Welcome to the WSC 2022 Interactive Program

Background and Aims

Delayed cerebral ischaemia (DCI) due to vasospasm can lead to worse prognosis in aneurysmal subarachnoid haemorrhage (SAH) patients. Transcranial Doppler (TCD) is a non-invasive tool for detecting and monitoring vasospasm. Through our study, we have tried to correlate MCA velocities with degree of vasosapsm seen on digital subtraction angiography.

Methods

Retrospective analysis of 5 patients of aneurysmal SAH was done. TCD was done to assess vasospasm from day 3 through day 10 of SAH. DSA was also done in all these patients with intraarterial vasodilator injection. Mild, Moderate and severe MCA stenosis was graded on DSA based on the ratio of involved MCA with cavernous ICA. Correlation with Peak Systolic Velocity (PSV) of MCA on TCD was done.

Results

Three patients had severe vasospasm and two had moderate vasospasm. Intraarterial (IA) nimodipine was used in four patients and milrinone in one patient. All the patients with severe vasospasm had MCA PSV > 150 cm/s, while patients with moderate vasospasm had MCA PSV between 120-150cm/s. Complete resolution of vasospasm was seen in 3 patients (two after IA milrinione and one after IA nimodipine). Corresponding MCA PSV ranged between 60-80 cm/s. Two patients had residual mild vasospasm on DSA. Corresponding MCA PCV ranged between 90-100cm/s.

Conclusions

TCD has an important role in the non-invasive radiation free detection and monitoring of vasospasm after SAH. MCA PSV correlate well with DSA appearance of vasospasm.

Background and Aims

Aneurysmal subarachnoid hemorrhage (aSAH) is a sudden onset, medical emergency occurring in adult patients. Delayed cerebral ischemia (DCI) is a serious complication following aSAH, which may cause disability. Clinical and economic burden are not yet fully understood. The RESOLVE study aims to compare hospital length of stay (LoS), healthcare resource utilization (HCRU), all-cause mortality, and costs among treated patients with aSAH who did and did not develop DCI.

Methods

RESOLVE is a retrospective, multicenter, single-country, observational cohort study using patient data from medical charts linked to the French National Health Data System (SNDS). Eligible patients: adults ≥18 years of age with aSAH who underwent endovascular coiling or surgical clipping (index date [ID]: procedure date) between 1‑Jan‑2017 and 31‑Dec‑2018 at ~10 centers across France. The study will employ consecutive stratified recruitment of ~300 patients in two strata: DCI versus non-DCI (ratio 1:1), according to whether they developed DCI at the earliest of hospital discharge, death or 21 days following ID. Primary outcome measures: overall hospital LoS; intensive care unit LoS; acute and subacute hospital setting LoS; inpatient rehabilitation center LoS. Secondary outcome measures: HCRU measures; all-cause mortality; costs.

Results

The study will describe observed impacts of DCI for 12- or 36-months following ID using data from medical charts linked to the SNDS.

Conclusions

This real-world evidence study will be one of the first to describe the impact of DCI on hospital LoS (including rehabilitation stays), HCRU, all-cause mortality, and costs.

Background and Aims

Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening emergency occurring when a brain aneurysm ruptures and bleeds into the subarachnoid space. Delayed cerebral ischemia (DCI) is a serious complication following aSAH, occurring in 20–50% of patients, and is associated with increased morbidity and mortality. Limited evidence exists on the humanistic burden of DCI; the PRESERVE study aims to assess this burden in patients with aSAH who did or did not develop DCI.

Methods

PRESERVE is a prospective, multicenter, observational, cohort study, administering validated and bespoke questionnaires to patients with aSAH and their caregivers in France. Eligible patients: adults ≥18 years of age with aSAH who undergo endovascular coiling or surgical clipping (index date [ID]: procedure date) at participating centers from 1‑Jun‑2022 until ~400 patients with aSAH are recruited. The study will employ consecutive recruitment of eligible patients in two groups: DCI versus no DCI, according to whether they developed DCI at the earliest of hospital discharge, death or 21 days following ID. Primary outcome measures: functional and cognitive status impairment; health-related quality of life; activities of daily living; mood; work and productivity outcomes. Secondary outcome measures: caregiver burden of providing informal care for patients with aSAH.

Results

Follow-up will last for up to 12 months post ID.

Conclusions

This real-world evidence observational study will describe the humanistic burden associated with DCI in patients with aSAH and their caregivers to address gaps in the literature.

Background and Aims

The main culprit lesion causing hiccup in patients with ischemic stroke is thought to involve the medulla oblongata, but some cases of hiccups caused by damage to the supratentorial cortex have been reported.

Methods

A 44 years old gentleman presented intractable hiccups, after a few weeks he developed a sudden onset of right-sided weakness. On examination, the patient had extensor right plantar response with motor weakness (3/5) of the right upper and lower limb.

Results

An immediate MRI brain revealed a left MCA acute infarct. MR Angio of brain vessels revealed a huge saccular left ACOM aneurysm (47*37 mm) with an altered intensity of 18*16.5 mm around the aneurysm suggestive of the false lumen with partial thrombosis. The aneurysm was not present in the MRI brain done for transient headache one year back. A cerebral DSA was performed which revealed circumferential eccentric multifocal areas of enhancement in left MCA branches and similar bilateral patchy vessel wall enhancements; suggestive of CNS vasculitis. Endovascular coiling of saccular left ACOM aneurysm was performed and the patient was treated with five days of pulse therapy of high dose IV Methylprednisolone.

The patient has a complete resolution of hiccups and right-sided weakness improved significantly. The patient has not experienced any new neurological symptoms on long-term follow-up.

Conclusions

Supratentorial lesions presenting with hiccups are rare, more so ACOM aneurysms presenting as hiccups are extremely rare. Association between underlying CNS vasculitis and the rapidly expanding ACOM aneurysm remains unclear. We recommend for high index for a CNS cause in intractable seizures.

Background and Aims

Vertebrobasilar dolichoectasia (VBD) is a vascular malformation characterized by marked ectasia, elongation, and tortuosity of the vertebrobasilar arteries, with a reported prevalence of 0.05 to 18%. Most often, it is associated with ischemic or hemorrhagic stroke, but this entity can also cause symptoms of cranial nerve compression. Trigeminal and facial nerves are most often affected, resulting in trigeminal neuralgia and hemifacial spasm, respectively. There are rare reports of third, fourth, eighth, ninth, and tenth cranial nerve compression from vertebrobasilar dolichoectasia. Notably, multiple cranial nerve involvement in patients with VBD is very rare.

Methods

A Non-smoker 46-year-old man with 10-years hypertension history presented with 3-weeks history of sudden onset bilateral abducens nerve palsy and left peripheral facial nerve palsy. Non-contrasted computed tomography (CT) and magnetic resonance imaging (MRI) showed a markedly dilated and tortuous vessel, compressing the mesencephalon. Diffusion-weighted MRI revealed no infarct in the mesencephalon. Digital subtraction angiography (DSA) examination confirmed bilateral V4 segment vertebral artery dolichoectasia to the basilar artery. During the 1-month follow-up period, his clinical condition remained stable, peripheral facial nerve palsy was improved but slight limitation of the eyes abduction.

Results

The patient subsequently improved after conservative treatment, with steroids, blood pressure control and antiplatelet drugs.

Conclusions

Vascular malformation should be considered when cranial nerve symptom is encountered, especially when multiple cranial nerves involved. To the best of our knowledge, simultaneous abducens and peripheral facial nerve symptoms precipitated by VBD compression have not yet been reported.

Background and Aims

Dural arteriovenous fistulas (DAVF) are abnormal arteriovenous shunt between dural arteries and venous sinuses. DAVFs account for 10-15% intracranial vascular malformation. The risk of hemorrhage is about 4,5-19% per year. Various clinical presentations and radiological findings can mimic other vascular malformations such as arteriovenous malformation (AVM).

Methods

Case Description

A 64-year-old male presented with recurrent focal to bilateral seizure 6 hours before admission with decreased level of consiousness after the seizures. Levetiracetam was given according to status epilepticus protocol. Patient discharged without any neurological deficits. Computed Tomography Angiography (CTA) showed tubular tortous lesions with two nidus supporting AVM (Spletzer Martin 1) features. Digital Subtraction Angiography (DSA) found DAVF with cortical vein involvement and venous ectasia is suspected of originating from the ophthalmic artery (Borden III Cognard IV).

Results

Discussion

Seizure is a frequent clinical feature of AVM (20-45%) while less common in DAVF (3%). Seizures in DAVF occur in cases with cortical vein involvement causing cerebral venous reflux which triggers the seizures. CTA only depicts the visualisation of cerebral blood vessel, hence venous ectasia in DAVF may resemble the nidus in AVMs. Meanwhile, DSA can assess blood flow through artery and venous phase which are very important to differentiate AVM and DAVF. Endovascular embolisation should be performed soon following the diagnosis.

Conclusions

Seizures may occur in DAVF with cortical venous drainage involvement. DSA is a very important procedure for diagnosing vascular malformations

Background and Aims

Presenting a case of spontaneous regression of fusiform aneurysm which contribute to potential mechanisms of pathogenesis leading to aneurysm regression

Methods

We describe a case of 21-years-old male patient who was admitted to the hospital because of double vision and hemiparesis

Clinical examination noted incompletely right third nerve palsy, left central facial palsy, vertical nystagmus, left subtle hemiparesis, unstable tandem gait, and no babinski sign. Brain Magnetic Resonance Imaging (MRI) showed ischemic lesions in the right midbrain, aneurysms of the right posterior cerebral artery (PCA).

Results

MRI showed an old cerebral infarct in the right midbrain, and a new infarct adjacent to it. Magnetic Resonance Angiography (MRA) and High Resolution-Vessel Wall Imaging (HR-VWI) presented right posterior cerebral aneurysm, concentric wall thickening with focal contrast enhancement of right PCA which showed possible vasculitis condition. The cerebral digital subtraction angiography showed three fusiform aneurysms of right PCA’s perforating branches, not directly arising from PCA. Cerebro-spinal fluid analysis showed a cell count of 8/mm3 (100% lymphocytes), protein level of 28.77mg/dL, glucose level of 4.5mmol/L, and negative test results for tuberculosis, mycoses, parasites, bacteria. Serologic screening for Human immunodeficiency virus, Treponema pallidum were negative. Test results of autoimmune disease, hypercoagulable states were unremarkable. The patient was treated with antiplatelet therapy, steroid 1g per day for 10 days.

A follow-up MRA and HR-VWI at three months showed all of aneurysms disappeared.

Conclusions

The formation and regression of these aneurysms was associated with changes in structure and function of arterial wall a right PCA due to vasculitis

Background and Aims

Cardiac myxomas are benign cardiac tumors that originate from subendocardial mesenchymal cells. Neurological manifestations of cardiac myxoma may present commonly as ischemic infarcts and rarely with myxomatous intracranial aneurysms, brain parenchymal myxomatous metastases and intracerebral hemorrhage. In 1894, the first case were reported and to date there are fewer than 60 published cases of myxomatous intracranial aneurysms in literature.

Methods

A 44 years old men was admitted to our hospital with sudden weakness of the right side of the body and cognitive impairment. Head CT showed hemorrhagic transformation of ischemic infarct at left parietal. The CTA showed no abnormalities were detected. On echocardiography, a tumor in the left atrium was identified, suggesting an atrial myxoma that excision was performed. After 4 months, the patient was hospitalized with sudden onset generalized tonic seizure. Head CT showed intracerebral hemorrhage at left temporal and chronic infarct at left parietal. Digital subtraction angiography showed multiple aneurysms in the territory of the left MCA suspected to be related to embolism from cardiac myxoma.

Results

We are considering radiotherapy instead of endovascular intervention for treatment the patient.

Conclusions

This is the first case report that shows multiple intracranial aneurysms as a manifestation of cardiac myxoma after initial surgical treatment at our hospital. Treatment protocols of this case unclear because on account of rarity and even surgical resection of the primary cardiac tumor might not completely prevent delayed occurrence of aneurysms that related cardiac myxoma. Patient with multiple intracranial aneurysms should be evaluated and treated based on their individual medical condition.

Background and Aims

Secondary ICH occurs in 13%-28% of the hemorrhages stroke. One of the underlying pathology is arteriovenous malformation [AVM]. This is 5 case report patients with secondary ICH caused by cerebral AVM

Methods

Case 1; 21 years old male with spastic right hemiparesis, right VII nerve paresis, NCCT show hemorrhage on left parietal lobe, sICH score 5, DSA confirmed arteriovenous malformation on left parietal. Case 2; 26 years old male, spastic right hemiparesis, right VII nerve paresis, NCCT show hemorrhage on left occipital lobe, sICH score 4, DSA confirmed arteriovenous malformation on left temporooccipital. Case 3; 26 years old male with flaccid left hemiplegia, left VII & XII nerve paresis, NCCT show hemorrhage on right temporoparietal lobe, sICH score 5, DSA confirmed arteriovenous malformation on right parietal. Case 4; 26 years old male with central vertigo and limb ataxia, NCCT show hemorrhage on cerebellum, sICH score 5, DSA confirmed arteriovenous malformation on cerebelum. Case 5; 30 years old female with spastic left hemiparesis, left VII & XII nerve paresis, NCCT show hemorrhage on right temporal lobe, sICH score 6, DSA confirmed giant arteriovenous malformation on right temporal.

Results

4 of 5 patient get embolization of the AVM.

Conclusions

This case series described five cases of secondary intracerebral hemorrhage on under 30 years old patient with various location of hemorrhages by NCCT and confirmed AVM by angiography. With the sICH score between 4-6.

Background and Aims

Antiplatelet agents like clopidogrel and aspirin are utilized during the endovascular treatment of cerebral aneurysms to prevent the occurrence of thromboembolic complications. The purpose of this study was to determine the efficiencies of clopidogrel and aspirin for this purpose in cases of ruptured cerebral aneurysm treated by elective coil embolization.

Methods

200 patients received oral clopidogrel (n=100) and aspirin (n=100) 75mg/day for up to six months postoperatively. This retrospective comparative observational study was conducted at the Lahore General Hospital, Lahore, between Feb 2017 and Feb 2020.

Results

At 24 hours post-coiling, significantly fewer high-intensity areas were detected using diffusion-weighted MRI in the aspirin group compared with the clopidogrel cohort. The rate of post-procedural thromboembolic events was lower with aspirin compared to clopidogrel.

Conclusions

The results of this study suggest that aspirin is an effective and well-tolerated antiplatelet agent for use in patients undergoing coil embolization of a ruptured cerebral aneurysm. Previous experience with Clopidogrel suggests that aspirin may offer superior short-term benefits. Aspirin was generally well tolerated with no signs of hemorrhagic complications or liver dysfunction and was associated with fewer surgical complications compared to Clopidogrel as evidenced by MRI findings and a reduced frequency of events.

Background and Aims

Some studies suggested cerebral vascular fenestration is associated with congenital cerebrovascular malformations, for instance intracerebral aneurysm, moyamoya disease, and intracranial arteriovenous malformation. There are also studies showing cerebral artery fenestrations could be associated with cerebral infarction or transient ischemic attack (TIA). In this study, we attempt to explore the clinical relevance between cerebral artery fenestration and other associated vascular diseases.

Methods

We retrospectively analyzed the computed tomography angiography (CTA), magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) imaging data of 76 cases of cerebral artery fenestrations from January 2017 and December 2021 in the Yantai Yuhuangding Hospital Affiliated to Qingdao University. The location, morphology and size of cerebral artery fenestration were described. The association between the cerebral artery fenestration and other vascular diseases were analyzed.

Results

Among the 76 patients, a total of 80 fenestrations were found. Basilar artery fenestration was most common, accounting for 35% (28/80).Nineteen patients had other vascular malformations：10 with aneurysms, 5 with moyamoya diseases and 4 with cerebral artery dissections. Thirty-seven patients had cerebral infarctions, of which sixteen patients had cerebral infarctions in the blood supply area of the arterial fenestration. No acute cerebral infarctions or transient ischemic attack occurred in patients with fenestration-relevant cerebral infarctions who had long-term antiplatelet and statin therapy during follow-up.

Conclusions

we conclude that there is no clinical relevance between fenestration and cerebral infarction, and there is also no clinical relevance between fenestration and aneurysm. For cerebral infarctions patients with cerebral vascular fenestrations, long-term antiplatelet and statin therapy may be safe and effective.

Background and Aims

The aim of this study was to determine the relationship between grades on modified WFNS, WFNS, and Hunt and Hess (H&H) scales and actual outcomes and to compare the accuracy of these scales in predicting the outcomes of aneurysmal SAH patients.

Methods

We performed a multicenter prospective cohort study of aneurysmal SAH patients (≥18 years) presenting to three central hospitals in Hanoi, Vietnam, from August 2019 to June 2021. We calculated OR with a corresponding 95% CI for the poor 90-day outcome for each category in comparison with the lowest category of all scales. AUROCs were calculated to determine the discriminatory ability of the scales for the patient prognosis. We also assessed factors associated with poor 90-day outcomes using multivariate analysis.

Results

Of 415 patients, 32.0% had a poor 90-day outcome. For modified WFNS, OR ranged from 1.566 (0.544-4.509) to 63.476 (24.947-161.511) and it did not increase more evenly than those for both WFNS and H&H. AUROCs were 0.839 (95% CI: 0.795-0.883) for modified WFNS, 0.837 (95% CI: 0.793-0.881) for WFNS, and 0.836 (95% CI: 0.791-0.881) for H&H. In the multivariate analysis, a modified WFNS score of 3 to 5 (OR: 9.353; 95% CI: 3.627-24.118) was independently associated with an increased risk of a poor 90-day outcome.

Conclusions

All three scales had a good discriminatory ability for the prognosis of aneurysmal SAH patients. Unlike WFNS and H&H, modified WFNS score of 3 to 5 was independently associated with an increased risk of poor outcomes, and it, therefore, seems preferable to WFNS and H&H scales.

Background and Aims

Direct carotid-cavernous fistula is an abnormal vascular connection, which allows blood to flow directly from the carotid artery into the cavernous sinus. CCF is commonly accompanied by ophthalmic sign that involved ophthalmic venous reflux. But rare to report a different flow of CCF can present cortical venous reflux which not performed ophthalmic sign.

Methods

We present a case of a 32-year-old man with decreased consciousness, seizures, vomiting, pulsatile tinnitus, a history of chronic headache, without scleral injection or chemosis and double vision in the past. In the cerebral catheter angiography results obtained arterial vein fistula from the right internal carotid artery to the cavernous sinus with the dominant vein draining into the cortical vein (the medial superficial cerebral vein continues to Superior anastomonic vein and the superior sagittal sinus), accompanied by dilatation and elongation of the veins.

Results

Endovascular therapy was performed to close the fistula with detachable balloon embolization modality, resulting 100% occlusion of fistula with good clinical recovery. After 6 months follow up, the position of balloon still close the fistula completely with good clinical condition of patient.

Conclusions

The symptom pattern of CCF depends on flow CCF venous drainage. The goal of CCF treatment is to completely close the fistula while maintaining normal blood flow.

Background and Aims

In brain arteriovenous malformations (AVM) there is mismatched communication between arteries and veins, causing a nidal bed between them. This systematic review explores whether MRA can be used as a diagnostic imaging modality instead of a DSA scan.

Methods

Utilizing PubMed, Cochrane, and Google Scholar, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for article selection, a literature search was conducted over the past five years.

Results

Eleven studies were included, with a majority of the articles suggesting a potential for consideration. Arterial spin labeling (ASL) versus time-of-flight (TOF) scans was a comparison study, in addition to the study on pseudo-continuous arterial spin labeling (pc-ASL), which proved its high sensitivity in comparison with DSA scans. Other studies included quantitative magnetic resonance angiogram (Q-MRA) measuring the blood flow and susceptibility weighted imaging (SWI) modality. Although promising, digital subtraction angiogram (DSA) scans have diagnostic superiority. In addition, articles discussed follow-up magnetic resonance angiogram (MRA) scans after surgery.

Conclusions

Overall, digital subtraction angiogram remains the gold standard due to its superior spatial resolution and hemodynamic properties; these are the key limitations of magnetic resonance studies. MRA has demonstrated its ability to reproduce high-quality diagnostic images for arteriovenous malformation (AVM) angioarchitecture; however, coupled with their limitations, not many studies with large sample sizes over longer periods have been conducted, and we urge more research into it.

Background and Aims

An aneurysm is an abnormal localized dilatation in the wall cerebral blood vessel, usually an artery, that develops as a result of a defect, disease, or injury. The most common form of intracranial aneurysm is a saccular arterial aneurysm, which is a progressive degenerative process involving the arterial wall. ICU is a part of hospital with special staff and equipmen. This research aims to find a complication of clipping aneurysm in ICU.

Methods

This research is a descriptive analysis method. Information was taken from medical record data, including the initial state of the patient on admission, age, sex, aneurysm location and size, the incidence of complications of obstructive hydrocephalus, neurogenic pulmonary edema, electrolyte imbalance, sepsis.

Results

Characteristics of respondents with aneurysm patients are more male (71.4%), age more than 70 years as much as 42.9%. The results also showed that about 85.7% of aneurysm locations were in the middle cerebral artery, 71.5% of medium size aneurysms, 57,1% of complications that were often obstructive hydrocephalus, neurogenic pulmonary edema 28,6 %, electrolyte imbalance 28,6 %, sepsis 14,3 %.

Conclusions

Common aneurysm complications are obstructive hydrocephalus, neurogenic pulmonary edema, electrolyte imbalance and sepsis.

Background and Aims

A complete Circle of Willis (CoW) is essential to maintain a stable hemodynamic of the cerebral circulation. This study aims to analyze the relationship between the anatomical variations of the CoW and the locations of intracranial aneurysms.

Methods

A retrospective cross-sectional study was conducted from October to November 2021 using data obtained from the Indonesia Aneurysm and Cerebral Vessel Registry from January 2017 to January 2020. The cerebral angiography was analyzed for the presence of CoW anatomical variations, intracranial aneurysms, and other vascular pathologies. Ethical clearance was obtained before the study began from the Dr. Soetomo General Hospital Health Research Ethics Committee (ethical clearance no. 0606/LOE/301.4.2/IX/2021). The relationship between CoW anatomical variations and intracranial aneurysm location was analyzed using SPSS.

Results

From a total of 100 data, we observe an anatomical variation of the CoW in 85 patients. The most common variation observed is aplastic Pcom (49%), followed by fetal Pcom (27%), and hypoplastic A1 (24%). We also found a total of 121 intracranial aneurysms, with Acom (23.97%), Pcom (20.66%), and ICA (16.53%) as the most common location. We found a significant correlation between Acom aneurysms with right hypoplastic/aplastic A1 (p<0.001); right Pcom aneurysms with right hypoplastic/aplastic Pcom (p=0.015); left Pcom aneurysms with left fetal Pcom (p=0.003).

Conclusions

Anatomical variation of the CoW is common among patients with intracranial aneurysms. Some anatomical variations of the CoW may contribute to the formation of intracranial aneurysms in certain locations, in accordance with the wall shear stress theory.

Background and Aims

Aneurysm associated arteriovenous malformation (AVM) is a rare condition account for 2.7-16.7%. The untreated aneurysm associated AVM increased risk of rupture 7% per year, compared with patient with isolated AVM (1,7% per year). Endovascular management and stereotactic radiosurgery (SRS) are the treatment options that are commonly used in AVM.

Methods

Case Description

A 23-year-old female with history of AVM and underwent SRS 5 years ago. She never done DSA evaluation, now came with moderate headache and left hemiparesis 5 hours before admission. Computed Tomography Angiography (CTA) showed ruptured narrow neck aneurysm located in draining vein, right after the ganglia basal AVM (intranidal). The parent artery of AVM was occluded with Precipitating Hydrophobic Injectable Liquid (PHIL) embolization, then flow of AVM decreased. Patient showed significant hemiparesis improvement and resolved headache.

Results

Discussion

SRS is expected to obliterate AVM blood flow. However, in large AVMs it could show no significant results and the risk of aneurysm development can still occur. Aneurysm associated AVM can be classified into prenidal, intranidal, and postnidal aneurysm. Intranidal aneurysm is affected by AVM blood flow, so liquid embolization of the AVM can occlude the aneurysm concurrently. PHIL provides better embolic control and occlusion than glue or EVOH. Abrupt hemodynamic changes post endovascular intervention need to be evaluated annually to assess blood flow, size of the nidus and aneurysms as well as evaluation of the feeder arteries and draining veins.

Conclusions

Liquid embolization could be favorable treatment modality for intranidal aneurysm. DSA evaluation should be done regularly on AVM after SRS.

Background and Aims

We aimed to investigate the causality between potentially modifiable risk factors and the risk of intracranial aneurysm.

Methods

Genetic instruments for 51 modifiable factors and intracranial aneurysm data were obtained from recently published genome-wide association studies. We applied two-sample Mendelian randomization methods to investigate their causal relationships.

Results

Genetically predicted cigarettes per day, smoking initiation, systolic blood pressure, hypertension and body fat percentage were significantly associated with an increased risk of intracranial aneurysm (odds ratios (OR) 2.67, 95% confidence interval (CI) 1.75-4.07, p=5.36×10-6, OR 1.53, 95% CI 1.32-1.77, p=9.58×10-9, OR 1.05, 95% CI 1.02-1.08, p=1.18×10-3, OR 1.65, 95% CI 1.19-2.28, p=2.56×10-3 and OR 1.29, 95% CI 1.11-1.52, p=1.33×10-3, respectively). Type 2 diabetes mellitus was significantly associated with a decreased risk of intracranial aneurysm (OR 0.89, 95% CI 0.83-0.95, p=8.54×10-4). Body fat percentage was significantly associated with subarachnoid haemorrhage (p=5.70×10-5).

Conclusions

This study provided genetic evidence of causal effects of smoking, blood pressure, type 2 diabetes mellitus and obesity on the risk of intracranial aneurysm.

Background and Aims

Aneurysmal subarachnoid hemorrhage (aSAH) is the most life-threatening complication of ruptured cerebral aneurysms with high mortality rate.^1,2 The aim of this study was to determine the predictors of in-hospital mortality of aSAH patients.

Methods

We retrospectively reviewed all data from the aneurysm registry of the National Brain Center Hospital Jakarta from January 2019 to June 2022. Demographic, clinical, treatment, and radiological variables of aSAH were analyzed by univariate analysis followed by multivariate logistic regression. Statistical analyzes were performed using STATA Ver.16.0.

Results

Of the 274 total cases; 260 cases of aSAH were identified and 14 cases were excluded due to missing data. Fifty-one patients (19.6%) did not survive during hospitalization. Most subjects were female (66.92%) with a mean age was 55 years old. Multivariate logistic regression analysis showed 5 variables as predictors of aSAH mortality, these included SAH grade (aOR= 2,428; p=0.047), aSAH treatment (coiling aOR=0.380; p=0.045 and clipping aOR=0.091; p=0.181), cardiovascular comorbid (aOR= 2.869; p= 0.039), pneumonia (aOR=8.869; p<0.0001), and respiratory failure (aOR=3.569; p=0.006). Treatment of aSAH was discovered as a protective factor towards mortality in aSAH.

Conclusions

High-grade SAH, respiratory failure, pneumonia, and cardiovascular comorbid were independent factors associated with in-hospital mortality in aSAH whereas aSAH treatment reduced the risk of mortality.

Background and Aims

Approximately 2-3% prevalence of intracranial aneurysm in acute ischemic stroke patients. However, administering recombinant tissue plasminogen activator (rTPA) for ischemic stroke treatment can induce subarachnoid hemorrhage in patients with intracranial aneurysms. Subarachnoid hemorrhage in blister aneurysm after intravenous thrombolysis in ischemic stroke is a rare complication.

Methods

We report a patient with ischemic stroke who developed subarachnoid hemorrhage in blister aneurysm after intravenous thrombolysis.

Results

A 65-year-old female patient was brought to the emergency department with dysarthria followed by weakness on the right side of the body 1 hour before with normal vital signs. She was conscious and obeying commands. Non-contrast computed tomography (CT) of the brain revealed brain atrophy and no evidence of intracerebral hemorrhage. She was diagnosed with ischemic stroke. We decided to administer rTPA (0,9mg/kg). The patient suddenly became unconscious 8 hours after rTPA. Brain CT was repeated and showed subarachnoid hemorrhage in both cerebral and cerebellar hemispheres and lateral intraventricular hemorrhage at the right, left, and 3rd ventricle. Angiography showed a blister aneurysm at the left PCom.

Conclusions

Subarachnoid hemorrhage in blister aneurysm after intravenous thrombolysis is rare, but cannot be ignored. Evaluation of a patient’s vasculature through angiography as an initial screening may be indicated in ischemic stroke patients before thrombolysis.

Background and Aims

PHIL (Precipitating hydrophobic injectable liquid; Microvention, USA) and Squid (Emboflu, Switzerland) are two newer liquid embolic agents used in endovascular embolization of cerebral arteriovenous malformation (AVM). This study aims to investigate and compare the effectiveness and safety profile of the two newer liquid embolic agents in embolization of cerebral AVM.

Methods

This is a retrospective study on all patients diagnosed with cerebral AVM undergoing endovascular embolization with liquid embolic agents PHIL and SQUID admitted to the Division of Neurosurgery, Department of Surgery in Prince of Wales Hospital from January 2014 to June 2021. Functional outcomes, morbidity and mortality were assessed after embolization. Patient demographics, imaging and embolization records were reviewed. Statistical analysis was performed with SPSS^TMVersion 28.0 (IBM Corp., Armonk, New York).

Results

23 patients with cerebral AVM were treated with 34 sessions of endovascular embolization with liquid embolic agents of either PHIL or SQUID (17 sessions each) with male to female ratio of 2.3:1 (male 16; female 7) and mean age of 44.6 (range from 12 to 67). Mean total nidus obliteration rate per session was 57% (range from 5% to 100%). 21 patients (91.3%) received further embolization, stereotactic radiosurgery or surgical excision after initial endovascular embolization. No mortality was recorded. All patients had static or improvement in modified Rankin Scale at 3 to 6 months upon discharge.

Conclusions

PHIL and SQUID are effective and safe liquid embolic agents for cerebral AVM, achieving satisfactory nidal obliteration rate and functional outcomes. This is the first local experience comparing two newer liquid embolic agents.

Background and Aims

To explore the efficacy and safety of ticagrelor in the treatment of unruptured Internal carotid artery aneurysms (ICA) with stent assisted coiling (SAC) and compare it with clopidogrel.

Methods

A total of 144 patients with unruptured internal carotid aneurysm who received stent-assisted embolization therapy from November 2018 to November 2021 were studied, including 68 patients in the ticagrelor group and 76 patients in the clopidogrel group. Efficacy evaluation: Postoperative acute stent thrombosis events were recorded and compared between the two groups. NIHSS score, BI score and mRS scores were taken to evaluate and compare the ischemic stroke events at admission，1 week, 1 month and 3 months after operation among the two groups. Safety assessment: The occurrence of bleeding events (intracranial bleeding, gingival bleeding and other bleeding at any site) within 3 months after operation was recorded and compared among the two groups.

Results

There were 6 cases of acute stent thrombosis in the clopidogrel group and no related events in the ticagrelor group, with significant difference between the two groups (P=0.03, P<0.05). Safety assessment found that the incidence of bleeding events in clopidogrel group (8 cases, 10.5%) was lower than that in ticagrelor group (10 cases, 14.7%), but there was no significant difference (P =0.46, P >0.05). There was 1 case of intracranial hemorrhage among both groups, and there was still no significant difference (P =1.0).

Conclusions

Tigrelol combined with aspirin and can effectively reduce the incidence of acute stent thrombosis and does not increase the risk of intracranial hemorrhage.

Background and Aims

Stem cell-based therapy of stroke is a promising approach, offering hope for preservation of damage brain tissue. There are various ways of cells administration, among which intra-arterial delivery has shown to be one of the most effective and challenging. Technical inaccuracies with intra-arterial transplantation can lead to the development of serious complications, such as thromboembolism. In this study we examine several methodological aspects of intra-arterial catheter placement in rats with experimantal stroke model, including catheter position, maintenance of blood flow around it and possible development of vasospasm after surgery.

Methods

Wistar rats 250-300g were subjected to transient 90min MCAO and after 24h microcatheter was inserted via the ECA into the lumen of the ICA in the direction of blood flow (n=4) or into the CCA (n=44) in the opposite direction of blood flow. After catheter placement experimental animals were transferred into MR-scaner for visualization of the catheter and cerebral arteries.

Results

In the group with the location of the catherer in the ICA in most animals there was no blood flow in the CCA and proximal part of the ICA. Vasospams was observed in both experimental groups. For the group with the location of the catherer in the CCA the following ratio of vasospasm was determined: 41% weak, 41% local and 18% strong.

Conclusions

Placement of the intra-arterial catheter into the CCA reduces the chance of brachiocephalic arteries occlusion and ensures cells administration with maintenance of blood flow. During transplantation, it is worth considering the possibility of angiospasm as a result of endovascular interventions.

Background and Aims

Endovascular treatment for aneurysmal subarachnoid hemorrhage (aSAH) has high fatality and permanent disability rates. It remains unclear how the prognosis is determined by the complex interaction between clinical severity and aneurysm characteristics.

Methods

We utilized a clinically homogenous dataset with 1029 aSAH patients received endovascular treatment to develop prognostic models. Eighteen clinical variables covering patient comorbidities, baseline neurological condition, and aneurysm characteristics were used for the prognostic analysis and model establishment. Considering the imbalance between the favorable and the poor outcomes in this clinical population, both ensemble learning and deep reinforcement learning approaches were used for prediction.

Results

The random forest (RF) model was selected as the best approach for the prognostic prediction for all patients and also for the patients with the good-grade aSAH. Using an independent test sample, the model made accurate predictions (AUC=0.869±0.036, sensitivity=0.709±0.087, specificity=0.805±0.034) with the clinical severity on admission as a leading contributor to the prediction. For the patients with the good-grade aSAH, the RF model performed the best (AUC=0.805±0.034, sensitivity=0.620±0.172, specificity=0.696±0.043) with the aneurysm characteristics as the leading contributor. The classic scoring systems failed in this patient group (AUC<0.600; sensitivity=0.000, specificity=1.000).

Conclusions

The proposed prognostic prediction model outperformed the classic scoring systems for the patients with aSAH after endovascular treatment, especially when the classic scoring systems failed to make any informative prediction for the patients with the good-grade aSAH, who constitute the majority group (79%) of this clinical population.