with large necks and low dome-to-neck ratio. The rate of aneurysm occlusion progressively increases during follow-up (81.5% overall rate in this review). The non-negligible rate of ischemic (mean 4.1%) and hemorrhagic (mean 2.9%) complications, the neurological morbidity (mean 3.5%) and the reported mortality (mean 3.4%) are the main limits of this technique.

CONCLUSION

Treatment with FDDs is a feasible and effective technique for unruptured aneurysms with complex anatomy (fusiform, dissecting, large neck, bifurcation with side branches) where coiling and clipping are difficult or impossible. Patient selection is very important to avoid complications and reduce the risk of morbidity and mortality. Further studies with longer follow-up are necessary to define the rate of complete occlusion.

ICA aneurysm surgically treated utilizing a choroidal to PCOM bypass and vein bypass

This video shows the surgical repair of a 2.3 cm ICA aneurysm found in a 58-year-old woman, who presented for right eye vision changes. The patient underwent a right modified orbitozygomatic craniotomy and saphenous vein bypass from the common carotid to the temporal M2. The aneurysm was then opened and repaired. However, since the anterior choroidal artery was not filling, a salvage bypass between the anterior choroidal and the PCOM was done. Both bypasses were patent and the patient has done well with a mRS of 1 for vision symptoms. The video can be found here: http://youtu.be/ciMyzfXgo8l.

Surgical treatment of a large ruptured internal carotid artery bifurcation aneurysm

Ruptured aneurysms with intraparenchymal hematoma and mass effect are primarily treated by surgical clipping. In this video presentation, a 68 year old male with a large ruptured right ICA bifurcation aneurysm is presented. Patient's neurological exam was rapidly deteriorating, therefore the patient was transferred to the operating theater after initial evaluation by CT and CT angiogram. A pterional craniotomy was performed, the frontal hematoma was partially removed and the aneurysm was clipped. Residual hematoma was removed after securing the aneurysm and the aneurysm dome was punctured(detail of surgical clipping in the video). Patient made a good recovery at 2 weeks post-op with complete recovery of left sided weakness, and some remaining cognitive deficit. The video can be found here: http://youtu.be/dKFWptdgC4M .