In recent years, in the absence of venous component, dilated, overlapping, and tortuous arteries forming a mass of arterial loops with a coil-like appearance have been defined as pure arterial malformation (PAM). It is extremely rare, and its etiology and treatment have not yet been fully elucidated. Here, we reported 2 cases of PAM with associated aneurysmal subarachnoid hemorrhage in this paper. Both patients had severe headache as the first symptom. Subarachnoid hemorrhage was found by CT and computed tomography angiography (CTA) and PAM with associated aneurysm was found by digital subtraction angiography (DSA). In view of the distribution of blood and the location of aneurysms, the aneurysm rupture was the most likely to be considered. Based on the involvement of the lesion in the distal blood supply, only the aneurysm was clamped during the operation. It used to be consider that PAM is safety, because of the presentation and natural history of previously reported cases. Through the cases we reported, we have doubted about "the benign natural history" and discussed its treatment. PAM can promote the formation of aneurysms and should be reviewed regularly. The surgical indications for PAM patients with aneurysm formation need to be further clarified. Management of PAM patients with ruptured aneurysm is the same as that of ruptured aneurysm. Whether there are indications needed to treat simple arterial malformations remains to be further elucidated with the multicenter, randomized controlled studies on this disease.
Aneurysm, Ruptured/surgery* ; Angiography, Digital Subtraction ; Cerebral Angiography ; Humans ; Intracranial Aneurysm/surgery* ; Subarachnoid Hemorrhage/etiology*

Adult ; Aneurysm, Ruptured ; diagnostic imaging ; surgery ; Computed Tomography Angiography ; Embolization, Therapeutic ; methods ; Endovascular Procedures ; methods ; Female ; Humans ; Intracranial Aneurysm ; diagnostic imaging ; surgery

OBJECTIVETo discuss the surgical strategies and analyze the clinical outcomes of multiple intracranial aneurysms (MIA).

METHODSThe clinical data of 49 MIA patients surgically treated between January 2009 and December 2013 was analyzed retrospectively. Among the 49 patients, 12 patients were male and 37 were female, mean age (49 ± 11) years. Thirty-five patients had ruptured aneurysms, and 14 had unruptured aneurysms. Treatment strategies included one-stage operation (MIA were treated in one-stage with an unilateral approach), two-stage treatment (MIA were treated stage by stage) and partial treatment (only ruptured aneurysm was treated). Postoperative CT angiograms (CTA) or digital subtraction angiograms (DSA) were reviewed and the Glasgow Outcome Scale (GOS) scores were evaluated during follow-up period.

RESULTSThirty-two patients (65.3%) underwent one-stage operation, 9 patients (18.4%) underwent two-stage treatment, and 8 patients (16.3%) underwent partial treatment. Forty-seven patients were followed up 4-49 months, mean (22 ± 7) months. Postoperative CTA or DSA showed no aneurysm recurrence. According to the GOS scores, 41 patients (83.7%) with good outcomes (GOS 4, 5), 6 patients (12.2%) were disabled (GOS 2, 3) and 2 patients (4.1%) were dead (GOS 1).

CONCLUSIONSelecting the right patients for surgery and making personalized surgical strategies based on the characteristics of patients and aneurysms could improve the surgical outcomes of MIA.

Adult ; Aneurysm, Ruptured ; surgery ; Cerebral Angiography ; Female ; Humans ; Intracranial Aneurysm ; surgery ; Male ; Middle Aged ; Patient Selection ; Prospective Studies ; Recurrence ; Retrospective Studies ; Vascular Surgical Procedures ; methods

PURPOSE: The operative risk and natural history rupture risk for the treatment of unruptured intracranial aneurysms (UIAs) should be evaluated. The purpose of this study was to report our experience with treating UIAs and to outline clinical risk factors associated with procedure-related major neurological complications. MATERIALS AND METHODS: We treated 1158 UIAs in 998 patients over the last 14 years. All patients underwent operation performed by a single microvascular surgeon and two interventionists at a single institution. Patient factors, aneurysm factors, and clinical outcomes were analyzed in relation to procedure-related complications. RESULTS: The total complication rate was 22 (2.2%) out of 998 patients. Among them, complications developed in 14 (2.3%) out of 612 patients who underwent microsurgery and in 8 (2.1%) out of 386 patients who underwent endovascular procedures. One patient died due to intraoperative rupture during an endovascular procedure. The procedure-related complication was highly correlated with age (p=0.004), hypertension (p=0.002), and history of ischemic stroke (p<0.001) in univariate analysis. The multivariate analysis revealed previous history of ischemic stroke (p=0.001) to be strongly correlated with procedure-related complications. CONCLUSION: A history of ischemic stroke was strongly correlated with procedure-related major neurological complications when treating UIAs. Accordingly, patients with UIAs who have a previous history of ischemic stroke might be at risk of procedure-related major neurological complications.
Aged ; Aneurysm, Ruptured ; Endovascular Procedures/*methods ; Female ; Humans ; Intracranial Aneurysm/epidemiology/*surgery ; Male ; Microsurgery ; Middle Aged ; Nervous System Diseases ; Neurosurgical Procedures ; Postoperative Complications/*epidemiology ; Risk ; Risk Assessment ; Risk Factors ; Treatment Outcome

OBJECTIVETo evaluate the short-term outcome of single stenting technique for unruptured, wide-necked, tiny aneurysms of the anterior circulation.

METHODSEleven unruptured, wide-necked, tiny aneurysms of the anterior circulation were treated by a single stent deployed in the parent artery between January 2008 and July 2013 in Department of Neurosurgery in Beijing Hospital. The maximum diameter of the aneurysms ranged from 2.0 to 3.0 mm, mean (2.4 ± 0.4) mm, and the dome-to-neck ratios were all ≤ 1.2. The locations were clinoid segment of internal carotid artery (n=2), posterior communicating artery origin (n=4), anterior choroidal artery origin (n=2) and middle cerebral artery bifurcation (n=3). All internal carotid aneurysms were located in the medial and/or ventral wall of the internal carotid artery. The rate of aneurysm obliteration and rupture during follow-up was obtained by repeat angiography and clinic or telephone interview respectively.

RESULTSSole stent placement in the parent artery was intentionally performed for nine aneurysms, while attempt of coiling after stent deployment for the other two aneurysms failed due to unsuccessful microcatherization. Ten stents were successfully deployed, of which one was used to treat two tandem lesions simultaneously. Only one aneurysm became smaller immediately postprocedure. No perioperative complications occurred. Angiographic follow-up after a mean period of (13 ± 6) months (range 8-24 months) revealed that 8 aneurysms did no change in size, 2 became smaller and only one was totally occluded. Asymptomatic in-stent stenosis of the parent artery was found in all 3 shrinking or occluded aneurysms. No aneurysm rupture was observed in the clinical follow-up.

CONCLUSIONFor those unruptured, wide-necked, tiny aneurysms arising at branching sites in the anterior circulation, single stenting technique seems to be a safe alternative treatment, while the short-term rate of aneurysm occlusion is low.

Aneurysm, Ruptured ; Beijing ; Cardiovascular Surgical Procedures ; methods ; Carotid Artery Diseases ; surgery ; Carotid Artery, Internal ; pathology ; Cerebral Angiography ; Constriction, Pathologic ; Humans ; Intracranial Aneurysm ; surgery ; Stents ; Treatment Outcome

A 28-year-old female patient was admitted to the Second Affiliated Hospital, Zhejiang University School of Medicine, with sudden headache and vomiting for 1 day. CT scan conducted at emergency revealed subarachnoid hemorrhage, whereas digital subtraction angiography demonstrated a wide-neck aneurysm located at A1 segment of the left anterior cerebral artery. The aneurysm was totally coiled using stent assistance, which, however, was recanalized at 3 month follow-up. This patient was then subjected to aneurysm and parent artery occlusion after bypass of the bilateral A3 segments, who recovered well and discharged without ischemic complications.
Adult ; Anastomosis, Surgical ; Aneurysm, Ruptured ; surgery ; Angiography, Digital Subtraction ; Anterior Cerebral Artery ; surgery ; Female ; Humans ; Intracranial Aneurysm ; surgery ; Recurrence ; Stents ; Subarachnoid Hemorrhage ; surgery ; Tomography, X-Ray Computed

OBJECTIVETo evaluate the efficacy of the surgery with lateral supraorbital approach for clipping anterior circulation aneurysms.

METHODSThe clinical data of 99 patients with anterior circulation aneurysms who underwent a clipping via lateral supraorbital approach from October 2012 to September 2014 and 75 patients, who underwent a clipping via pterional approach from January 2010 to December 2011 in the second Affiliated Hospital, Zhejiang University School of Medicine were reviewed. The operative duration, prognosis, residual rate and rupture rate during surgery were compared between two groups.

RESULTSThe patients by lateral supraorbital approach had a shorter operative duration, namely 37~61 min less than that in the patients by pterional approach. No difference were found in residual rate and rupture rate between two groups. The Glasgow Outcome Scale (GOS) at 3 months after surgery showed no significant difference between two groups.

CONCLUSIONThe lateral supraorbital approach can be used safely and effectively with shorter operative duration and less tissue damage for treatment of patients with anterior circulation aneurysms.

Aneurysm, Ruptured ; surgery ; Glasgow Outcome Scale ; Humans ; Intracranial Aneurysm ; surgery ; Neurosurgical Procedures ; methods

OBJECTIVETo review the surgical modality with pterional keyhole approach in treatment of anterior circulation aneurysm.

METHODSThree hundred and thirteen patients with ruptured anterior circulation intracranial aneurysm treated surgically with pterional keyhole approach between January 2009 and June 2014 in Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, were included in the analysis. Complete occlusion rate of aneurysms and incidence of major complications including delayed cerebral ischemia and chronic hydrocephalus were documented. Surgical outcomes at 6-month follow up were assessed by modified Rankin Scale.

RESULTSTotally 348 aneurysms were treated with pterional keyhole approach, 326 aneurysms were completely clipped, 16 aneurysms were partly clipped, and 6 aneurysms were wrapped with gauze material. Among 313 patients, 15 patients (4.79%) suffered from delayed cerebral ischemia, and 10 patients (3.19%) suffered from hydrocephalus. At the 6-month follow up, the rate of good outcome was 66.77% (209/313).

CONCLUSIONSThe pterional keyhole approach can be used to clip most of anterior circulation aneurysms, and it seems to have advantages over the traditional approaches with lower incidence of complications and similar outcomes.

Aneurysm, Ruptured ; surgery ; Humans ; Intracranial Aneurysm ; surgery ; Neurosurgical Procedures ; methods ; Retrospective Studies ; Treatment Outcome

OBJECTIVETo investigate risk factors for the occurrence of shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODSA cohort of 136 consecutive patients who were treated for ruptured aneurysms within 72 h after onset of aSAH from January 2011 to January 2013 were retrospectively analyzed. Lumbar drainage was performed during the surgery in all patients. The risk factors of shunt-dependent hydrocephalus were analyzed.

RESULTSOf 136 patients, 23 (16.91%) underwent shunt operation to treat shunt-dependent hydrocephalus. Univariate analysis showed that Hunt-Hess grade at admission (P<0.01), Fisher grade (P<0.01), the presence of intraventricular hemorrhage (P<0.01), location of ruptured aneurysm (P=0.001), and the average daily volume of cerebrospinal fluid drainage (CSF) (P=0.047) were associated with shunt-dependent hydrocephalus.

CONCLUSIONThe aSAH patients with poor Hunt-Hess grade at admission, high Fisher grade, the presence of intraventricular hemorrhage, ruptured aneurysm in posterior circulation, and abnormal average daily volume of CSF are more likely to develop shunt-depended hydrocephalus.

Adult ; Aged ; Aneurysm, Ruptured ; complications ; Arteriovenous Shunt, Surgical ; adverse effects ; Female ; Humans ; Hydrocephalus ; etiology ; prevention & control ; Intracranial Aneurysm ; complications ; Male ; Middle Aged ; Retrospective Studies ; Risk Factors ; Subarachnoid Hemorrhage ; etiology ; surgery

OBJECTIVETo evaluate the effect of aneurysm clipping and partial blood clot removal in the subarachnoid space on hemorrhage volume in the subarachnoid space and cerebral vasospasm in patients with different Fisher grades.

METHODSPatients with subarachnoid space hemorrhage (SAH) of Fisher Grades I, II, and III were subdivided into control and treatment groups for comparative studies. The patients with unruptured intracranial aneurysms (UIAs) undergoing aneurysm clipping were also compared with Fisher grade I control subgroup. OxyHb levels in the cerebrospinal fluid and cerebral blood flow volume (CBFV) of the middle cerebral artery (MCA) were measured on days 3, 7, and 13 day after SAH.

RESULTSThe patients with UIAs and Fisher Grade I control subgroup showed significant differences in OxyHb levels on day 3 in CBFV of the MCA on days 3 and 7 (P<0.05). In the SAH groups, OxyHb levels increased significantly on day 3 day in the treatment subgroups of Fisher Grades I and II, but declined significantly on days 7 and 13 in Fisher Grade III treatment subgroup as compared with the corresponding control subgroups (P<0.05); in Fisher Grade I group on days 3 and 7 and in Fisher Grade II group on day 7, CBFV of the MCA increased significantly in the treatment subgroups, but in Fisher Grade III group, CBFV decreased significantly on days 7 and 13 compared with the control subgroup (P<0.05). A positive correlation was found between OxyHb levels in the cerebrospinal fluid and CBFV of the MCA (P<0.05).

CONCLUSIONFor patients with Fisher Grades I and II aneurysms, craniotomy may increase hemorrhage volume in the subarachnoid space and exacerbate cerebral vasospasm, but for Grade III patients, aneurysm clipping and blood clot removal shows beneficial effects in terms of reducing hemorrhage volume and relieving cerebral vasospasm.

Aged ; Aneurysm, Ruptured ; surgery ; Female ; Humans ; Intracranial Aneurysm ; surgery ; Male ; Middle Aged ; Subarachnoid Hemorrhage ; cerebrospinal fluid ; surgery ; Vasospasm, Intracranial ; surgery