T Cells Immune Imbalance Present in Patients With Multiple Intracranial Aneurysms.

Growing evidence suggests that systemic immune and inflammatory responses may play a critical role in the formation and development of aneurysms. Exploring the differences between single intracranial aneurysm (SIA) and multiple IAs (MIAs) could provide insights for targeted therapies. However, there is a lack of comprehensive and detailed characterization of changes in circulating immune cells in MIAs. Peripheral blood mononuclear cell (PBMC) samples from patients with SIA (n = 16) or MIAs (n = 6) were analyzed using high-dimensional mass cytometry to evaluate the frequency and phenotype of immune cell subtypes. A total of 25 cell clusters were identified, revealing that the immune signature of MIAs included cluster changes. Compared to patients with SIA, patients with MIAs exhibited immune dysfunction and regulatory imbalance in T-cell clusters. They also had reduced numbers of CD8+ T cells and their subgroups CD8+ Te and CD8+ Tem cells, as well as reduced numbers of the CD4+ T-cell subgroup CD27-CD4+ Tem cells. Furthermore, compared to SIA, MIAs were associated with enhanced T-cell immune activation, with elevated expression levels of CD3, CD25, CD27, CCR7, GP130, and interleukin 10. This study provides insights into the circulating immune cell profiles in patients with MIAs, highlighting the similarities and differences between patients with SIA and those with MIAs. Furthermore, the study suggests that circulating immune dysfunction may contribute to development of MIAs.

A model with multiple intracranial aneurysms: possible hemodynamic mechanisms of aneurysmal initiation, rupture and recurrence.

BACKGROUND: Hemodynamic factors play an important role in aneurysm initiation, growth, rupture, and recurrence, while the mechanism of the hemodynamic characteristics is still controversial. A unique model of multiple aneurysms (initiation, growth, rupture, and recurrence) is helpful to avoids the confounders and further explore the possible hemodynamic mechanisms of aneurysm in different states. METHODS: We present a model with multiple aneurysms, and including the states of initiation, growth, rupture, and recurrence, discuss the proposed mechanisms, and describe computational fluid dynamic model that was used to evaluate the likely hemodynamic effect of different states of the aneurysms. RESULTS: The hemodynamic analysis suggests that high flow impingement and high WSS distribution at normal parent artery was found before aneurysmal initiation. The WSS distribution and flow velocity were decreased in the new sac after aneurysmal growth. Low WSS was the risk hemodynamic factor for aneurysmal rupture. High flow concentration region on the neck plane after coil embolization still marked in recanalized aneurysm. CONCLUSIONS: Associations have been identified between high flow impingement and aneurysm recanalization, while low WSS is linked to the rupture of aneurysms. High flow concentration and high WSS distribution at normal artery associated with aneurysm initiation and growth, while after growth, the high-risk hemodynamics of aneurysm rupture was occurred, which is low WSS at aneurysm dome.

Quantitative Evaluation of Hemodynamic Changes After Multiple Intracranial Aneurysms Occlusion Using Computational Fluid Dynamics.

OBJECTIVE: Multiple intracranial aneurysms (MIA) are prevalent. This study conducted hemodynamic calculations on MIA to analyze the effects of occlusion of the internal carotid artery (ICA) and middle cerebral artery (MCA) aneurysms on the hemodynamics of other arteries, as well as the issue of the treatment order for these aneurysms. METHODS: The models of 9 patients with MIA were selected for the study. A computational fluid dynamics model combining 1-dimension and 3-dimension was used to obtain the vascular flow pattern and wall pressure. RESULTS: There was increased pressure at the MCA and anterior cerebral artery (ACA) after occlusion of the aneurysm at the ICA. However, the pressure at the ICA has hardly changed after the aneurysm occlusion at the MCA. Occlusion of the aneurysm of different sizes at the MCA had almost no impact on the pressure at the ICA and ACA. For small aneurysm, the pressure of the ACA and MCA increases with decreasing size of the aneurysm at the ICA. After occlusion of a large aneurysm at the ICA, the impact on the pressure of the ACA and MCA is almost the same as after occlusion of a medium-sized aneurysm. CONCLUSIONS: If the treatment order of ICA and MCA aneurysms cannot be determined based on patient factors and aneurysm characteristics, the MCA aneurysm should be treated as a priority.

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.

Two consecutive ruptured intracranial aneurysm in patient with multiple intracranial aneurysms.

When aneurysmal subarachnoid hemorrhage due to multiple aneurysms is suspected, identifying the rupture site is essential to determine the exact surgical site, but it may not be easy. Even if embolization is adequately performed, complications may remain. Typical complications include rebleeding and hydrocephalus in the early phase and delayed cerebral ischemia in the delayed phase. Herein, we describe a case of rupture of an intracranial aneurysm after performing embolization for a different ruptured intracranial aneurysm in a patient with multiple intracranial aneurysms. Patients with multiple intracranial aneurysms need to be considered for closer observation than those with a single ruptured intracranial aneurysm, even if the patient's prognosis is good.

Rupture discrimination of multiple small (< 7 mm) intracranial aneurysms based on machine learning-based cluster analysis.

BACKGROUND: Small multiple intracranial aneurysms (SMIAs) are known to be more prone to rupture than are single aneurysms. However, specific recommendations for patients with small MIAs are not included in the guidelines of the American Heart Association and American Stroke Association. In this study, we aimed to evaluate the feasibility of machine learning-based cluster analysis for discriminating the risk of rupture of SMIAs. METHODS: This multi-institutional cross-sectional study included 1,427 SMIAs from 660 patients. Hierarchical cluster analysis guided patient classification based on patient-level characteristics. Based on the clusters and morphological features, machine learning models were constructed and compared to screen the optimal model for discriminating aneurysm rupture. RESULTS: Three clusters with markedly different features were identified. Cluster 1 (n = 45) had the highest risk of subarachnoid hemorrhage (SAH) (75.6%) and was characterized by a higher prevalence of familiar IAs. Cluster 2 (n = 110) had a moderate risk of SAH (38.2%) and was characterized by the highest rate of SAH history and highest number of vascular risk factors. Cluster 3 (n = 505) had a relatively mild risk of SAH (17.6%) and was characterized by a lower prevalence of SAH history and lower number of vascular risk factors. Lasso regression analysis showed that compared with cluster 3, clusters 1 (odds ratio [OR], 7.391; 95% confidence interval [CI], 4.074-13.150) and 2 (OR, 3.014; 95% CI, 1.827-4.970) were at a higher risk of aneurysm rupture. In terms of performance, the area under the curve of the model was 0.828 (95% CI, 0.770-0.833). CONCLUSIONS: An unsupervised machine learning-based algorithm successfully identified three distinct clusters with different SAH risk in patients with SMIAs. Based on the morphological factors and identified clusters, our proposed model has good discrimination ability for SMIA ruptures.

Clinical Characteristics and Outcome of Patients with Multiple Intracranial Aneurysms from a University Hospital in Nepal.

Objective The risk factors, management strategies, and outcomes of patients with multiple intracranial aneurysms (MIAs) are different compared with that of patients with a single aneurysm. Data are scarce regarding patients with MIAs from developing countries. The objective of this study was to describe the clinical characteristics, management strategies, and outcomes of patients treated microsurgically from Nepal. Methods The clinical records of patients confirmed to have MIAs and microsurgically clipped between July 2014 and December 2019 were retrospectively reviewed. Data on demographic and clinical characteristics, computed tomography findings, multiplicity and location of aneurysms, management strategies, and the 1-year outcome were abstracted and analyzed. Results Two hundred cerebral aneurysms were microsurgically clipped in 170 consecutive patients during the study period. Twenty-six (13.0%) patients harbored 60 aneurysms. The mean age of the patients was 58.5 (43-73) years. Smoking and hypertension were found in 20 (76.9%) and 16 (61.5%) patients, respectively. The majority of patients [17 (65.4%)] were in good grades at presentation. Twenty-one patients had two aneurysms, four had three aneurysms, and one patient had five aneurysms. The middle cerebral artery was the commonest (20) followed by distal anterior cerebral artery (14) and anterior communicating artery (13) involved in multiplicity. A single-stage surgery was performed on 17 patients. Serial clipping was performed in six patients. In three patients, a single aneurysm on the contralateral side was left untreated for various reasons. The favorable outcome was achieved in 23 (88.5%) patients whereas three (11.5%) patients had an unfavorable outcome. One patient died. Conclusion The demographic and clinical characteristics of patients in our series are comparable with those described in the published literature from other countries. With an individualized treatment strategy, an acceptable outcome can be achieved in the majority of the patients.

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.

Surgical Resection and Clipping of an Atherosclerotic Partially Calcified Middle Cerebral Artery Trifurcation Aneurysm with Clipping of an Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

It is estimated within the western population that 10%-13% of patients possess multiple intracranial aneurysms1 and are linked to certain risk factors. Thrombotic aneurysms are a rare subgroup of complex aneurysms characterized by an organized intraluminal thrombus.2,3 They differ from typical saccular aneurysms in terms of morphology, natural history, symptomatology, and difficulty in treatment with conventional strategies.2,4 The risk of rupture is poorly characterized and assumed to be comparable with that of nonthrombotic aneurysms.2 A subset of thrombotic aneurysms can be treated surgically with conventional clipping, and direct clipping has been associated with the best surgical outcome.2 Despite its safety, endovascular treatment is associated with a high risk of recurrence and retreatment compared with surgical treatment,5 with recanalization rates up to 5× higher compared with nonthrombosed aneurysms.6,7 A 64-year-old male presented with headaches and dizziness for 6 months. He was neurologically intact. Imaging revealed a calcified thrombosed right middle cerebral artery aneurysm and an anterior communicating artery aneurysm, both of which underwent clipping. The patient consented to the procedure. Preservation of blood flow in branch arteries in thrombosed aneurysms is challenging. Thrombectomy and clip reconstruction in such cases can occlude the branch vessels, compromising blood flow. Achieving adequate proximal control and meticulous dissection of the branches is necessary before reconstruction. We present a 2-dimensional video demonstrating the surgical steps of clipping and reconstruction of the giant thrombosed middle cerebral artery aneurysm. Complete occlusion was achieved, and the patient tolerated the operation well with an uneventful postoperative course.

Delayed multiple intracranial aneurysms caused by left atrial myxoma: a case report and literature review.

Intracranial aneurysm may appear even after the removal of the cardiac myxoma. However, the pathogenesis and treatment of such aneurysm lesions are not clear. The study aimed to explore the clinical and imaging manifestation, hypothetical pathogenesis, and therapy in one case of left atrial myxoma causing multiple intracranial aneurysms. A 14-year-old male displayed a 3-hour history of episodic loss of consciousness and right hemiplegia after a leapfrog-like movement. The myxoma was diagnosed by a combination of clinical examination, leading to the diagnosis of mitral dynamic obstruction with a Grade III mitral diastolic murmur and tumor plop; magnetic resonance imaging, revealing multiple ischemic sites in both semi-oval centers; and transthoracic echocardiography, demonstrating a mitral valve obstruction. The myxoma was removed surgically; however, computed tomography angiography showed multiple intracranial aneurysms in both middle cerebral arteries 18 months after resection of the atrial myxoma. After conservative treatment, the patient had no neurological dysfunction symptoms for 5 years after myxoma resection. His condition is relatively stable. In conclusion, resection of the atrial myxoma may eliminate the early neurological symptoms, but it cannot ensure the nonoccurrence of delayed intracranial aneurysms. The neoplastic process theory was favored for explaining the aneurysm development in this case. According to the specific conditions of the patient, a combination of open surgery, chemotherapy, radiotherapy, and coil embolization is recommended.

Development and External Validation of a Dynamic Nomogram With Potential for Risk Assessment of Ruptured Multiple Intracranial Aneurysms.

BACKGROUND AND PURPOSE: About 20.1% of intracranial aneurysms (IAs) carriers are multiple intracranial aneurysms (MIAs) patients with higher rupture risk and worse prognosis. A prediction model may bring some potential benefits. This study attempted to develop and externally validate a dynamic nomogram to assess the rupture risk of each IA among patients with MIA. METHOD: We retrospectively analyzed the data of 262 patients with 611 IAs admitted to the Hunan Provincial People's Hospital between November 2015 and November 2021. Multivariable logistic regression (MLR) was applied to select the risk factors and derive a nomogram model for the assessment of IA rupture risk in MIA patients. To externally validate the nomogram, data of 35 patients with 78 IAs were collected from another independent center between December 2009 and May 2021. The performance of the nomogram was assessed in terms of discrimination, calibration, and clinical utility. RESULT: Size, location, irregular shape, diabetes history, and neck width were independently associated with IA rupture. The nomogram showed a good discriminative ability for ruptured and unruptured IAs in the derivation cohort (AUC = 0.81; 95% CI, 0.774-0.847) and was successfully generalized in the external validation cohort (AUC = 0.744; 95% CI, 0.627-0.862). The nomogram was calibrated well, and the decision curve analysis showed that it would generate more net benefit in identifying IA rupture than the "treat all" or "treat none" strategies at the threshold probabilities ranging from 10 to 60% both in the derivation and external validation set. The web-based dynamic nomogram calculator was accessible on https://wfs666.shinyapps.io/onlinecalculator/. CONCLUSION: External validation has shown that the model was the potential to assist clinical identification of dangerous aneurysms after longitudinal data evaluation. Size, neck width, and location are the primary risk factors for ruptured IAs.

Contralateral Clipping of Multiple Intracranial Aneurysms.

The reported incidence of multiple intracranial aneurysms (MIA) is approximately 7-35% of all intracranial aneurysms. The primary goal in the management of MIAs is to secure the ruptured aneurysm and to treat as many of the remaining lesions as possible without affecting the outcome of the patient. In recent era endovascular treatment is the preferred treatment of multiple bilateral intracranial aneurysms if all aneurysms are amenable to addressed in single stage. But most often all aneurysms were not possible to addressed due to complexity of different aneurysms, technical limitation and infrastructure. In such scenarios options left were two stage sequential craniotomy on either sides and clipping of bilateral aneurysms or unilateral craniotomy and clipping of bilateral MIA. Bilateral two stage surgery or two stage endovascular treatment caries risk of bleeding from one of the untreated aneurysms, morbidity due to two stage and increase the cost of treatment. In properly selected cases of unilateral craniotomy and clipping of bilateral MIA secure the all aneurysm in one stage and decreased morbidity and cost of treatment. When patient selection done meticulously, clipping of MIA including contralateral side aneurysms is feasible and safe.

Development of multiple intracranial aneurysms: beyond the common risk factors.

OBJECTIVE: The prevalence of multiple intracranial aneurysms (MIAs) has increased over the last decades. Because MIAs have been identified as an independent risk factor for formation, growth, and rupture of intracranial aneurysms (IAs), a more profound understanding of the underlying pathophysiology of MIAs is needed. Therefore, the authors' extensive institutional aneurysm database was analyzed to elucidate differences between patients with a single IA (SIA) and those with MIAs. METHODS: A total of 2446 patients seen with or for IAs at the University Hospital of Essen, Essen, Germany, from January 2003 to June 2016 were included in this retrospective cohort study and were separated into MIA and SIA subgroups. Patient data were screened for sociodemographic and radiographic parameters, preexisting medical conditions, and results of blood examinations. These parameters were analyzed for their correlations with MIAs and absolute number of IAs. RESULTS: MIAs were identified in 853 (34.9%) patients. In multivariable analysis, MIAs were independently associated with female sex (p = 0.001), arterial hypertension (p = 0.023), tobacco abuse (p = 0.009), AB blood group (p = 0.010), and increased admission values for C-reactive protein (p = 0.006), mean corpuscular volume (p = 0.009), and total serum protein (p = 0.034), but not with diagnostic modality (3D vs 2D digital subtraction angiography, p = 0.912). Absolute number of IAs was independently associated with female sex (p < 0.001), arterial hypertension (p = 0.014), familial predisposition to IA (p = 0.015), tobacco consumption (p = 0.025), increased mean corpuscular volume (p = 0.002), and high platelet count (p = 0.007). CONCLUSIONS: In this sizable consecutive series of patients with IAs, the authors confirmed the impact of common IA risk factors on the genesis of MIAs. In addition, specific hemorheological and hemocytological features may also contribute to the development of MIAs.

Simultaneous Craniotomies for Multiple Intracranial Aneurysm Clippings-One-Stage Surgery with Multiple Craniotomies.

OBJECTIVE: The treatment of multiple intracranial aneurysms (MIAs) involves various modalities and sometimes requires staged operations. This study aimed to prove the efficacy and safety of one-stage multiple craniotomies (OSMC) for multiple cerebral aneurysms. METHODS: We retrospectively reviewed the medical records of the patients who underwent treatment for intracranial aneurysms between May 2003 and April 2020. The surgical results, complications, and lengths of hospital stay were compared between the patients who underwent OSMC and those who underwent multistage multiple craniotomies. RESULTS: The demographic characteristics of the OSMC and multistage multiple craniotomies groups (n = 82 and 43, respectively) were similar. There were no statistically significant differences between the 2 groups when the amount of blood transfused, complications, and surgical results were compared (P = n.s. for all); however, the operation time and hospitalization period (353.9 minutes vs. 490.3 minutes and 12.3 days vs. 21.8 days, respectively; P = 0.001 for both) were shorter in the OSMC group. The treatment cost (17,000 USD vs. 22,000 USD, P = 0.001) was lower in the OSMC group. CONCLUSIONS: OSMC for aneurysm clipping in patients with MIAs is a relatively safe and economical method. Furthermore, it has good clinical outcomes. This new surgical method is worthwhile in that it can be applied to patients who are afraid to undergo multiple surgeries, and we suggest that it is an efficient, low-cost option for the treatment of MIAs.

External Validation of the PHASES Score in Patients with Multiple Intracranial Aneurysms.

OBJECTIVES: This study sought to assess whether the Population, Hypertension, Age, Size, Earlier Subarachnoid Hemorrhage, Site (PHASES) score can do risk stratification of patients with multiple aneurysms (MIAs). MATERIAL AND METHODS: Patients between January 1, 2016 and January 1, 2019 were recruited retrospectively. The PHASES score was applied to assess the theoretical risk of IA rupture. For patients-level analyses, four modes of the application of the score were used: largest IA PHASES score, highest PHASES score, sum PHASES score, and mean PHASES score. RESULTS: A total of 701 patients with 1673 IAs were included in this study. At aneurysm-level analysis, the average PHASES score was 3.0 ± 3.0 points, with 2.8 ± 3.0 points and 4.1 ± 2.9 points in the unruptured and ruptured groups, respectively (p < 0.001). At the patient-level analysis, for the largest IA PHASES score, the areas under the curves (AUC) was 0.572. The discrimination performance of the largest IA PHASES score decreases as IA number increases, with AUCs were 0.597, 0.518, and 0.450 in the 2 IAs, 3 IAs and, 4 or more IAs subgroups, respectively. For highest PHASES score, sum PHASES score, and mean PHASES score, the AUCs were 0.577, 0.599, and 0.619, respectively. CONCLUSIONS: In this study, PHASES score only serve as a weak tool in decision-making settings for MIAs patients; as such, more accurate models should be developed for MIAs patients and the cumulative effect of MIA may should be considered.

One-stage coiling versus clipping of multiple intracranial aneurysms in elderly patients.

OBJECTIVES: Although multiple intracranial aneurysms (MIAs) are frequent and disastrous, determining treatment strategy for them is often complicated, especially in elderly patients (≥60 years old). We evaluated the safety and effectiveness of one-stage coiling versus surgical clipping for MIAs in elderly patients. METHODS: All elderly patients who underwent one-stage embolization or surgical clipping for more than two aneurysms were identified in our hospital between January 2012 and June 2018. Patient characteristics and clinical outcomes at discharge and follow-up were retrospectively evaluated. RESULTS: A total of 32 patients with 76 IAs underwent one-stage coiling and 21 patients with 46 IAs underwent one-stage clipping were enrolled in this study. Patients who underwent clipping were younger (mean age 64.1 versus 67.2, P = 0.006) and had lower total hospital costs (mean14764 $ versus 24,620 $, P < 0.001) compared with patients who underwent coiling. Immediate posttreatment angiography showed complete occlusion in 56 aneurysms, near complete in 11 and incomplete in 2 in coiling group. Aneurysms wrapping was performed in 2, incomplete clipping in 1 and complete clipping in 41 aneurysms in clipping group. At discharge, 49 (92.5 %) patients were in a good condition (GOS score 4 and 5), 4 (7.5 %) were disabled. At 12 months after discharge, 25 (92.6 %) and 16 (94.1 %) patients had favorable outcomes in the coiling and clipping groups, respectively. CONCLUSIONS: Both one-stage coiling and surgical clipping are safe, effective methods for treating MIAs in elderly patients.

Management of Unruptured Small Multiple Intracranial Aneurysms in China: A Comparative Effectiveness Analysis Based on Real-World Data.

BACKGROUND: Unruptured small aneurysms with a size of <7 mm were often followed conservatively. However, it is unknown whether unruptured small multiple intracranial aneurysms (MIAs) are better to be prophylactically treated or conservatively followed. OBJECTIVE: We aim to compare the effectiveness of different strategies regarding their management. METHODS: A decision-analytic Markov model was built over a entire life cycle. The compared strategies include natural history, treat one aneurysm, treat both aneurysms, annual follow-up, biennial follow-up, and follow-up every 5 years. The inputs for the model were obtained from real-world data and related medical literature. Outcomes were measured in terms of quality-adjusted life-years (QALYs). RESULTS: Treat both aneurysms had the highest effectiveness of 15.36 QALYs and treat one aneurysm had the second-highest effectiveness of 15.11 QALYs. Probabilistic sensitivity analysis with 10,000 iterations showed that treat both aneurysms and treat one aneurysm were optimal in 67.28 and 17.91% of all cases, respectively. One-way and two-way sensitivity analyses showed that the result was sensitive to the proportion of moderate to severe disability after treating two aneurysms, mortality after treating two aneurysms, proportion of moderate to severe disability after treating one aneurysm, and rupture rate of small growing aneurysm. Either treat both aneurysms or treat one aneurysm would be the optimal strategy under most of the circumstances with the variations of these parameters. CONCLUSION: For patients with small unruptured MIAs, prophylactic coiling was superior to conservative management and at least one aneurysm should be treated.

Risk factors involved in the formation of multiple intracranial aneurysms.

BACKGROUND: Although several risk factors of the multiple intracranial aneurysms (MIAs) formation has been reported, the results are controversial. We aimed to find out the risk factors of MIAs formation by analyzing our clinic data combined with a meta-analysis. MATERIAL AND METHODS: A retrospective review work of medical records for the patients with aneurysms was undertaken. Univariate analysis was used to examine all mentioned variables. Binary logistic regression analysis was used to identify the risk factors of MIAs formation. RESULTS: In the retrospective review work, a total of 565 patients with aneurysm were included in this study. Of these 565 participants, 449 patients suffered SIAs and 116 patients suffered MIAs. Univariate analysis showed a significant difference in terms of female, cigarette smoking, family history of hypertension, and primary hypertension between the SIAs and MIAs group. The binary logistic regression analysis showed that the female (OR = 1.624), primary hypertension (OR = 1.563), and family history of hypertension (OR = 2.496) were independent risk factors of the formation of MIAs (for each P < 0.05). With regard to the meta-analysis results, it revealed that there was significant difference in the rates of female (P < 0.001), cigarette smoking (P < 0.001), primary hypertension (P = 0.001), and higher age (P = 0.011) among the MIAs patients. CONCLUSIONS: A higher rate of the formation of MIAs is closely associated with the elder and female. Patients with hypertension history, cigarette smoking, and family primary hypertension history also affected the formation of MIAs, these risk factors should be a guard against.

Outcome of Microsurgical Clipping for Multiple Versus Single Intracranial Aneurysms: A Single-Institution Retrospective Comparative Cohort Study.

OBJECTIVE: To evaluate the results of microsurgical clipping for single intracranial aneurysm (SIA) and multiple intracranial aneurysms (MIA) and compare the outcomes. METHODS: All patients who underwent surgery for intracranial aneurysm (IA) at our institution over a 3-year period (June 2013 to May 2016) were included in this study. RESULTS: A total of 157 patients with 225 IAs were included. Forty-one of these patients had MIA (109 IAs, mean, 2.7 ± 1.2; range, 2-7), and remaining 116 had SIA. In the patients with MIA, all aneurysms were secured during the same admission whenever possible. Depending on the locations of the IAs and condition of brain during surgery (tense/lax), all aneurysms were secured on same day (in a single session, single or multiple craniotomy in 28 patients) or on different days (multiple sessions in 13 patients). Postoperative control angiography (DSA) before discharge could be done for 216 aneurysms (MIA, n = 105; SIA, n = 111). Successful occlusion of the aneurysm from circulation was noted in 96.2% (101/105) of MIA and 93.7% (104/111) of SIA. Follow-up of 6 months or longer was available for 146 patients. A modified Rankin Scale score ≤2 was considered a good outcome. Univariate analysis of the entire group revealed no significant difference in clinical outcomes between patients with SIA and MIA both at discharge (good outcome: MIA, 82.9%; SIA, 93.1%; P = 0.068) and at a final follow-up of ≥6 months (good outcome: MIA, 87.2%; SIA, 94.4%; P = 0.164). Clipping for MIA was not associated with poor outcome in multivariate analysis. CONCLUSIONS: Comparable clinical outcomes and high rates of complete aneurysm occlusion following microsurgical clipping can be expected in patients with SIA and patients with MIA.

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

BACKGROUND: In aneurysmal subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms (MIAs) identification of the bleeding source cannot always be assessed according to the hemorrhage pattern. Therefore, we developed a statistical model for the prediction of the ruptured aneurysm in patients with SAH and multiple potential bleeding sources at the time of ictus. METHODS: Between 2012 and 2015, 252 patients harboring 619 aneurysms were admitted to the authors' institution. Patients were followed prospectively. Aneurysm and patient characteristics, as well as radiological findings were entered into a computerized database. Gradient boosting techniques were used to derive the statistical model for the prediction of the ruptured aneurysm. Based on the statistical prediction model, a scoring system was produced for the use in the clinical setting. The aneurysm with the highest score poses the highest possibility of being the bleeding source. The prediction score was then prospectively applied to 34 patients suffering from SAH and harboring MIAs. RESULTS: According to the statistical prediction model the main factors affecting the rupture in patients harboring multiple aneurysms were: 1) aneurysm size, 2) aneurysm location and 3) aneurysm shape. The prediction score identified correctly the ruptured aneurysm in all the patients that were used in the prospective validation. Even in the five most debatable and challenging cases assessed in the period of prospective validation, for which the score was designed for, the ruptured aneurysm was predicted correctly. CONCLUSIONS: This new and simple prediction score might provide additional support for neurovascular teams for treatment decision in SAH patients harboring multiple aneurysms. In a small prospective sample, the prediction score performed with high accuracy but larger cohorts for external validation are warranted.