Complex networks approach to study comorbidities in patients with unruptured intracranial aneurysms.

The role of complex network analysis in patients with diagnosis of unruptured intracranial aneurysm is unexplored. The objective of this study is to assess the applicability of this methodology in aneurysm patients. We retrospectively analyze comprehensive unbiased local digital data of a large number of patients treated for any reason between January 2004 and July 2019. We apply an age-cohort approach to a total of 628,831 patients and construct the diagnostic history of each patient-and include the information how old the patient was when diagnosed for the first time with each diagnosis coded according to International Classification of Diseases. For each cohort of age within a 10 year interval and for each gender, we construct a statistically validated comorbidity network and focused on crucial comorbidity links that the aneurysm code has to other disease codes within the whole network. For all cohorts of different age and gender, the analysis shows that 267 diagnose codes have nearest neighbour statistically validated links to unruptured aneurysm ICD code. Among the 267 comorbidities, 204 (76%) were found in patients aged from 40 to 69-years old. Patterns of connectivity with aneurysms were found for smoking, hypertension, chronic obstructive pulmonary disease, dyslipidemia, and mood disorders. A few uncommon connections are also detected in cohorts of female patients. Our study explored the applicability of network analysis and statistical validation in aneurysm observational study.

PET imaging of unruptured intracranial aneurysm inflammation (PET-IA) study: a feasibility study protocol.

INTRODUCTION: Positron emission tomography (PET) imaging can be used to evaluate arterial wall inflammation in extracranial vascular diseases. However, the application of PET imaging in unruptured intracranial aneurysms (UIA) remains unexplored. Our objective is to investigate feasibility of PET imaging using 18F-FDG and 68Ga-DOTANOC tracers to evaluate arterial wall inflammation in UIA. METHODS AND ANALYSIS: This PET imaging feasibility study will enrol patients scheduled for surgical treatment of UIA. The study subjects will undergo PET imaging of the intracranial arteries within 1 month before planned surgery. The imaging protocol includes 18F-FDG PET MRI, MRA with gadolinium enhancement, and 68Ga-DOTANOC PET CT. The study will also involve preoperative blood samples, intraoperative cerebrospinal fluid (CSF) samples, and aneurysm sac biopsy. Planned sample size is at least 18 patients. Primary outcome is uptake of 18F-FDG or 68Ga-DOTANOC in intracranial arterial aneurysms compared with contralateral normal vessel as maximum standardised uptake value or target-to-blood pool ratio and correlation of uptake of 18F-FDG or 68Ga-DOTANOC to aneurysm histological findings. Secondary outcomes include estimating the correlations between uptake of 18F-FDG or 68Ga-DOTANOC and histological findings with blood and CSF miRNA-levels, arterial wall enhancement in gadolinium enhanced MRA, aneurysm size and shape, smoking, hypertension, and location of the aneurysm. ETHICS AND DISSEMINATION: This study is approved by the Human Research Ethics Committee of the Hospital District of Southwest Finland, Finnish Medicines Agency Fimea, and Turku University Hospital. Findings will be disseminated through peer-reviewed journal articles and presentations at national and international conferences. TRIAL REGISTRATION NUMBER: NCT04715503.

Low and Borderline Ankle-Brachial Index Is Associated With Intracranial Aneurysms: A Retrospective Cohort Study.

BACKGROUND AND OBJECTIVES: A low ankle-brachial index (ABI) has been linked to systemic inflammation and an elevated risk of cardiovascular events, most notably myocardial infarction and stroke. Intracranial aneurysms (IAs) share similar risk factors with other cardiovascular diseases. However, the association between low ABI and IAs has not been sufficiently investigated. Our objective was to investigate the potential connection between ABI values and the prevalence of unruptured IAs. METHODS: This retrospective cohort study reviewed 2751 patients who had ABI measurements at a public tertiary hospital from January 2011 to December 2013. Patients with available cerebrovascular imaging or a diagnosis of ruptured IA were included in the study (n = 776) to examine the association between ABI and saccular IAs. The patients were classified into 4 groups: low ABI (≤0.9, n = 464), borderline ABI (0.91-0.99; n = 47), high ABI (>1.4, n = 57), and normal ABI (1.00-1.40; n = 208). RESULTS: The prevalence of IAs was 20.3% (18.1% unruptured IAs) in the low ABI group, 14.9% (12.8% unruptured IAs) in the borderline ABI group, 7.0% (5.3% unruptured IAs) in the high ABI group, and 2.4% (1.9% unruptured IAs) in the normal ABI group (P < .001). There were no significant differences in the prevalence of ruptured IAs between the ABI groups (P = .277). Sex- and age-adjusted multinomial regression, including clinically relevant variables, revealed that low ABI (odds ratio [OR], 13.02; 95% CI, 4.01-42.24), borderline ABI (OR, 8.68; 95% CI, 2.05-36.69), and smoking history (OR, 2.01; 95% CI, 1.07-3.77) were associated with unruptured IAs. CONCLUSION: The prevalence of unruptured IAs was 9-fold higher in the low ABI group and nearly 7-fold higher in the borderline ABI group when compared with the normal ABI group. ABI measurements could be clinically relevant for identifying individuals at higher risk of IAs and may help guide screening and preventive strategies.

Detection Rates and Trends of Asymptomatic Unruptured Intracranial Aneurysms From 2005 to 2019.

BACKGROUND AND OBJECTIVES: The trend in detection rates of asymptomatic unruptured intracranial aneurysms (UIAs) on brain computed tomography angiography/magnetic resonance angiography (CTA/MRA) is not well established. Our objective was to evaluate time trends in asymptomatic UIA detection rates on brain CTA/MRA between 2005 and 2019. METHODS: We conducted a retrospective study of all brain computed tomography/magnetic resonance scans (n = 288 336 scans in 130 621 patients) performed between January 2005 and December 2019 at a tertiary referral hospital. Patients who underwent brain CTA/MRA examinations were included (n = 81 261 scans in 48 037 patients). The annual detection rate of new UIA cases was calculated based on the first brain CTA/MRA imaging. Detection rates were compared between three periods and across different age groups. RESULTS: The number of first CTA/MRA examinations increased significantly from 2005 to 2009 (n = 12 190 patients) to 2010-2014 (n = 14 969 patients) and 2015-2019 (n = 20 878 patients) ( P < .001). The UIA detection rate also increased significantly from 1.7% in 2005-2009 to 2.5% in 2010-2014 and 3.4% in 2015-2019 ( P < .001). The UIA detection rate increased significantly from 2010-2014 to 2015-2019 (relative risk [RR], 1.33; 95% CI, 1.17-1.51), particularly in patients aged 60-69 years (RR, 1.29; 95% CI, 1.01-1.63), 70-79 years (RR, 1.71; 95% CI, 1.30-2.25), and >79 years (RR, 2.33; 95% CI, 1.56-3.47). Furthermore, the detection rate of <5-mm UIAs increased from 2010-2014 to 2015-2019 (RR, 1.51; 95% CI, 1.28-1.77). CONCLUSION: The detection rate of asymptomatic UIAs, particularly in elderly patients, has increased significantly over the past 15 years, coinciding with the increased use of CTA/MRA imaging. Furthermore, the size of the identified UIAs has decreased. These findings raise concerns about the management strategies for UIAs, indicating the need for further research.

Effect of xenon on brain injury, neurological outcome, and survival in patients after aneurysmal subarachnoid hemorrhage-study protocol for a randomized clinical trial.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is a neurological emergency, affecting a younger population than individuals experiencing an ischemic stroke; aSAH is associated with a high risk of mortality and permanent disability. The noble gas xenon has been shown to possess neuroprotective properties as demonstrated in numerous preclinical animal studies. In addition, a recent study demonstrated that xenon could attenuate a white matter injury after out-of-hospital cardiac arrest. METHODS: The study is a prospective, multicenter phase II clinical drug trial. The study design is a single-blind, prospective superiority randomized two-armed parallel follow-up study. The primary objective of the study is to explore the potential neuroprotective effects of inhaled xenon, when administered within 6 h after the onset of symptoms of aSAH. The primary endpoint is the extent of the global white matter injury assessed with magnetic resonance diffusion tensor imaging of the brain. DISCUSSION: Despite improvements in medical technology and advancements in medical science, aSAH mortality and disability rates have remained nearly unchanged for the past 10 years. Therefore, new neuroprotective strategies to attenuate the early and delayed brain injuries after aSAH are needed to reduce morbidity and mortality. TRIAL REGISTRATION: ClinicalTrials.gov NCT04696523. Registered on 6 January 2021. EudraCT, EudraCT Number: 2019-001542-17. Registered on 8 July 2020.

Brain white matter hyperintensities in Kawasaki disease: A case-control study.

Background: Cerebrovascular involvement of Kawasaki disease (KD) is poorly studied. White matter hyperintensities (WMH) indicate cerebral small vessel disease and increase the risk for stroke. Purpose: To investigate whether childhood KD is associated with WMHs and other cerebrovascular findings later in adulthood. Materials and methods: In this case-control study, patients diagnosed with KD (cases) at our tertiary hospital between 1978 and 1995 were invited to brain magnetic resonance (MRI) between 2016 and 2017. Migraine patients (controls) with available brain MRI were matched with cases (ratio 4:1) by age (±2 years) and sex. Two blinded neuroradiologists evaluated independently cerebrovascular findings from the brain MRI scans. Modified Scheltens' visual rating scale was used to evaluate WMH burden and the total WMH volume was measured using manual segmentation. Results: Mean age [years, (SD)] at the time of brain MRI was 33.3 (3.8) and 32.8 (4.0) for cases (n = 40) and controls (n = 160), respectively (P = 0.53). Mean follow-up time for cases was 29.5 years (4.3). Total volume of WMHs (median) was 0.26 cm3 (IQR 0.34) for cases and 0.065 cm3 (IQR 0.075) for controls, P = 0.039. Cases had higher total WMH burden (P = 0.003), deep WMH burden (P = 0.003), and more periventricular WMHs (prevalence 7.5 vs. 0%, P = 0.008) than controls. Cases had greater risk of having total Scheltens' score ≥2 vs. < 2 (odds ratio, 6.88; 95% CI: 1.84-25.72, P = 0.0041) and ≥3 vs. < 3 (odds ratio, 22.71; 95% CI: 2.57-200.53, P = 0.0049). Diabetes type 1/type 2, hypertension, smoking status or hypercholesterolemia were not risk factors for WMH burden, p > 0.1. Myocarditis at the acute phase of KD increased the risk for periventricular WMHs (P < 0.05). Three cases (7.5%) and three controls (1.9%) had lacune of presumed vascular origin (P = 0.0096). Conclusion: History of KD could be associated with an increased WMH burden. More studies are needed to confirm our results.

Physical exertion as a risk factor for perimesencephalic nonaneurysmal subarachnoid hemorrhage.

BACKGROUND: Perimesencephalic and nonperimesencephalic nonaneurysmal subarachnoid hemorrhage (PM-naSAH and NPM-naSAH) have a different bleeding pattern and clinical course. The etiology and risk factors for PM-naSAH and NPM-naSAH are unclear. The objective of this study was to compare risk factors and triggering events between PM-naSAH and NPM-naSAH. METHODS: We reviewed retrospectively all patients (n = 3475) who had undergone cerebral digital subtraction angiography between 2003 and 2020 at our tertiary hospital. Of these, 119 patients had 6-vessel angiography negative subarachnoid hemorrhage (47 (39%) PM-naSAH and 72 (61%) NPM-naSAH) and accurate information about the triggering event was available in 42 (89%) PM-NASAH and 64 (89%) NPM-naSAH patients. RESULTS: PM-naSAH were younger compared to NPM-naSAH (mean age [SD]; 55.3 [11.1] years vs. 59.6 [12.2] years, p = .045. PM-naSAH was triggered during the physical exertion in 79% of patients and 16% of patients with NPM-naSAH (relative risk 5.4; 95% CI, 2.9-10.1, p < .0001). There were no significant difference in sex, smoking, alcohol abuse, hypertension, diabetes, hyperlipidemia, or anticoagulation/antithrombotic usage between PM-naSAH and NMP-naSAH, p > .05. CONCLUSION: Physical exertion was a triggering factor in most of the PM-naSAH cases and the risk was five times greater than in NMP-naSAH. More studies are needed to confirm our results and to study pathophysiology of PM-naSAH and NPM-naSAH.

Surgical treatment of brainstem cavernous malformations: an international Delphi consensus.

OBJECTIVE: Indication for surgery in brainstem cavernous malformations (BSCMs) is based on many case series, few comparative studies, and no randomized controlled trials. The objective of this study was to seek consensus about surgical management aspects of BSCM. METHODS: A total of 29 experts were invited to participate in a multistep Delphi consensus process on the surgical treatment of BSCM. RESULTS: Twenty-two (76%) of 29 experts participated in the consensus. Qualitative analysis (content analysis) of an initial open-ended question survey resulted in 99 statements regarding surgical treatment of BSCM. By using a multistep survey with 100% participation in each round, consensus was reached on 52 (53%) of 99 statements. These were grouped into 4 categories: 1) definitions and reporting standards (7/14, 50%); 2) general and patient-related aspects (11/16, 69%); 3) anatomical-, timing of surgery-, and BSCM-related aspects (22/37, 59%); and 4) clinical situation-based decision-making (12/32, 38%). Among other things, a consensus was reached for surgical timing, handling of associated developmental venous anomalies, handling of postoperative BSCM remnants, assessment of specific anatomical BSCM localizations, and treatment decisions in typical clinical BSCM scenarios. CONCLUSIONS: A summary of typical clinical scenarios and a catalog of various BSCM- and patient-related aspects that influence the surgical treatment decision have been defined, rated, and interpreted.

Intracranial aneurysm is predicted by abdominal aortic calcification index: A retrospective case-control study.

BACKGROUND AND AIMS: Patients with intracranial aneurysms (IA) have excess mortality for cardiovascular diseases, but little is known on whether atherosclerotic manifestations and IA coexist. We investigated abdominal aortic calcification index (ACI) association with unruptured and ruptured IAs. METHODS: This retrospective case-control study reviews all tertiary centers patients (n = 24,660) who had undergone head computed tomography angiography (CTA), magnetic resonance angiography (MRA) or digital subtraction angiography (DSA) for any reason between January 2003 and May 2018. Patients (n = 2020) with unruptured or ruptured IAs were identified, and patients with available abdominal CT were included. IA patients were matched by sex and age to controls (available abdomen CT, no IAs) in ratio of 1:3. ACI was measured from abdomen CT scans and patient records were reviewed. RESULTS: 1720 patients (216 ruptured IA (rIA), 246 unruptured IA (UIA) and 1258 control) were included. Mean age was 62.9 ± 11.9 years and 58.2% were female. ACI (OR 1.02 per increment, 95%CI 1.01-1.03) and ACI>3 (OR 5.77, 95%CI 3.29-10.11) increased risk for rIA compared to matched controls. UIA patients' ACI was significantly higher but ACI did not increase odds for UIA compared to matched controls. History of coronary artery disease was less frequent in rIA patients. There was no calcification in aorta in 8.8% rIA and 13.6% UIA patients (matched controls 25.7% and 22.6% respectively, p < 0.01). CONCLUSIONS: Aortic calcification is greater in rIA and UIA patients than matched controls. ACI increases risk for rIAs.

Outcome in Patients with Spinal Cavernomas Presenting with Symptoms Due to Mass Effect and/or Hemorrhage: Conservative versus Surgical Management: Meta-analysis of Direct Comparison of Approach-Related Complications.

OBJECTIVE: We sought to examine the conservative treatment of symptomatic spinal cavernomas and evaluate the efficacy and safety of surgical management of spinal cord cavernous malformations. METHODS: This meta-analysis included articles comparing outcomes of conservative treatment and surgical management of spinal cavernomas, published in the full-text form (from 2000 to June 31, 2020). Collected variables included first author name, country, covered study period, publication year, the total number of patients and at follow-up, bleeding, motor weakness, pain, bladder and/or bowel dysfunction neurologic improvement or deterioration after discharge, and the need for reintervention after subtotal surgical resection or hemorrhage. RESULTS: After the initial searching and applying all exclusion and inclusion criteria, there were 9 articles left in the final article pool. The total number of patients was 396 with 264 (66.6%) undergoing surgical resection and 132 (33.4%) electing conservative management. Regarding motor weakness, bladder/bowel dysfunction, deterioration, and reintervention, the final results demonstrated no potential significant difference between the 2 groups. In regard to the subgroup of patients with bleeding, improvement, and pain, the results of the analysis showed a statistically significant difference between the 2 groups. CONCLUSIONS: Patients who have experienced a hemorrhagic episode should consider surgical intervention, which decreases the risk of recurrent hemorrhage and further neurologic deterioration. In addition, surgical decompression obtained by resection of the hemorrhage and cavernoma seems to lead to slight neurologic improvement in some patients. In nonhemorrhagic cavernomas, conservative treatment might be optimal due to surgery-related morbidity risks.

An international call for a new grading system for cerebral and cerebellar cavernomas.

Surgical indications for cerebral cavernous malformations remain significantly center- and surgeon-dependent. Available grading systems are potentially limited, as they do not include epileptological and radiological data. A novel grading system is proposed for supratentorial and cerebellar cavernomas: it considers neuroradiological features (bleeding, increase in size), neurological status (focal deficits and seizures), location of the lesion and age of the patient. The score ranges from -1 to 10; furthermore, surgery should be considered when a score of 4 or higher is present. Based on neuroradiological characteristics, 0 points are assigned if the CCM is stable in size at different neuroradiological controls, 1 point if there is an increase in volume during follow-up, 2 points if intra- or extra-lesional bleeding <1 cm is present and 3 points if the CCM produced a hematoma >1 cm. Regarding focal neurological deficits, 0 points are assigned if absent and 2 points if present. For seizures, 0 points are assigned if absent, 1 point if present, but controlled by medications, and 2 points if drug resistant. We considered the site of the CCM, and in case of deep-seated lesions in a critical area (basal ganglia, thalamus) 1 point (-1) is subtracted, while for subcortical or deep cerebellar lesions 0 points are assigned, for CCMs in a cortical critical area 1 point is assigned and in case of lesions in cortical not in critical area or superficial cerebellar area, 2 points are assigned. As far as age is concerned, 0 points are assigned for patients older than 50 years and 1 point for patients younger than 50. In conclusion, a novel grading for surgical decision making in cerebral cavernomas, based on the experience of selected neurosurgeons, basic scientists, and patients, is suggested with the aim of further improving and standardizing the treatment of CCMs. The aim of this paper was also to call for both retrospective and prospective multicenter studies with the aim of testing the efficacy of the grading system in different centers.

Brainstem Cavernous Malformations Management: Microsurgery vs. Radiosurgery, a Meta-Analysis.

Given the rareness of available data, we performed a systematic review and meta-analysis on therapeutic strategy microsurgical resection and stereotactic radiosurgery (SRS) for brainstem cavernous malformations (BSCMs) and assessed mortality, permanent neurological deficits (PNDs), rebleeding rate, and patients who require reintervention to elucidate the benefits of each treatment modality. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used for protocol development and manuscript preparation. After applying all inclusion and exclusion criteria, six remaining articles were included in the final manuscript pool. In total, this meta-analysis included 396 patients, among them 168 patients underwent microsurgical treatment and 228 underwent SRS. Findings of the present meta-analysis suggest that regarding the total group of patients, in terms of mortality, late rebleeding rate, and PNDs, there was no superiority of the one method over the other. Applying the leave-one-out method to our study suggests that with low robust of the results for the bleeding rate and patients who require reintervention outcome factor, there was no statistical difference among the surgical and SRS treatment. Microsurgical treatment of BSCMs immediately eliminates the risk of rehemorrhage; however, it requires complete excision of the lesion and it is associated with a similar rate of PNDs compared with SRS management. Apparently, SRS of BSCMs causes a marked reduction in the risk of rebleeding 2 years after treatment, but when compared with the surgical treatment, there was not any remarkable difference.

Superficial Temporal Artery: Distal Posterior Cerebral Artery Bypass through the Subtemporal Approach: Technical Note and Pilot Surgical Cases.

BACKGROUND: Posterior cerebral artery (PCA) aneurysms are rare and the majority are fusiform in shape. Proximal occlusion of PCA represents a treatment option for these lesions. However, this procedure carries a high risk of ischemic complications. OBJECTIVE: To describe the technique of trapping a fusiform PCA aneurysm and revascularization of the distal PCA using a superficial temporal artery (STA) graft through the same microsurgical approach. METHODS: From September 2012 to October 2014, we retrospectively identified 3 patients harboring a fusiform PCA aneurysm (P2 segment aneurysm) who underwent trapping of the aneurysm and reconstruction of the distal PCA through the same subtemporal approach. We analyzed immediate morbidity, surgical complications, and the patency of the bypass to determine the feasibility of this procedure. RESULTS: All 3 patients underwent successful trapping of the fusiform PCA aneurysm and revascularization of the distal PCA. The origin of P3 segment or posterior temporal artery (PTA) served as recipient arteries. In all 3 cases, adequate blood flow was evident after performing the STA-P3/PTA bypass. None of the patients experienced a new permanent neurological deficit. At 1-year follow-up, the STA-PTA/PCA bypasses remained patent. CONCLUSION: The STA-P3/PTA bypass through the subtemporal approach is a feasible option to maintain blood flow in cases of PCA fusiform aneurysms requiring trapping of the P2 segment.

Open Surgery for Recurrent Intracranial Aneurysms: Techniques and Long-Term Outcomes.

BACKGROUND: After occlusion of an aneurysm, a patient may experience aneurysm regrowth at the same site or develop de novo aneurysms. We present our experience in microsurgery of recurrent aneurysms with analysis of long-term results. METHODS: The senior authors (R. T. and H. K.) performed recurrent aneurysm clipping on 44 patients at Teishinkai Hospital and Asahikawa Red Cross Hospital in Sapporo, Japan. Operative techniques included clipping only, clipping and protective bypass, trapping of aneurysm with bypass, proximal occlusion, and bypass. Postoperative outcome was analyzed retrospectively using the modified Rankin Scale. RESULTS: Our series included 10 men (23%) and 34 women (77%), with a mean patient age of 63 years (range, 7-82 years). Before primary treatment, 11 patients (25%) had a ruptured aneurysm, while 33 patients (75%) had an unruptured aneurysm. The mean follow-up time after primary surgery was 7.6 years (range, 0.8-25 years). At our department the treatment of recurrent aneurysm included the clipping in 19 patients (43%), clipping with bypass in 6 patients (14%), aneurysm trapping with bypass in 10 patients (23%), and proximal occlusion and bypass in 9 patients (20%). The mean follow-up time after surgical treatment of recurrent aneurysms stood at 3.5 years (range 0.1-9 years). Altogether, 37 patients (84%) experienced favorable outcomes at last follow-up examination (modified Rankin Scale scores 0 and 1). CONCLUSIONS: Microsurgery of recurrent aneurysms may be performed safely and effectively, as shown by our study, in which 84% of patients experienced favorable results.

Muscle Insertion Line as a Simple Landmark To Identify the Transverse Sinus When Neuronavigation Is Unavailable.

OBJECTIVE: Skull opening in occipital and suboccipital regions might be associated with risk of damage to the transverse venous sinus and the confluence of sinuses. We analyze the value of magnetic resonance (MR) imaging in localizing the venous sinuses in relation to the superior muscle insertion line (MIL) on the occipital bone. METHODS: We retrospectively analyzed head MR images of 100 consecutive patients imaged for any reason from 1 January 2013. All MR images were interpreted by a radiologist (R.K.). The superior MIL was identified at the midline and on both midpupillar lines, which represent the most frequent sites of skin incision and craniotomy (median and lateral suboccipital craniotomy, respectively). RESULTS: Patients comprised 56 women (56%) and 44 men (44%). Their mean age was 54 (range 18-84) years. The muscles of the posterior skull were readily visible and clearly identified in both T1 and T2 images of all patients. Identification of the insertion zone and its relation to the venous structures was most readily made in the sagittal plane. CONCLUSION: We found that the upper muscle insertion line on occipital bone corresponds to the underlying venous sinus and can be used as a reliable anatomic landmark. We identified it in 100% of preoperative MR images of heads with an intact occiput.

The orbitozygomatic stich: A technical modification of the lateral supraorbital approach.

BACKGROUND: The lateral supraorbital approach (LSO) provides access to a variety of pathologies including anterior and some posterior circulation aneurysms, sellar and suprasellar lesions, and anterior fossa tumors. Technical modifications of LSO improve the surgical exposure of the skull base. METHODS: We retrospectively analyzed 73 consecutive patients treated by the senior author (Juha A. Hernesniemi), at the Department of Neurosurgery, Helsinki University Hospital in Helsinki, Finland from May 2013 to October 2013. This study cohort underwent a modified LSO to access anterior circulation aneurysms, sellar and suprasellar tumors, and anterior fossa tumors. The studied population comprised 30 men and 43 women, with a mean age at treatment of 54 years (9-83 years). RESULTS: LSO was successfully used to access anterior circulation aneurysms in 59 (81%) patients, 10 (14%) patients with anterior cranial fossa tumors, and 4 (5%) patients with suprasellar tumors. The skull base drilling provided a mean of 6.8 mm (1.7-22 mm) in increased exposure. CONCLUSION: LSO provides adequate access to vascular and neoplastic lesions of the anterior cranial fossa, by drilling approximately 6.8 mm (1.7-22 mm) of the lateral orbital wall and sphenoid wing. This enhances surgical exposure and trajectory. An additional trick while performing an LSO is to place a single or multiple stiches (orbitozygomatic stich) at the base of the dura once opened, eliminating the dead space between the dura and anterior skull base.

Presigmoid Approach to Vertebrobasilar Artery Aneurysms: A Series of 31 Patients and Review of the Literature.

OBJECTIVE: The presigmoid approach can be used to treat vertebrobasilar artery aneurysms when circumstances require more operative exposure. High morbidity and mortality in these cases have been reported. In this study, we describe our modified presigmoid approach for vertebrobasilar artery aneurysms and our clinical results. METHODS: This series includes patients with vertebrobasilar aneurysms clipped via the modified presigmoid approach at the Department of Neurosurgery at Helsinki University Hospital from 1998 to 2014. Data were collected from the operating record books, patients' medical records, and a radiologic database server. RESULTS: Thirty-three presigmoid procedures of 31 patients were performed to treat 34 aneurysms (14 ruptured, 20 unruptured). The aneurysms had a mean distance from the posterior clinoid process to the aneurysm neck of 12.2 mm (range, 0-26.6 mm). A favorable outcome was achieved in 21 patients (64%). A favorable outcome was achieved in 74% of unruptured and good-grade patients, whereas favorable outcome was achieved in only 36% of poor-grade patients. Complete or near-complete occlusion was achieved in 79%. Larger aneurysms, fusiform morphology, and anterior dome projection had lower occlusion rates. CONCLUSIONS: We have described our experiences of using the presigmoid approach to treat vertebrobasilar aneurysms. The clinical and radiographic results are acceptable given the complex location and configuration of the treated aneurysms. Unfavorable outcomes are related to the poor admission Hunt and Hess grade, aneurysm morphology, and aneurysm size.

Factors Determining Surgical Approaches to Basilar Bifurcation Aneurysms and Its Surgical Outcomes.

BACKGROUND: The basilar bifurcation aneurysm (BBA) is still considered to be one of the most challenging aneurysms for micro- and endovascular surgery. Classic surgical approaches, such as subtemporal, lateral supraorbital (LSO), and modified presigmoid, are still reliable and effective. OBJECTIVE: To analyze the clinical and radiological factors that affect the selection of these classic surgical approaches and their outcomes. METHODS: A retrospective analysis was conducted on the clinical and radiological data from computed tomographic angiography of BBA that have been clipped in the Department of Neurosurgery of Helsinki University Central Hospital between 2004 and 2014. Statistical analyses were performed using parametric and nonparametric tests where values were considered significant below P = .05. RESULTS: One hundred four patients with BBA underwent surgical clipping in our department between 2004 and 2014. Eight patients were excluded from the study because of incomplete preoperative radiological evaluations, leaving 96 patients for further analysis. Multiple aneurysm clipping, mean basilar bifurcation angle, and aneurysm neck distance from posterior clinoid process were shown to be factors that determine the surgical approach. Unfavorable outcome is strongly associated with poor Hunt-Hess grade on admission, distance from aneurysm neck (the posterior clinoid process), thrombosis, and dome size. CONCLUSION: Microsurgery for BBA clipping can be performed safely with simple surgical approaches: subtemporal and LSO. There are several factors determining the approach selected. Poor patient outcome in BBA was highly associated with poor preoperative clinical grade and large size of aneurysm dome.

Serum Levels of Monocyte Chemoattractant Protein-1 Correlate with Poor Clinical Grades in Cerebral Aneurysms.

BACKGROUND: Ruptured cerebral aneurysms (ICAs) are the most common non-traumatic cause of subarachnoid hemorrhage (SAH) that is associated with life threatening complications such as Vasospasm, Infarction, and Hydrocephalus (HCP). The active participation of macrophage/monocyte-mediated inflammatory response in the pathogenesis of cerebral aneurysm as labeled with Monocyte Chemoattractant Protein-1 (MCP-1) is suggested. OBJECTIVE: To measure the serum level of MCP-1 in ruptured CAs in different time intervals. METHODS: We measured the serum levels of MCP-1 in SAH patients who had CAs and compared it with that of MCP-1 in two control groups: including patients with SAH without CAs, and the normal population of blood donors. We also measured the MCP-1 levels in patients with CAs one week afterward to evaluate the effect of treatment. Serum level of MCP-1 was measured by a commercial ELISA assay. RESULTS: Mean serum MCP-1 level in patients with SAH and CAs was 188.2168 Pg/ml and 331.3982 Pg/ml in the normal population. There was no statistically significant difference between serum levels of MCP-1 on the first (mean=188.2168 Pg/ml) and 7th days after SAH onset (mean=171.8450 Pg/ml) (p=0.739). Serum level of MCP-1 increased significantly as Glasgow Coma Scale decreased (p=0.078) and Hunt and Hess score increased (p=0.089). CONCLUSION: Our results did not show an increasing MCP-1 serum level in patients with aneurysmal SAH. There was a relationship between poor clinical grade and MCP-1 levels in patients with CAs. MCP-1 may be a local inflammatory marker for cerebral aneurysms without systemic manifestation.