Tag: intracranial aneurysms

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Neuropsychological profile and risk factors for poor cognitive outcomes in survivors of aneurysmal subarachnoid hemorrhage

J Neurosurg 144:517–525, 2026

This clinical study characterizes long-term neuropsychological outcomes in 156 survivors of aneurysmal subarachnoid hemorrhage (aSAH), using MoCA-22, digit span, and verbal fluency tests. Findings show that 34% scored below the 25th percentile despite largely favorable functional recovery, with deficits concentrated in executive function, working memory, and language.

Multivariable analysis identified modified Fisher grade 4 on admission and new radiological infarction during hospitalization as independent predictors of poor cognitive outcomes. Secondary assessments revealed frequent depressive symptoms and acquired personality disturbances, implicating impacts on work productivity and social relationships.

Objective Characterize neuropsychological deficits in aneurysmal subarachnoid hemorrhage (aSAH) survivors and identify clinical variables linked to poor cognitive outcomes.

Design/assessments Retrospective cohort (2009–2024) with cognitive testing ≥6 months post-aSAH using MoCA-22, Digit Span Forward/Backward, and Verbal Fluency; poor outcome defined as MoCA-22 <25th percentile (norm-adjusted).

Prevalence 34% (53/156) had MoCA-22 <25th percentile despite most having good functional recovery at discharge (mRS ≤2 in 79% of those with poor MoCA-22).

Cognitive profile Moderate/severe deficits (z-score >1 SD below norms) occurred in 11% on DST-F, 27% on DST-B, and 9% on VFT, highlighting prominent working-memory/executive-function vulnerability.

Key risk factors Modified Fisher grade 4 on admission and new radiological infarction during hospitalization were independently associated with poor MoCA-22 outcomes (aOR 2.43 and 2.71, respectively).

Quality of life impact Radiological infarction was associated with worse work productivity (OR 0.69) and social relationships (OR 0.72).

Behavioral sequelae Among those assessed, 27% reported at least mild depressive symptoms and 64% showed acquired personality disturbance.

Bottom line Cognitive/behavioral deficits can persist long after aSAH even with favorable mRS; higher hemorrhage burden (modified Fisher 4) and in-hospital infarction signal higher risk.

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Institutional experience using the endoscopic endonasal approach for the treatment of 40 intracranial aneurysms: indications, outcomes, and technical considerations

J Neurosurg 143:1575–1587, 2025

This clinical series reviews 40 intracranial aneurysms treated via the endoscopic endonasal approach (EEA) over 20 years, outlining patient selection, operative techniques, reconstruction evolution, and outcomes. It emphasizes indications where EEA provides superior ventral access for paraclinoid and selected posterior circulation aneurysms, especially when endovascular therapy is unsuitable.

The report details complication rates—notably CSF leaks—and their temporal improvement, intraoperative adjuncts, follow-up imaging, illustrative cases, and statistical correlations identifying posterior location, age, and SAH as risk factors.

Endoscopic Endonasal Approach (EEA) Indications: EEA is reserved for carefully selected intracranial aneurysms—primarily medially projecting paraclinoidal/cavernous internal carotid artery (ICA) and posterior circulation aneurysms—especially when endovascular treatment is unsuitable and open surgery would risk cranial nerve or brain injury.

Advantages of EEA: Provides a direct ventral surgical corridor, enabling superior proximal/distal vascular control, avoiding brain retraction and cranial nerve manipulation, and facilitating treatment of concomitant sellar pathologies or multiple lesions in a single procedure.

Patient Selection and Outcomes: Out of 34 patients (40 aneurysms) over 20 years, most aneurysms treated were in the paraclinoid/cavernous ICA or posterior circulation; EEA was only used if it was considered safer than open or endovascular approaches, with less than 1% of aneurysm patients treated annually by EEA.

Complication Profile: The main complication was cerebrospinal fluid (CSF) leak (8 cases), particularly in posterior circulation or post-subarachnoid hemorrhage (SAH) cases; other complications included meningitis, clip exposure, lacunar infarcts, and transient cranial nerve palsies. No permanent cranial nerve deficits, visual loss, or procedure-related mortalities occurred since 2019.

Technical Evolution: Advancements in reconstruction techniques and instrumentation (e.g., dedicated endonasal clip appliers, multilayer closure) have reduced complications such as clip exposure and improved overall safety and outcomes over time.

Limitations of EEA: Not suitable for most anterior communicating artery (AcomA) aneurysms due to limited exposure and control; not feasible for revascularization procedures; requires a highly experienced, multidisciplinary team for optimal results.

Comparative Morbidity: EEA appears to reduce the risk of cranial nerve deficits and parenchymal injury compared to lateral (open) approaches, especially for midline lesions, but CSF leak remains the main limitation.

Clinical Recommendation: EEA should be considered only for selected cases where endovascular and open approaches are suboptimal, and only by experienced teams aware of the risks and reconstruction challenges, with all treatment options discussed in a multidisciplinary setting.

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Trends in the size of treated unruptured intracranial aneurysms over 35 years

J Neurosurg 139:1328–1338, 2023

In the absence of clear guidelines and consistent natural history data, the decision to treat unruptured intracranial aneurysms (UIAs) is a matter of some controversy. Currently, decisions are often guided by a consensus of cerebrovascular specialist teams and patient preferences. It is unclear how paradigm-shifting developments in the detection and treatment of UIAs have affected the size of the UIAs that are selected for treatment. Herein, the authors aimed to study potential changes in the average size of the UIAs that were treated over time. They hypothesized that the average size of UIAs that are treated is decreasing over time.

METHODS A systematic search of the literature was performed to identify all studies describing the size of UIAs that were treated using any modality. Scatter diagrams with trend lines were used to plot the size of the aneurysms treated over time and assess for the presence of a potentially significant trend via statistical correlation tests. Subgroup analyses based on type of treatment, country of study, and specialty of the authors were performed.

RESULTS A total of 240 studies including 35,150 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. The mean age of patients was 55.5 years, and 70.7% of the patients were females. There was a significant decrease in the size of treated UIAs over time (Spearman’s r = −0.186, p < 0.001), with a 0.71-mm decrease in the average size of treated UIAs every 5 years since 1987 and an annual mean dropping below 7 mm in 2012. This decreasing trend was present in surgically and endovascularly treated UIAs (p < 0.001 for both), in more developed and developing countries (p < 0.001 for both), within neurosurgical and non-neurosurgical specialties (p < 0.001 for both), most prominently in the US (Spearman’s r = −0.482, p < 0.001), and less prominently in Europe (Spearman’s r = −0.221, p < 0.001) and was not detected in East Asia.

CONCLUSIONS The present study indicates that based on the treated UIA size data published in the literature over the past 35 years, smaller UIAs are being treated over time. This trend is likely driven by safer treatments. However, future studies should elucidate the cost-effectiveness of treating smaller UIAs as well as the possible real-world contribution of this trend in preventing aneurysmal subarachnoid hemorrhage.

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A Meta-Analysis of Risk Factors for the Formation of de novo Intracranial Aneurysms

Neurosurgery, Volume 85 (4) 2019, 454–465

Understanding the risk factors for the formation of de novo intracranial aneurysms (IAs) is important for patients who have ever suffered a cerebral aneurysm.

OBJECTIVE: To estimate the risk factors for the development of a de novo IA to identify which patients need more aggressive surveillance after aneurysm treatment.

METHODS: We followed the preferred reporting items for systematic reviews and metaanalyses guidelines and searched the PubMed, CENTRAL, EMBASE, and LILACS databases using the key words cerebral aneurysms, de novo, IAs, risk factors combined using and/or. The search was performed in July 2017.We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using RevMan 5.3 (Cochrane, London, United Kingdom) to evaluate risk factors. Statistical significance was set at P < .05.

RESULTS: The analysis included 14 studies involving 6389 patients, of whom 197 patients had de novo IAs. The main risk factors for formation included sex (OR = 1.82, 95% CI [1.30,2.56], P = .0005, female vs male), age <40 yr (OR = 2.96, 95% CI [1.76,4.96], P < .0001), family history (OR = 2.05, 95% CI [1.07,3.93], P = .03), smoking history (OR = 2.73, 95% CI [1.81,4.12], P < .0001), and multiple saccular intracranial aneurysms (sIAs) at first diagnosis (OR = 2.10, 95% CI [1.12,3.91], P = .02), internal carotid artery (ICA) as the initial site (OR = 2.58, 95% CI [1.43,4.68], P = .002). Heterogeneous analysis showed that these I 2 were less than 50% and the results were reliable.

CONCLUSION: Observational evidence identified multiple clinical and anatomic risk factors for the formation of de novo IAs, including female sex, age <40 yr, family history, smoking history, multiple sIAs at first diagnosis, and IC as the initial site. More aggressive long-term angiographic follow-up with digital subtraction angiography, computed tomography angiography, or magnetic resonance angiography is recommended for these patients.

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Ruptured PICA aneurysms: presentation and treatment outcomes compared to other posterior circulation aneurysms

Acta Neurochirurgica (2019) 161:1325–1334

Aneurysms of the posterior inferior cerebellar artery (PICA) are relatively uncommon and evidence is sparse about patients presenting with ruptured PICA aneurysms. We performed an analysis of the Swiss SOS national registry to describe clinical presentation, treatment pattern, and neurological outcome of patients with ruptured PICA aneurysms compared with other ruptured posterior circulation (PC) aneurysms.

Methods This was a retrospective analysis of anonymized data from the Swiss SOS registry (Swiss Study on Aneurysmal Subarachnoid Hemorrhage; 2009–2014). Patients with ruptured PC aneurysms were subdivided into a PICA and non-PICA group. Clinical, radiological, and treatment-related variables were identified, and their impact on the neurological outcome was determined in terms of modified Rankin score at discharge and at 1 year of follow-up for the two groups.

Results Data from 1864 aneurysmal subarachnoid hemorrhage patients were reviewed. There were 264 patients with a ruptured PC aneurysm. Seventy-four PICA aneurysms represented 28% of the series; clinical and radiological characteristics at admission were comparable between the PICA and non-PICA group. Surgical treatment was accomplished in 28% of patients in the PICA group and in the 4.8% of patients in the non-PICA group. No statistically significant difference was found between the two groups in terms of complications after treatment. Hydrocephalus requiring definitive shunt was needed in 21.6% of PICA patients (p = 0.6); cranial nerve deficit was present in average a quarter of the patients in both PICA and non-PICA group with no statistical difference (p = 0.3). A more favorable outcome (66.2%) was reported in the PICA group at discharge (p < 0.05) but this difference faded over time with a similar neurological outcome at 1-year follow-up (p = 0.09) between both PICA and non- PICA group. The Kaplan-Meyer estimation showed no significant difference in the mortality rate between both groups (p = 0.08).

Conclusions In the present study, patients with ruptured PICA aneurysms had a favorable neurological outcome in more than two thirds of cases, similar to patients with other ruptured PC aneurysms. Surgical treatment remains a valid option in a third of cases with ruptured PICA aneurysms.

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Diffusion-weighted imaging–detected ischemic lesions associated with flow-diverting stents in intracranial aneurysms

Diffusion-weighted imaging–detected ischemic lesions associated with flow-diverting stents in intracranial aneurysms

J Neurosurg 122:627–636, 2015

It was initially considered safe for flow-diverting stents to cover the ostia of branching vessels during endovascular procedures for the treatment of intracranial aneurysms. As more recent evidence suggests, however, their use is not always free of ischemic concerns in terms of covered arterial ostia. The authors sought to determine the frequency of silent and clinically evident diffusion-weighted imaging (DWI)–detected abnormalities related to stent placement as a means of elucidating potential clinical risks.

Methods This is a prospective single-center study on a series of patients with intracranial aneurysms that were treated with flow-diverting stents. All patients systematically underwent an MRI protocol that included DWI before treatment, between 24 and 48 hours postprocedure, and 3 months postembolization. Effectiveness of anticoagulation treatment was assessed for all patients. Lesions seen on DWI were correlated to the parent artery and the side-branch territories and were statistically analyzed in relation to their time of occurrence and clinical presentation. The authors compared the DWI findings in these patients to findings obtained in patients treated with a stent-assisted coiling technique during the same time period.

Results Over the course of 18 consecutive months, 38 consecutive patients (7 males and 31 females) with 49 intracranial aneurysms were treated using flow-diverting stents. Overall, 81.6% of the DWI spots found remained clinically silent during the follow-up period. Five ischemic clinical complications (13.2%) occurred in the postprocedural period. No statistically significant correlation could be established between DWI spots or aneurysm location and clinical complications or follow-up modified Rankin Scale score at 3 months. The complication rate was 7.8% (n = 3) at the 3-month follow-up, and mortality was 0%. Compared with stent-assisted coiling, use of flow-diverting stents showed a statistically significant correlation with silent DWI findings postintervention.

Conclusions Lesions seen on DWI resulting from the procedure are far more common than anticipated, but the technique remains safe and effective, providing an interesting alternative for “difficult” aneurysms, regardless of location. Late-occurring DWI-detected lesions distal to side arterial branches imply a local pressure gradient drop, related to flow competition by collateral networks. Further research is needed to assess the extent and significance of these events.

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Treatment of Blister-Like Aneurysms With the Pipeline Embolization Device

Treatment of Blister-Like Aneurysms With the Pipeline Embolization Device

Neurosurgery 74:527–532, 2014

Endovascular vessel reconstruction with the pipeline embolization device (PED) has become common practice. Data on the safety and efficacy of the PED in blister-like aneurysms (BLAs) are limited.

OBJECTIVE: To retrospectively present our experience with use of the PED in BLAs.

METHODS: A total of 8 patients harboring 8 BLAs were treated with the PED at our institution between November 2011 and April 2013.

RESULTS: Aneurysm size was 2.5 mm on average. Five patients had sustained a subarachnoid hemorrhage (SAH), 1 patient presented with sentinel headaches, and in 2 patients the aneurysm was incidentally discovered. Seven aneurysms arose from the ICA and 1 from the basilar artery. Placement of the PED was successful in all 8 patients. There were no procedural or perioperative complications in any of the patients. At the latest follow-up, all 8 patients achieved a favorable outcome (mRS 0-2). Angiographic follow-up was available for 6 patients at a mean time point of 3.9 months. Follow-up angiography showed 100% aneurysm occlusion in 5 patients and marked decrease in aneurysm size in 1 patient.

CONCLUSION: The findings of this study suggest that the PED may be a safe and effective treatment for BLAs. Given the limitations of other treatment modalities and the challenging nature of BLAs, flow diversion may be a valuable option for these lesions.

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Differences in the Basilar Artery Bifurcation Angle Among Patients Who Present With a Ruptured Aneurysm at the Top of the Basilar Artery and Patients With Perimesencephalic Subarachnoid Hemorrhage

Differences in the Basilar Artery Bifurcation Angle Among Patients Who Present With a Ruptured Aneurysm at the Top of the Basilar Artery and Patients With Perimesencephalic Subarachnoid Hemorrhage

Neurosurgery 73:2–7, 2013

The angle of the basilar artery bifurcation of (BAB angle) is thought to influence the risk of the development and rupture of aneurysms at this site. It is, however, unknown whether the BAB angle also influences the incidence of angiographically negative perimesencephalic subarachnoid hemorrhage (PMSAH).

OBJECTIVE: We performed a retrospective cross-sectional study comparing the BAB angle in a series of patients who presented with subarachnoid hemorrhage from a ruptured aneurysm at the top of the basilar artery (BSAH) with the BAB angle in a series of patients who presented with PMSAH.

METHODS: Consecutive patients who presented to our institution with PMSAH or BSAH between January 1, 2005 and December 31, 2010 were studied. Patients with PMSAH were further subdivided into patients with classic PMSAH (CPMSAH) and those with nonclassic PMSAH (NCPMSAH) based on initial head computed tomography examinations. In each patient, the BAB angle was measured on the standard cranial anteroposterior projections after vertebral artery injections.

RESULTS: A total of 21 patients with CPMSAH, 30 patients with NCPMSAH, and 31 patients with BSAH were studied. The BAB angle was significantly smaller in patients with CPMSAH (87.7 6 17.1 degrees) and NCPMSAH (98.4 6 21.1 degrees) compared with patients with BSAH (135.0 6 30.8 degrees) (P , .001).

CONCLUSION: The significantly lower BAB angle in PMSAH patients compared with BSAH patients suggests that bleeding in PMSAH is either nonarterial in nature or is secondary to variations in hemodynamic arterial stress at the top of the basilar artery that need to be studied further with computational models.

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Posterior Communicating Artery Aneurysms: Technical Pitfalls

Neurosurg Q 2010;20:74–81

The posterior communicating artery aneurysms correspond on 25% of all ruptured aneurysms. The clinical course is typically a subarachnoid hemorrhage and third nerve palsy. We intend to introduce a new classification for PComA aneurysms to help neurosurgeons in day-to-day practice present. We review our experience in PComA aneurysms and discuss the main factors involving morbidity, mortality, signs and symptoms, and prognosis of these aneurysms.

Material and Methods: We reviewed historical records, images, surgical videos, and CDs of 46 surgically clipped aneurysms in 39 patients from June 2000 to July 2009, in 2 Institutions: Hospital Sa˜o Camilo and Santa Paula, Sa˜o Paulo, Brazil. They were classified in 2 groups, the A group composed by patients who presented subarachnoid hemorrhage in acute phase and the B group composed by incidental aneurysms carriers. All patients were classified according to Hunt-Hess scale.

Results: The average age found was 53.6 years old (min 28 to Max 92). The incidence was higher among women (3.6:1). Worse outcomes were observed in group A. The mortality rate was 20% in group A and zero cases in group B. Similar rate was found for rupture cases (20% in A group vs zero in B group). Morbidity was similar for both groups. The mean aneurismal size for A group was 6mm (ranging from 5 to 25mm) and 5.3mm (ranging from 3 to 10 mm) for B group.

Conclusions: Posterior communicating artery aneurysms occurred 3 to 4 times more frequently in women than man. Oculomotor palsy associated with severe headache were commonly related to posterior circulation aneurysms. Type II aneurysms (temporal) were the most frequently found in our study. The worst prognosis in cases with acute bleeding occurred with fetal variant circulation. Intratentorial aneurysms, mainly those with increased Hunt-Hess, have the worst prognosis. Infundibular aneurysms had the best results with surgical clipping.

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