Spontaneous Disappearance of Unruptured Intracranial Aneurysm: A Case Report

Spontaneous resolution or thrombosis of giant or ruptured intracranial aneurysms is occasionally reported. However, spontaneous resolution of unruptured aneurysms without any intervention is extremely rare. Recently, we encountered a case of spontaneous resolution of a small unruptured aneurysm of the anterior communicating artery. We describe this rare case and discuss the mechanism of resolution with a review of the related literature.

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A Review of Size and Location of Ruptured Intracranial Aneurysms

Neurosurgery ◽

10.1097/00006123-200112000-00006 ◽

2001 ◽

Vol 49 (6) ◽

pp. 1322-1326 ◽

Cited By ~ 169

Author(s):

Thomas R. Forget ◽

Ronald Benitez ◽

Erol Veznedaroglu ◽

Ashwini Sharan ◽

William Mitchell ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Patient Population ◽

Intracranial Aneurysms ◽

Thomas Jefferson ◽

Posterior Communicating Artery ◽

Anterior Communicating Artery ◽

Unruptured Aneurysms ◽

Ruptured Aneurysms ◽

Ruptured Intracranial Aneurysms ◽

Small Aneurysms

ABSTRACT OBJECTIVE To review our experience and examine the size at which aneurysms ruptured in our patient population. METHODS Patient charts and angiograms for all patients admitted with a diagnosis of subarachnoid hemorrhage to the Thomas Jefferson/Wills Eye Hospital between April 1996 and March 2000 were reviewed. RESULTS Of the 362 cases reviewed, definite measurements of the ruptured aneurysm were obtained in 245. The data clearly showed that most ruptured aneurysms presenting to our institution were less than 10 mm in diameter. We found that, regardless of location on the circle of Willis, 85.6% of all aneurysms presenting with rupture were less than 10 mm. Review by location shows that aneurysms of the anterior communicating artery most often presented with rupture at sizes less than 10 mm (94.4%). A large number of ruptured posterior communicating artery aneurysms also presented at sizes less than 10 mm (87.5%). This trend continued for all aneurysm sites in our review. The incidence of subarachnoid hemorrhage in Western countries is estimated at 10 per 100,000 people per year. Recent reports have indicated that aneurysms less than 10 mm in size are unlikely to rupture. CONCLUSION We argue that the risk of small aneurysms rupturing is not insignificant, especially those of the anterior communicating artery. Our findings indicate that surgery on unruptured aneurysms should not be predicated on aneurysm size alone.

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Comprehensive review of imaging of intracranial aneurysms and angiographically negative subarachnoid hemorrhage

Neurosurgical FOCUS ◽

10.3171/2019.9.focus19653 ◽

2019 ◽

Vol 47 (6) ◽

pp. E20 ◽

Cited By ~ 4

Author(s):

Brian M. Howard ◽

Ranliang Hu ◽

Jack W. Barrow ◽

Daniel L. Barrow

Keyword(s):

Subarachnoid Hemorrhage ◽

Best Practices ◽

Intracranial Aneurysms ◽

Vascular Lesion ◽

Reference Standard ◽

Unruptured Intracranial Aneurysm ◽

Imaging Protocols ◽

Ruptured Intracranial Aneurysms

Intracranial aneurysms confer the risk of subarachnoid hemorrhage (SAH), a potentially devastating condition, though most aneurysms will remain asymptomatic for the lifetime of the patient. Imaging is critical to all stages of patient care for those who harbor an unruptured intracranial aneurysm (UIA), including to establish the diagnosis, to determine therapeutic options, to undertake surveillance in patients who elect not to undergo treatment or whose aneurysm(s) portends such a low risk that treatment is not indicated, and to perform follow-up after treatment. Neuroimaging is equally as important in patients who suffer an SAH. DSA remains the reference standard for imaging of intracranial aneurysms due to its high spatial and temporal resolution. As noninvasive imaging technology, such as CTA and MRA, improves, the diagnostic accuracy of such tests continues to increasingly approximate that of DSA. In cases of angiographically negative SAH, imaging protocols are necessary not only for diagnosis but also to search for an initially occult vascular lesion, such as a thrombosed, ruptured aneurysm that might be detected in a delayed fashion. Given the crucial role of neuroimaging in all aspects of care for patients with UIAs and SAH, it is incumbent on those who care for these patients, including cerebrovascular neurosurgeons, interventional neurologists and neuroradiologists, and diagnostic radiologists and neurointensivists, to understand the role of imaging in this disease and how individual members of the multispecialty team use imaging to ensure best practices to deliver cutting-edge care to these often complex cases. This review expounds on the role of imaging in the management of UIAs and ruptured intracranial aneurysms and in the workup of angiographically negative subarachnoid hemorrhage.

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Safety and Efficacy of Endovascular Embolization of Ruptured Intracranial Aneurysms within 72 hours of Subarachnoid Hemorrhage

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0041-1731752 ◽

2021 ◽

Author(s):

Xin-Yu Li ◽

Cong-Hui Li ◽

Ji-Wei Wang ◽

Jian-Feng Liu ◽

Hui Li ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Aneurysms ◽

Endovascular Embolization ◽

Safety And Efficacy ◽

Unruptured Aneurysms ◽

Ruptured Aneurysms ◽

Significant Difference ◽

Group A ◽

Group B ◽

Ruptured Intracranial Aneurysms

Abstract Purpose The purpose of the study was to investigate the safety and efficacy of endovascular embolization of ruptured intracranial aneurysms within 72 hours of subarachnoid hemorrhage (SAH). Materials and methods Patients with intracranial aneurysms treated with embolization were divided into group A (n = 277), patients with ruptured aneurysms treated within 72 hours of SAH; group B (n = 138), patients with ruptured aneurysms treated beyond 72 hours; and group C (n = 93), patients with unruptured aneurysms. Results Embolization was successful in all but four patients (99.2%). The periprocedural complication rate was 36.2% in group B, significantly (p < 0.05) greater than that in group A (24.5%) or group C (11.8%). The rebleeding rate was 9.7% (6/62 patients) in groups A and B after embolization and only 0.3% (1/346 patients) in aneurysms with total or subtotal occlusion. Of these three groups of patients, 69.7% in group A, 58.7% in group B, and 76.3% in group C achieved Glasgow Outcome Scale (GOS) score of 5 or modified Rankin Scale (mRS) score of 0– to 1 at discharge. A significant difference (p < 0.05) existed in the clinical outcome between the three groups. The percentages of patients without deficits (GOS 5 or mRS 0–1) and slight disability (mRS 2) were 80.2% in group A, 81.2% in group B, and 96.7% in group C. The mortality rate was 4.3% (12/277 patients) in group A and 7.2% (10/138 patients) in group B with no significant (p = 0.21) difference. Follow-up was performed at 3 to 54 months (mean 23.2), and the recanalization rate was 28.6% (32/112 patients) in group A, 22.4% (11/49 patients) in group B, and 28.6% (16/56 patients) in group C, with no significant differences (p = 0.15). Hydrocephalus occurred in 30.5% (39/128 patients) in group B, which was significantly (p < 0.01) greater than that in group A (9.4%) or group C (2.2%). Conclusion Early embolization of ruptured cerebral aneurysms within 72 hours of rupture is safe and effective and can significantly decrease periprocedural complications compared with management beyond 72 hours. Timely management of cisternal and ventricular blood can reduce hydrocephalus incidence and improve prognosis.

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In-Stent Thrombosis and Stenosis After Neck-Remodeling Device-Assisted Coil Embolization of Intracranial Aneurysms

Neurosurgery ◽

10.1227/neu.0b013e3181f8d194 ◽

2010 ◽

Vol 67 (6) ◽

pp. 1523-1533 ◽

Cited By ~ 44

Author(s):

Hilal Kanaan ◽

Brian Jankowitz ◽

Aitziber Aleu ◽

Dean Kostov ◽

Ridwan Lin ◽

...

Keyword(s):

Coil Embolization ◽

Intracranial Aneurysms ◽

Anterior Communicating Artery ◽

Complication Rates ◽

Stent Patency ◽

Unruptured Aneurysms ◽

Short And Long Term ◽

Stent Complications

Abstract BACKGROUND: Intrinsic thrombosis and stenosis are complications associated with the use of neck-remodeling devices in the treatment of intracranial aneurysms. OBJECTIVE: To examine the technical and anatomic factors that predict short- and long-term stent patency. METHODS: We undertook a retrospective review of 161 patients who underwent coil embolization of 168 ruptured and unruptured aneurysms assisted by the use of a neck-remodeling device. One hundred twenty-seven patients had catheter-based angiographic follow-up to evaluate 133 stent-coil constructs (mean, 15.4 months; median, 12.7 months). The technique of microcatheter jailing was used in a majority of patients; nonstandard stent configurations were also used. RESULTS: Clinical follow-up for all patients who had catheter-based angiograms demonstrated that among 133 stent constructs, a total of 9 (6.8%) had an in-stent event: 6 acute or subacute thrombosis (4.5%) and 3 delayed stenosis or occlusion (2.3%). Seven of these constructs were associated with a symptomatic event (5.3%). A significantly higher rate of in-stent events was seen with the use of constructs to treat anterior communicating artery aneurysms. When all patients are considered, including those who did not receive catheter-based follow-up imaging, 2 of 168 procedures (1.2%) resulted in the death of a patient, and procedural morbidity was 14.9%. CONCLUSION: From these results and those in the published literature, in-stent complication rates are low in carefully selected patients. The use of dual antiplatelet therapy, sensitivity assays, and glycoprotein IIb/IIIa inhibitors may decrease the rate of acute and chronic in-stent complications.

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Transcranial Doppler Studies in Aneurysm Patients

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100029486 ◽

1989 ◽

Vol 16 (4) ◽

pp. 411-416 ◽

Cited By ~ 20

Author(s):

Kenneth Hutchison ◽

Bryce Weir

Keyword(s):

Subarachnoid Hemorrhage ◽

Transcranial Doppler ◽

Intracranial Aneurysms ◽

Transitional Zone ◽

Progressive Increase ◽

Doppler Studies ◽

Unruptured Aneurysms ◽

Clinical Symptomatology ◽

Clinically Significant ◽

Ruptured Intracranial Aneurysms

ABSTRACT:Fifty patients with ruptured intracranial aneurysms and 8 patients with elective clipping of unruptured aneurysms had daily transcranial Doppler (TCD) measurements performed. The highest mean middle cerebral artery velocity (MCA-Vel) was considered to be the best single parameter forjudging a patient's susceptibility to clinically significant vasospasm (VSP). Surgery for the clipping of unruptured aneurysms by itself does not lead to an increase in MCA-Vel. There is a progressive increase in MCA-Vel after subarachnoid hemorrhage (SAH) from aneurysms which peaks between 7 and 10 days. The MCA-Vel is higher on the side of the ruptured aneurysm and the degree of rise is greater if blood is seen on the initial CT scan. It is highly unlikely that a patient whose MCA-Vel remains under 100 cm/sec has a degree of angiographic VSP which causes clinical symptomatology. Patients whose MCA-Vel is > 200 cm/sec are at great risk of developing clinical symptomatology of VSP and are very likely to have significant angiographic VSP. There is a transitional zone in between these two levels.

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Acute Pure Spontaneous Subdural Haematoma from Ruptured Intracranial Aneurysms

Interventional Neuroradiology ◽

10.1177/159101990200800408 ◽

2002 ◽

Vol 8 (4) ◽

pp. 393-398 ◽

Cited By ~ 11

Author(s):

A. Nozar ◽

D. Philippe ◽

P. Fabrice ◽

M. Silvia ◽

T. Marc

Keyword(s):

Endovascular Treatment ◽

Intracranial Aneurysms ◽

Subdural Haematoma ◽

Good Prognosis ◽

Anterior Communicating Artery ◽

Acute Subdural Haematoma ◽

Surgical Clipping ◽

Urgent Surgery ◽

Ruptured Intracranial Aneurysms ◽

Aneurysmal Bleeding

Acute subdural haematoma (ASDH) is rarely caused by an aneurysmal rupture. We report four cases of pure acute subdural haematomas caused by ruptured intracranial aneurysms. Aneurysms were localized in the posterior communicating artery in two cases, in the anterior communicating artery in one case and in the middle cerebral artery in one other case. Possible mechanisms for this type of aneurysmal bleeding are discussed. A good prognosis for these patients can be expected with rapid evacuation of the haematoma (in case of high intracranial pressure and midline structure shift), and treatment of the aneurysm (surgical clipping or endovascular treatment). Our report demonstrates the utility of angiography in the evaluation of nontraumatic acute subdural haematomas. Angiography has to be performed before haematoma evacuation or just after if the patient requires urgent surgery in case of intracranial hypertension. Aneurysms may require surgical clipping or endovascular treatment.

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Superciliary Keyhole Approach for Small Unruptured Aneurysms in Anterior Cerebral Circulation

Operative Neurosurgery ◽

10.1227/neu.0b013e3182124810 ◽

2011 ◽

Vol 68 (suppl_2) ◽

pp. ons300-ons309 ◽

Cited By ~ 6

Author(s):

Jaechan Park ◽

Hyunjin Woo ◽

Dong-Hun Kang ◽

Joo-Kyung Sung ◽

Yongsun Kim

Keyword(s):

Intracranial Aneurysms ◽

Internal Carotid ◽

Control Group ◽

Anterior Communicating Artery ◽

Consecutive Series ◽

Pterional Approach ◽

Unruptured Aneurysms ◽

Operative Duration ◽

Unruptured Intracranial Aneurysms ◽

Keyhole Approach

Abstract Background: Neurovascular surgeons have been trying to find a solution to the problem of surgical invasiveness by applying minimally invasive keyhole approaches. Objective: To evaluate the feasibility and surgical outcomes of a superciliary keyhole approach for unruptured intracranial aneurysms (UIAs) as an alternative to a pterional approach. Methods: The authors report on a consecutive series of patients who underwent a superciliary approach for clipping UIAs smaller than 15 mm arising at the supraclinoid internal carotid artery (ICA), A1 segment, anterior communicating artery (ACoA), and M1 segment including the middle cerebral artery (MCA) bifurcation. The data were compared with a historical control group (n = 90) who underwent a pterional approach for UIAs. Results: A total of 120 aneurysms were successfully clipped in 102 patients with a mean age of 58 years. There was no direct mortality related to the surgery, and only 1 (1.0%) patient developed significant morbidity adversely affecting the Glasgow Outcome Scale score. The superciliary approach demonstrated statistically significant advantages over the pterional approach, including a shorter operative duration (mean, 120 min), no intraoperative blood transfusion, and extremely rare postoperative epidural hemorrhages. In addition, temporalis atrophy was rare and palsy of the frontalis persisting more than 6 months only occurred in 6 patients (5.9%) and was resolved within 2 years. The overall cosmetic outcome was excellent. Conclusion: A superciliary approach can be a reasonable alternative to a pterional approach for small (<15 mm) UIAs arising at the supraclinoid ICA, A1, ACoA, and M1 segment including the MCA bifurcation.

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Size of Intracranial Aneurysms

Neurosurgery ◽

10.1227/00006123-198303000-00007 ◽

1983 ◽

Vol 12 (3) ◽

pp. 291-297 ◽

Cited By ~ 163

Author(s):

Neal F. Kassell ◽

James C. Torner

Keyword(s):

Intracranial Aneurysms ◽

Optimal Time ◽

Anterior Communicating Artery ◽

Mortality And Morbidity ◽

Unruptured Aneurysms ◽

Computed Tomographic ◽

Maximal Diameter ◽

Median Diameter ◽

Middle Cerebral Artery Aneurysms ◽

Overall Mortality

Abstract Intracranial aneurysms are common lesions, occurring in as many as 2% of the age-corrected population of North America. Most aneurysms are small and innocuous, but some will enlarge and rupture. The clinical frequency of intact aneurysms has been increasing as a result of computed tomographic scanning and digital subtraction angiography, and this trend can be expected to accelerate in the future. Intact aneurysms are an important neurosurgical problem. Once an aneurysm ruptures, there is an associated 50 to 60% overall mortality and morbidity. In contrast, surgical correction of an unruptured aneurysm in skilled hands carries a mortality and morbidity of approximately 3%. Obviously, the optimal time for correction of aneurysm is before it ruptures. For effective management of patients with intact aneurysms, prognostic criteria for rupture are clearly needed. Aneurysm size is both theoretically and empirically a key prognostic factor for rupture. However, the critical size at which an aneurysm becomes hazardous is not known. The purpose of this investigation was to study the size of ruptured aneurysms in an attempt to infer the behavior of unruptured aneurysms. The angiographic size of aneurysms in the 1092 patients admitted to the Cooperative Aneurysm Study between 1970 and 1977 was measured. The average maximal diameter was 8.2 + 3.9 (SD) mm, and the median diameter was 7.0 mm. Seventy-one per cent of the sacs were smaller than 10 mm and 13% were less than 5 mm in diameter. Middle cerebral artery aneurysms were the largest and anterior communicating artery aneurysms were the smallest. These data suggest that aneurysms less than 1 cm in diameter are hazardous and that operation should be considered for lesions more than approximately 5 mm in diameter. Additional prognostic factors for rupture are clearly needed.

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The Medina Embolic Device: early clinical experience from a single center

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012539 ◽

2016 ◽

Vol 9 (1) ◽

pp. 77-87 ◽

Cited By ~ 28

Author(s):

Marta Aguilar Perez ◽

Pervinder Bhogal ◽

Rosa Martinez Moreno ◽

Hansjörg Bäzner ◽

Oliver Ganslandt ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Internal Carotid ◽

Clinical Status ◽

Anterior Communicating Artery ◽

Major Step ◽

Unruptured Aneurysms ◽

True Value ◽

Unruptured Intracranial Aneurysms ◽

Flow Diverters

ObjectiveTo report our initial experience with the Medina Embolic Device (MED) in unruptured intracranial aneurysms either as sole treatment or in conjunction with additional devices.Methods15 consecutive patients (6 women, 9 men) with unruptured aneurysms were treated between September 2015 and April 2016. The aneurysm fundus measured at least 5 mm. We evaluated the angiographic appearances of treated aneurysms at the end of the procedure and at follow-up, the clinical status, complications, and requirement for adjunctive devices.ResultsThe MED was successfully deployed in all but one case and adjunctive devices were required in 10 cases. Aneurysm locations were middle cerebral artery bifurcation (n=3), internal carotid artery (ICA) bifurcation (n=1), supraclinoid ICA (n=5), posterior communicating artery (n=1), anterior communicating artery (n=2), cavernous ICA (n=2), distal basilar sidewall (n=1), basilar tip (n=1). Three patients had complications although none could be attributed to the MED. Immediate angiographic results were modified Raymond-Roy classification (mRRC) I=1, mRRC II=5, mRRC IIIa=3, mRRC IIIb=5, and one patient showed contrast stasis within the fundus of the aneurysm. Follow-up angiography was available in 11 patients, with four showing complete aneurysm exclusion, six with stable remnants and one patient with an enlarging neck remnant.ConclusionsThe MED represents a major step forward in the treatment of intracranial aneurysms. It can result in rapid exclusion of an aneurysm from the circulation and has a good safety profile. We believe that the true value of the MED will be in combining its use with adjunctive devices such as endoluminal flow diverters that will result in rapid aneurysmal exclusion.

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Characteristics of Unruptured Compared to Ruptured Intracranial Aneurysms: A Multicenter Case–Control Study

Neurosurgery ◽

10.1093/neuros/nyx365 ◽

2017 ◽

Vol 83 (1) ◽

pp. 43-52 ◽

Cited By ~ 10

Author(s):

Isabel C Hostettler ◽

Varinder S Alg ◽

Nichole Shahi ◽

Fatima Jichi ◽

Stephen Bonner ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Artery ◽

Intracranial Aneurysms ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Anterior Communicating Artery ◽

Imaging Data ◽

Unruptured Aneurysms ◽

Ruptured Aneurysms ◽

Multivariable Analyses ◽

Different Characteristics

Abstract BACKGROUND Only a minority of intracranial aneurysms rupture to cause subarachnoid hemorrhage. OBJECTIVE To test the hypothesis that unruptured aneurysms have different characteristics and risk factor profiles compared to ruptured aneurysms. METHODS We recruited patients with unruptured aneurysms or aneurysmal subarachnoid hemorrhages at 22 UK hospitals between 2011 and 2014. Demographic, clinical, and imaging data were collected using standardized case report forms. We compared risk factors using multivariable logistic regression. RESULTS A total of 2334 patients (1729 with aneurysmal subarachnoid hemorrhage, 605 with unruptured aneurysms) were included (mean age 54.22 yr). In multivariable analyses, the following variables were independently associated with rupture status: black ethnicity (odds ratio [OR] 2.42; 95% confidence interval [CI] 1.29-4.56, compared to white) and aneurysm location (anterior cerebral artery/anterior communicating artery [OR 3.21; 95% CI 2.34-4.40], posterior communicating artery [OR 3.92; 95% CI 2.67-5.74], or posterior circulation [OR 3.12; 95% CI 2.08-4.70], compared to middle cerebral artery). The following variables were inversely associated with rupture status: antihypertensive medication (OR 0.65; 95% CI 0.49-0.84), hypercholesterolemia (0.64 OR; 95% CI 0.48-0.85), aspirin use (OR 0.28; 95% CI 0.20-0.40), internal carotid artery location (OR 0.53; 95% CI 0.38-0.75), and aneurysm size (per mm increase; OR 0.76; 95% CI 0.69-0.84). CONCLUSION We show substantial differences in patient and aneurysm characteristics between ruptured and unruptured aneurysms. These findings support the hypothesis that different pathological mechanisms are involved in the formation of ruptured aneurysms and incidentally detected unruptured aneurysms. The potential protective effect of aspirin might justify randomized prevention trials in patients with unruptured aneurysms.

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