Whole-brain CT Perfusion at Admission and During Delayed Time-window Detects the Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage

Objective To evaluate the utility of computed tomography perfusion(CTP)both at admission and during delayed cerebral ischemia time-window(DCITW)in the detection of delayed cerebral ischemia(DCI)and the change in CTP parameters from admission to DCITW following aneurysmal subarachnoid hemorrhage.Methods Eighty patients underwent CTP at admission and during DCITW.The mean and extreme values of all CTP parameters at admission and during DCITW were compared between the DCI group and non-DCI group,and comparisons were also made between admission and DCITW within each group.The qualitative color-coded perfusion maps were recorded.Finally,the relationship between CTP parameters and DCI was assessed by receiver operating characteristic(ROC)analyses.Results With the exception of cerebral blood volume(P=0.295,admission;P=0.682,DCITW),there were significant differences in the mean quantitative CTP parameters between DCI and non-DCI patients both at admission and during DCITW.In the DCI group,the extreme parameters were significantly different between admission and DCITW.The DCI group also showed a deteriorative trend in the qualitative color-coded perfusion maps.For the detection of DCI,mean transit time to the center of the impulse response function(Tmax)at admission and mean time to start(TTS)during DCITW had the largest area under curve(AUC),0.698 and 0.789,respectively.Conclusion Whole-brain CTP can predict the occurrence of DCI at admission and diagnose DCI during DCITW.The extreme quantitative parameters and qualitative color-coded perfusion maps can better reflect the perfusion changes of patients with DCI from admission to DCITW.

Genetic causal relationship between tea intake and cerebral aneurysm: a two-sample Mendelian Randomization Study

Background:Prior research has established a strong link between cerebral aneurysm(CA)occurrence and inflammation.Tea intake(TI)has been found to have anti-inflammatory properties through multiple mechanisms,potentially lowering CA incidence.This study aims to employ Mendelian Randomization(MR)methodology to explore the genetic causality between TI and CA.Methods:We collected Genome-wide association study(GWAS)data for CA,TI,Green tea intake(GTI),Herbal tea intake(HTI),and Rooibos tea intake(RTI).The MR analysis employed the TwoSampleMR package and utilized the inverse variance-weighted(IVW)method.Results:The findings suggest no genetic causal relationship between TI and CA(IVW:OR=1.10,95%CI:0.59–2.05,P=0.772).Similarly,there is no genetic causal association between GTI and CA(IVW:OR=1.07,95%CI:0.91–1.26,P=0.388),HTI and CA(IVW:OR=1.00,95%CI:0.89–1.13,P=0.943),or RTI and CA(IVW:OR=1.02,95%CI:0.96–1.09,P=0.472).Conclusion:There is no genetic causal relationship between TI and CA,and the different types of tea do not change this result.Further MR analysis is needed to investigate whether there is a potential genetic causal association between the quantity of TI and CA.

Surgical Treatment of Poor Grade Middle Cerebral Artery Aneurysms Associated with Large Sylvian Hematomas Following Prophylactic Hinged Craniectomy

The clinical characteristics of patients who presented in poor clinical grade due to ruptured middle cerebral artery aneurysms （MCAAs） associated with large sylvian hematomas （SylH） were ana- lyzed and an ingenious designed prophylactic hinged craniectomy was introduced. Twenty-eight pa- tients were graded into Hunt-Hess grades IV-V and emergency standard micro-neurosurgeries （aneu- rysm clipping, hematoma evacuation and prophylactic hinged craniectomy） were performed, and their clinical data were retrospectively analyzed. 46.43% of the patients reached encouraged favorable out- comes on discharge. The favorable outcome group and the poor outcome group significantly differed in terms of patients＇ anisocoria, Hunt-Hess grade before surgery, extent of the midline shift and time to the surgery after bleeding （P〈0.05）. There were no significant differences in age, sex, volume and location of the hematoma, size of aneurysm between the favorable and poor groups （P〉0.05）. However, ingen- ious designed prophylactic hinged craniectomy efficiently reduced the patients＇ intracranial pressure （ICP） after surgery. It was suggested that preoperative conditions such as Hunt-Hess grading, extent of the midline shift and the occurrence of cerebral hernia affect the prognosis of patients, but time to the surgery after bleeding and prophylactic hinged craniectomy are of significant importance for optimizing the prognosis ofMCAA oatients 19resenting with large SylH.

Impact of Intraoperative Blood Pressure Control and Temporary Parent Artery Blocking on Prognosis in Cerebral Aneurysms Surgery

Objective In cerebral aneurysm clipping and embolization, blood pressure control and temporaryparent artery blocking are common methods to prevent aneurysm rupture. Their influence on the prognosis isuncertain. In this study, we try to find out the association between methods above and prognostic indicators.

Outcomes of early physiotherapy in patients with cerebral aneurysms treated by surgical clipping or endovascular embolization

Early physiotherapy was given to 124 patients with ruptured or unruptured cerebral aneurysms who were treated by surgical clipping or endovascular embolization.Patients were divided into four groups according to their Hunt and Hess grade at admission and aneurysm treatment modality： Group 1,Hunt and Hess grade≤II and surgical clipping;Group 2,Hunt and Hess grade≤II and endovascular embolization;Group 3,Hunt and Hess grade≥III and surgical clipping;Group 4,Hunt and Hess grade≥III and endovascular embolization.Level of consciousness was evaluated using the Glasgow Coma Scale,functional status using the Glasgow Outcome Scale,level of the mobility using the Mobility Scale for acute stroke patients,and independence in activities of daily living using the Barthel Index.After early physiotherapy,the level of consciousness and functional status improved significantly in Groups 1,3,and 4;mobility improved significantly in all groups;and independence in activities of daily living improved significantly in Groups 1 and 3.At discharge, Groups 1 and 2 had better functional status than Groups 3 and 4.Level of consciousness,functional status,mobility and independence in activities of daily living improved after early physiotherapy. These findings suggest that early physiotherapy improved the prognosis of patients with cerebral aneurysms who were treated by surgical clipping or endovascular embolization.Patients with a worse clinical status at presentation had a poorer functional status at discharge.The outcome of physiotherapy was not affected by whether surgical clipping or endovascular embolization was chosen for treatment of the aneurysm.

Three-Dimensional Cerebral Aneurysm Models for Surgical Simulation and Education—Development of Aneurysm Models with Perforating Arteries and for Application of Fenestrated Clips

We modified a three-dimensional cerebral aneurysm model for surgical simulation and educational demonstration. Novel models are made showing perforating arteries arising around the aneurysm. Information about perforating arteries is difficult to obtain from individual radiological data sets. Perforators are therefore reproduced based on previous anatomical knowledge instead of personal data. Due to their fragility, perforating arteries are attached to the model using hard materials. At the same time, hollow models are useful for practicing clip application. We made a model for practicing the application of fenestrated clips for paraclinoid internal carotid aneurysms. Situating aneurysm models in the fissure of a brain model simulates the real surgical field and is helpful for educational demonstrations.

Analysis on Emergency Microsurgical Treatment for Cerebral Hernia Caused by Intracranial Anterior Circulation Aneurysm with Intracranial Hematoma

Objective: This study is to discuss CT performances and direct surgical strategy as well as therapeutic effect of patients who have rupture hemorrhage of intracranial anterior circulation aneurysm with complications of intracranial hematoma and cerebral hernia. Methods: CT performances and treatment of 14 patients who have rupture hemorrhage of intracranial anterior circulation aneurysm with complications of intracranial hematoma and cerebral hernia in our hospital from March, 2019 to March, 2021 were reviewed. The relationship between hematoma caused by intracranial anterior circulation aneurysm and position of the aneurysm was analyzed. Besides, surgical processing keys were discussed. Results: For all selected patients, intracranial hemorrhage is proved to be caused by rupture of aneurysm. Among them, there are 2 cases of anterior communicating aneurysms, 3 cases of posterior communicating aneurysms, and 9 cases of middle cerebral aneurysms. According to exploration, we found 1 case of multiple aneurysm, which is the combination of a middle cerebral aneurysm (the responsible aneurysm) and ipsilateral posterior communicating aneurysm. There were two cases of intraoperative rupture. In this study, 3 patients died. According to GOS grading at 3 months after the operation, there were 1 case of V-grade (good recovery), 3 cases of IV-grade (self-maintenance), 5 cases of III-grade (severe disabled), 2 cases of II-grade (persistent vegetative state) and 3 cases of I-grade (died). Conclusions: Emergency microsurgical treatment can lower the death rate of cerebral hernia caused by intracranial anterior circulation aneurysm with intracranial hematoma and recover the neurological functions to the maximum extent.

Clinical Efficacy of Shenmai Injection in the Treatment of Cerebral Vasospasm after Ruptured Aneurysm Surgery

Objective: To investigate the therapeutic effect of Shenmai Injection on postoperative cerebral vasospasm in patients with ruptured aneurysms. Methods: Seventy patients undergoing craniotomy for ruptured aneurysms in our hospital were selected as study subjects and randomly divided into control (n = 33) and research (n = 37) groups, they were treated with nimodipine and nimodipine combined with Shenmai injection after operation. The blood flow velocity in the middle cerebral artery (MCA) before and at 1, 3, 7, 11 and 14 days after surgery and the incidence of cerebral vasospasm during these days were compared, and the GCS scores at 14 days postoperatively and GOS scores at 6 months postoperatively were compared between the two groups. Results: There were no statistically significant differences in the occurrence of cerebral vasospasm, GCS or GOS scores between the two groups (P > 0.05), but the period of postoperative cerebral vasospasm in the study group was significantly shorter than that in the control group. Conclusion: Shenmai injection has the effect of shortening the cycle of occurrence of cerebral vasospasm after the operation of ruptured aneurysms, promoting patients to recover as early as possible and reducing their physical and mental burden.

Microsurgical treatment on distal anterior cerebral artery aneurysms (9 cases report)

Objective To report the clinical diagnosis and microsurgical treatment of ruptured distal anterior cerebral artery aneurysm (DACAA) patients treated over the last 3 years. Methods 9 consecutive cases of ruptured DACAA operated from October 2007 to March 2010 were reviewed and followed up. Results 11 aneurysms were clipped

Clinical application of retrograde cerebral perfusion for brain protection during the surgery of ascending aortic aneurysm:50 cases report

Objective To assess retrospectively the effects of different protective methods on brain in ascending aortic aneurysm surgery. Methods In 65 patients, aneurysm was dissected to the aortic arch or right arch. To protect brain, deep hypotermic circulatory arrest ( DHCA.) combined with retrograde cerebral perfusion ( RCP) June 2003 Vol11 No2 through the superior vena cava ( n = 50) and simple DHCA ( n = 15) were used during the procedure. Blood samples for lactic acid level from the jugular vein were compared in both groups at different plase, and perfusion blood distribution and oxygen content difference between the perfused and returned blood were measured in some RCP patients. Results The DHCA time was 35.9 ± 8 min (10. 0 - 63. 0 min) and DHCA+ RCP time was 45.5 ± 17. 2 min (16. 0 - 81. 0 min)The resuscitationtime was 7.1 ± 1.6 h (4.4 - 9.4H)in DHCA patients and 5.4±2.2h(2.0-9.0 h)in RCP patients. Operation death was 3/15 in the DHCA group and 1/50 in the RCP patients. Central nervous complication

Study on the role of Cathepsin B and JNK signaling pathway in the development of cerebral aneurysm

Objective: To investigate the correlation between JNK signal and the apoptosis of VSMC as well as the expression of Cathepsin B and to explore the role of JNK signal in the development of cerebral aneurysm. Methods: Rat models of cerebral aneurysm were established and histopathologic changes of cerebral aneurysm and the apoptosis of VSMC were analyzed. Rat models were respectively subject to subcutaneous injection of Cathepsin B si RNA and JNK inhibitor SP600125. Western blot technique was used to detect the expression of proteins like Cathepsin B, Caspase-3, and p-JNK. Spearman's rho was used to examine the correlation between p-JNK and Cathepsin B, as well as the expression of relevant proteins. Results:The success rate of modeling rats with cerebral aneurysm was 88.75%. After the respective injection of Cathepsin B si RNA, SP600125 and their combination, the cell densities of VSMC of rats with cerebral aneurysm all increased significantly(P<0.05 or P<0.01), but the apoptosis rate of VSMC decreased significantly(P<0.01). Compared with normal rats, the expression of Cathepsin B, Caspase-3 and p-JNK in cerebral aneurysm models increased significantly. Effectively intervening Cathepsin B genes with Cathepsin B si RNA could significantly inhibit the expression of Cathepsin B and Caspase-3, but hardly influence the expression of p-JNK. JNK inhibitor SP600125 had no influence on the expression of Cathepsin B and Caspase-3, but effectively inhibited the expression of p-JNK. In cerebral aneurysm tissues, positive correlation was observed between the expression of p-JNK and Cathepsin B, the correlation coefficient was r=0.640. Conclusion: After the attack of cerebral aneurysm, proteins like Cathepsin B, Caspase-3 and p-JNK are all involved in the apoptosis of VSMCs. This process may be realized by Cathepsin B which activates the apoptosis mechanism of Caspase-3 and mediate the apoptosis of VSMC through the JNK signaling pathway. Therefore, silencing Cathepsin B gene or inhibiting the conduction through JNK signaling pathway can mitigate the apoptosis of vascular smooth muscle cells in cerebral aneurysm.

Intraoperative hemodynamic parameters of middle cerebral artery and other artery aneurysms utilizing transcranial Doppler ultrasonography

BACKGROUND： Hemodynamic changes accompany the initiation, development and rupture of middle cerebral artery （MCA） aneurysms. The complexity of the intraaneurysmal hemodynamic factors has not been completely clarified by the indirect measures and methods used in previous studies. OBJECTIVE： To evaluate correlations of intraoperative hemodynamic factors to initiation and rupture of MCA aneurysms. DESIGN, TIME AND SETTING： A case-control study was performed at the Department of Neurosurgery, Tiantan Hospital Affiliated to Capital Medical University, China between March and October 2008. PARTICIPANTS： A total of 12 consecutive patients diagnosed with MCA aneurysms （MCA aneurysms group） and five patients without middle cerebral artery aneurysms （with aneurysms located at other arteries, control group） were enrolled at the Department of Neurosurgery, Tiantan Hospital Affiliated to Capital Medical University, China. METHODS： The proximal and distal arteries of MCA aneurysms were exposed visibly in the MCA aneurysm group. The M1 segment of MCA without the aneurysm and the aneurysm on other arteries were also exposed visibly in the control group. Hemodynamic indices were then measured using an intraoperative 16 MHz probe installed in a Multi-Dop TCD8X4 device. MAIN OUTCOME MEASURES： Mean （time-averaged velocity） difference, maximum mean, pulsatility index difference, maximum pulsatility index, resistance index difference, maximum resistance index; correlation of development and rupture of MCA aneurysms to intraoperative hemodynamic factors of the parent artery. RESULTS： A total of 12 patients underwent microsurgery for treatment to occlude 15 MCA aneurysms. Of the 15 MCA aneurysms, 12 were located at the bifurcation, two at the M1 segment and one at the M3 segment; eight of the aneurysms were unruptured and seven were ruptured. The whole indices with combination mean difference, maximum mean, and maximum pulsatility index of the aneurysms were important factors influencing the rupture of MCA aneurysms （t = 2.92, P = 0.03, constant）. A higher velocity intraaneurismal flow at the bifurcation was identified （t = 3.48, P = 0.01, constant）. After the aneurysm was completely occluded, global high-velocity flow could not be detected in the parent arteries （t = 2.57, P=0.03, constant）. CONCLUSION： When short-term high-velocity blood flow is present, aneurysms can be easily initiated and ruptured at the bifurcation of MCA.

Angiographic follow-up of cerebral aneurysms treated with Guglielmi detachable coils(GDCs): An analysis of 162 cases of 173 aneurysms

Objective To evaluate the mid- and long-term radiological outcomes of cerebral aneurysms with GDCs embolization.Methods One hundred and sixty-two patients with 173 aneurysms embolized with GDCs underwent angiographic follow-up from 1 to 54 months post-operatively and were retrospectively reviewed. Three neuro-radiologists reviewed each angiogram and made a comparison between initial and follow-up angiograms. Morphological outcomes were evaluated as follows: unchanged; progressive thrombosis; and re-opening or re-growth. Results Of 173 aneurysms with GDC embolization, 142 aneutysms had total or nearly total occlusion, 23 subtotal occlusion and 8 partial occlusion shown on initial angiograms. The incidence of re-opening was 17.1% (13/76) in less than 3 months, and 6.2% (6/97) between 3 and 6 months postoperatively. Four aneurysms showed recurrency(2.3%) on second follow-up angiography in one year after procedure and one-year cumulative recurrent rate was 13.3% of 56 aneurysms with the third follow-up angiography in the post-operation period of 12 to 54 months, four showed a little enlargement and the cmnulative recurrent rate so far was 20.2% (35/173). Conclusions The direct and main causes for aneurysmal recurrence are incomplete and loosening packing. The first angiographic follow-up is recommended to be performed at 3 months or earlier after the procedure, especially in aneurysms with initial incomplete occlusion. Re-treatment with balloon- or stent-assisted coil embolization is recommended in re-opening aneurysms.

Effects of Elasticity on Wall Shear Stress in Patient-Specific Aneurysm of Cerebral Artery

The behavior of wall shear stress (WSS) was previously reported in a deformable aneurysm model using fluid-structure interactions. However, these findings have not been validated. In the present study, we examined the effect of elasticity (i.e., deformation) on wall shear stress inside a cerebral aneurysm at the apex of a bifurcation using particle image velocimetry in vitro. The flow model simulated a human patient-specific aneurysm at the apex of the bifurcation of the middle cerebral artery. Flow characteristics by wall elasticity were examined for both elastic and non-deformable aneurysm models with pulsatile blood flow. The absolute temporally- and spatially-averaged WSS along the bleb wall was smaller in the elastic model than that in the non-deformable model. This small WSS may be related to attenuation of the WSS. Further, the WSS gradient had a finite value near the stagnation point of the aneurysm dome. Finally, the WSS gradient near the stagnation point was slightly smaller in the elastic model than that in the non-deformable model. These data suggest that elasticity of the aneurysm wall can affect the progression and rupture of aneurysms via hemodynamic stress.

Ruptured intracranial aneurysm presenting as cerebral circulation insufficiency:A case report

BACKGROUND Rupture of an intracranial aneurysm is a type of acute stroke that is a serious threat to human health.Misdiagnosis of ruptured intracranial aneurysms is a serious clinical event that may have disastrous consequences in some patients.To date,ruptured intracranial aneurysms have been misdiagnosed as meningitis,tumors,stroke,or trauma,among other conditions.Here,we report what appears to be the first case of a ruptured intracranial aneurysm that presented as cerebral circulation insufficiency.CASE SUMMARY A middle-aged man was admitted to our hospital because of a parasellar lesion identified on a noncontrast computed tomography(CT)image after a mild traffic accident that was caused by a brief loss of consciousness.Notably,he was diagnosed with cerebral circulation insufficiency after two unexplained episodes of a transient loss of consciousness within the past 8 mo.The patient was diagnosed with right internal carotid artery aneurysm based on CT angiography and completely recovered after a craniotomy at our hospital.A few clots and severe adhesions around the aneurysm were observed in the subarachnoid space during the operation,suggesting that the aneurysm had ruptured and may had been misdiagnosed as cerebral circulation insufficiency.CONCLUSION Ruptured intracranial aneurysms may show negative imaging results and present as cerebral circulation insufficiency,which should be recognized as soon as possible to ensure timely management.

Biomechanical Considerations in the Unruptured Cerebral Aneurysm Study (UCAS Japan): Rupture Risk and True Stress of Wall

When an unruptured aneurysm is found, deciding whether to operate or follow up is one of the most important issues. There are guidelines for making the best final decision on treatment, taking into account the effectiveness of diagnostic and therapeutic devices and the risk-benefit ratio of patients, caregivers, and healthcare professionals. The guidelines evidence-based of large clinical data for this purpose are presented by national medical societies. As one of the rupture risk indicators, there is the hazard risk ratio derived by the UCAS Japan research group based on the statistical method of 6697 aneurysms in 5720 patients with cerebral aneurysms of 3 mm or more. Therefore, we investigated the biomechanical significance of this hazard risk ratio using a spherical aneurysm model. It was revealed that 1) the reason why the frequency of aneurysm rupture is relatively high up to about 10 mm, 2) the UCAS hazard risk ratio corresponds to stress of the aneurysm wall, and the true stress can be calculated by multiplying the patient’s blood pressure, and 3) the factors that cause the daughter’s sac (irregular protrusion of the aneurysm wall). In addition, our two methods for measuring the strength of the blood vessel wall of an individual patient were described.

Superficial Temporal Artery to Middle Cerebral Artery Bypass and Endovascular Parent Artery Occlusion in the Treatment of Giant Intracranial Aneurysms

The authors are reporting on a study drawn from unpublished dissertation done by the corresponding author when he completed his neurosurgical training in Paris, France in 2004, few years before the advent of flow diverters. The study was a retrospective review of giant intracranial aneurysms treated by superficial temporal artery to middle cerebral artery bypass combined with endovascular occlusion of the parent artery. From 1990 to 2003, 29 consecutive cases of giant cerebral aneurysms, not suitable to selective treatment were managed in that way. Twenty-one medical records had enough data to allow objective evaluation. Sixteen female and five male patients bearing 21 giant aneurysms were involved. Their mean age was 46 years. The aneurysm was revealed by mass effect in 13 cases and subarachnoid hemorrhage in one case. On admission 19 patients presented with unruptured aneurysms and two have sustained a subarachnoid hemorrhage. The balloon occlusion test before the bypass operation was not tolerated in 18 patients. The treatment was completed in 19 patients and 17 of them had parent artery occlusion with latex detachable balloons. The only death of the series occurred before the endovascular treatment. The mean follow-up period was 30 months. After completion of the treatment, 16 (84%) patients had no symptom. Aneurysm recanalization or rupture was not observed after the parent artery occlusion. With the combination of superficial temporal artery to middle cerebral artery bypass + endovascular parent artery occlusion, 90% of giant intracranial aneurysms untreatable selectively were permanently excluded with a good outcome in 95%.

Clinical Analysis of Embryonic Posterior Cerebral Artery

Objective:To understand the clinical characteristics of patients with embryonic posterior cerebral artery and its correlation with abnormal vascular development.Methods:The clinical data of 396 patients with embryonic posterior cerebral artery confirmed by magnetic resonance angiography(MRA)and computed tomography angiography(CTA)were analyzed.Results:Two-hundred patients had clinical manifestations of posterior circulation ischemia,including recurrent dizziness,vertigo,and tinnitus;45 had headaches,97 had limb weakness,and 16 patients had syncope or impaired consciousness.Seventy-six patients with circulatory infarction were admitted to the hospital.There were 251 patients with history of hypertension,74 with diabetes,113 with hyperlipidemia,13 with dominant vertebral artery,10 with intracranial aneurysm,and 19 with absence of A1 segment of the anterior cerebral artery(considering developmental variation).Conclusion:Embryonic posterior cerebral artery develops abnormally during the embryonic period,often accompanied by abnormal vascular access.Due to abnormal hemodynamics,the incidence of posterior circulation ischemia,aneurysm,and infarction increases in such patients.

Endovascular treatment of ruptured lobulated anterior communicating artery aneurysms:A retrospective study of 24 patients

BACKGROUND Lobulated intracranial aneurysm is a special type of aneurysm with at least one additional cyst in the neck or body of the aneurysm.Lobulated intracranial aneurysm is a complex aneurysm with complex morphology and structure and weak tumor wall,which is an independent risk factor for rupture and hemorrhage.Lobular aneurysms located in the anterior communicating artery complex account for 36.9%of all intracranial lobular aneurysms.Due to its special anatomical structure,both craniotomy and endovascular treatment are more difficult.Compared with single-capsule aneurysms,craniotomy for lobular intracranial aneurysms has a higher risk and complication rate.AIM To investigate the efficacy and safety of endovascular treatment for ruptured lobulated anterior communicating artery aneurysm(ACoAA).METHODS Patients with ruptured lobulated ACoAA received endovascular treatment in Sanming First Hospital Affiliated to Fujian Medical University from June 2020 to June 2022 were retrospectively included.Their demographic,clinical and imaging characteristics,endovascular treatment methods and follow-up results were collected.RESULTS A total of 24 patients with ruptured lobulated ACoAA were included,including 9 males(37.5%)and 15 females(62.5%).Their age was 56.2±8.9 years old(range 39-74).The time from rupture to endovascular treatment was 10.9±12.5 h.The maximum diameter of the aneurysms was 5.1±1.0 mm and neck width were 3.0±0.7 mm.Nineteen patients(79.2%)were double-lobed and 5(20.8%)were multilobed.Fisher's grade:Grade 2 in 16 cases(66.7%),grade 3 in 6 cases(25%),and grade 4 in 2 cases(8.3%).Hunt-Hess grade:Grade 0-2 in 5 cases(20.8%),grade 3-5 in 19 cases(79.2%).Glasgow Coma Scale score:9-12 in 14 cases(58.3%),13-15 in 10 cases(41.7%).Immediately postprocedural Raymond-Roy grade:grade 1 in 23 cases(95.8%),grade 2 in 1 case(4.2%).Raymond-Roy grade in imaging follow-up for 2 wk to 3 months:grade 1 in 23 cases(95.8%),grade 2 in 1 case(4.2%).Followup for 2 to 12 months showed that 21 patients(87.5%)had good functional outcomes(modified Rankin Scale score≤2),and there were no deaths.CONCLUSION Endovascular treatment is a safe and effective treatment for ruptured lobulated AcoAA.

Saccular trilobed aneurysm of azygos anterior cerebral artery

Multiple saccular or giant aneurysms of azygos anteriorcerebral artery(AACA) at the distal segments A2-A5 are very rarely reported. Distal anterior cerebral artery(DACA) aneurysms represent approximately 2%-7% of all cerebral aneurysms. We present the case of an Albanian 62-year-old male, admitted at our service after sudden onset of severe headache and vomiting. Computerized tomography(CT) of the head showed hemorrhage in the front of corpus callosum. CT angiography followed by digitally subtracted angiography(DSA) documented a large necked aneurysm with three lobes at the origin of calloso-marginal artery and a single DACA, also known as AACA. A frontal parasagittal craniotomy was performed. Obliteration of the aneurysm was done only by separate clipping of each three lobes at the respective neck. Postoperative DSA demonstrated complete exclusion of the aneurysm and a regular flow of AACA. The patient recovered uneventfully. Despite it is a rare occurrence, an aneurysm of distal segments of anterior cerebral artery A2-A5, concomitant to AACA should be studied with DSA. In the era of embolization, conserving good microsurgical skills is fundamental for dealing with multilobar cerebral aneurysms, associated with rare anatomical variations.