PURPOSE: To analyze the diagnostic efficacy of computed tomography angiography compared to digital cerebral angiography for the diagnosis of traumatic aneurysms (TAs) associated with combat-related penetrating head injuries and propose the most suitable angiography protocol in this clinical context. METHODS: A retrospective analysis was conducted on patients admitted to the neurosurgical clinic for penetrating traumatic brain injuries between February, 2022 and July, 2024, for whom both cerebral multidetector computed tomography angiography (MCTA) and digital cerebral angiography (DCA) were available. The inclusion were patients (1) with penetrating head injuries, (2) with missile trajectory traverses through the Sylvian or great longitudinal fissure, (3) basal cisterns with/or major subarachnoid hemorrhage. The sensitivity, specificity, positive predictive value, and negative predictive value of MCTA were calculated. DCA was considered as the gold standard of diagnosis. The sensitivity, specificity, positive predictive value, and negative predictive value of MCTA were calculated. Descriptive statistics and nonparametric statistics were used to analyze the study results and their differences, respectively. RESULTS: A total of 40 patients with 45 TAs were included in the study. Of these, 26 patients (65.0%) were found to have aneurysms on MCTA. The median diameter of the aneurysms diagnosed by MCTA was 4.9 (3.6, 4.8) mm (range of 2.5 - 10.4 mm). However, the mean diameter of TAs not detected by MCTA but diagnosed by DCA was (3.0 ± 1.3) mm (range of 1.3 - 4.9 mm). MCTA demonstrated sensitivity and specificity of 35.5% and 99.5%, respectively, with positive and negative predictive values of 92.3% and 90.7%. CONCLUSIONS A low sensitivity of MCTA for the diagnosis of TAs associated with combat-related penetrating head injuries was reported. When MCTA is inconclusive in the setting of radiologic predictors of cerebral artery injury, DSA may be required.
Humans ; Male ; Retrospective Studies ; Adult ; Multidetector Computed Tomography/methods* ; Intracranial Aneurysm/etiology* ; Computed Tomography Angiography/methods* ; Female ; Head Injuries, Penetrating/diagnostic imaging* ; Middle Aged ; Cerebral Angiography/methods* ; Predictive Value of Tests ; Sensitivity and Specificity ; Young Adult

OBJECTIVE: To assess the safety and efficacy of Neuroform Atlas stent used in treatment of unruptured wide-neck intracranial aneurysms. METHODS: Clinical data of 62 patients with unruptured wide-neck intracranial aneurysms undergoing Neuroform Atlas stent-assisted coiling from August 2020 to September 2021 were retrospectively analyzed. There were 64 aneurysms in those 62 patients. Among them, 25 aneurysms were located at the bifurcation of M1 segment on middle cerebral artery, 16 at the anterior communicating artery, 10 at the C7 segment of internal carotid artery, 5 at the C6 segment of internal carotid artery, 4 at the apex of basilar artery, 3 at the A3 segment of anterior cerebral artery, and 1 at the M2 segment of middle cerebral artery. All the patients underwent Neuroform Atlas stent-assisted coiling, including 49 patients with single stent assisted coiling and 15 patients with dual stents assisted coiling (14"Y"style and 1"X"style). After the procedure, the immediate DSA was performed to evaluate the status of aneurysm occlusion and the parent artery patency. The clinical follow-up was performed 3 months after the operation and evaluated based on the modified Rankin Scale(mRS).DSA image was reviewed at 6 months after operation and Raymond grading scale was used to assess the status of aneurysm occlusion and the parent artery patency. RESULTS: A total of 62 patients with 64 aneurysms were all achieved technical success(100%).The immediate post-procedural Raymond scale was assessed, including Raymond Ⅰ in 57 aneurysms(89.1%, 57/64), Raymond Ⅱ in 6 aneurysms(9.3%, 6/64) and Raymond Ⅲ in 1 aneurysm(1.6%, 1/64). The peri-procedural complications rate was 4.8%(3/62), 2 patients developed intraoperative thrombosis and 1 patient suffered from local subarachnoid hemorrhage. Among them, 55 patients obtained 3 months clinical follow-up after operation and all the patients had good outcomes (mRS≤2), 50 patients with 52 aneurysms were followed up with DSA 6 months after operation, including Raymond Ⅰ in 45 aneurysms(86.5%, 45/52), Raymond Ⅱ in 4 aneurysms(7.7%, 4/52) and Raymond Ⅲ in 3 aneurysms(5.8%, 3/52). CONCLUSION Neuroform Atlas stent for the treatment of unruptured wide-neck intracranial aneurysms has high safety and good efficacy, and has its advantages over other traditional stents.
Humans ; Intracranial Aneurysm/etiology* ; Retrospective Studies ; Treatment Outcome ; Embolization, Therapeutic/methods* ; Stents/adverse effects* ; Cerebral Angiography

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*

The traditional classification, diagnosis, and treatment of intracranial aneurysms are based on the characteristics of their vascular lumen. However, in the past few years, some advances in MRI technology with high-resolution imaging can assess the pathology of intracranial vascular walls. Compared with traditional methods of computed tomography angiography, magnetic resonance angiograhpy, and digital subtraction angiography, high resolution magnetic resonance imaging technology can help us to newly understand the disease by directly evaluating the characteristics of vascular wall, such as aneurysm wall thickness, inflammation, enhancement, permeability and hemodynamics. At present, high-resolution magnetic resonance imaging is increasingly used in clinic to assess the rupture risk of intracranial aneurysms, which is of great significance for guiding the diagnosis and treatment of intracranial aneurysms.
Aneurysm, Ruptured/diagnostic imaging* ; Cerebral Angiography ; Humans ; Intracranial Aneurysm/diagnostic imaging* ; Magnetic Resonance Angiography ; Magnetic Resonance Imaging ; Risk Assessment ; Technology

BACKGROUND: The cerebral blood flow velocity (CBFV) and rate pressure product (RPP) have been reported to benefit hemodynamics more during exercise in the recumbent position than during that in the upright position. However, it is unclear which angle is of the greatest benefit to hemodynamics during exercise in the recumbent position. This study aimed to evaluate the effect of the recumbent angle on CBFV and RPP during exercise. METHODS: In a balanced crossover study, 15 healthy volunteers (age, 18.7±1.1 years) were asked to perform the bicycle exercise four times in the upright and at recumbent angles of 67° (R), 47°R, and 15°R, with weekly intervals between each condition. The exercise intensity was set initially at 50 W and increased by 25 W every 2 minutes up to 150 W. CBFV in the middle cerebral artery (MCA) was measured using transcranial doppler sonography. All data were analyzed using two-way repeated-measures analysis of variance. RESULTS: CBFV at 15°R was significantly higher than that in the upright position and at 67°R at 10 minutes recovery (69±16 vs. 56±7 and 58±10 cm/s, respectively; P<0.05). The RPP was significantly lower at 67°R, 47°R, and 15°R than in the upright position immediately after exercise (176±23, 177±22, and 173±26, respectively, vs. 241±42 mmHg×beats/min×10⁻²; P<0.001). CONCLUSIONS: At an angle of less than 67°R, exercise increases CBFV and reduces RPP, relative to those during exercise in the upright position. This hemodynamic effect was most prominent at 15°R, where cerebral circulation was further increased in the recovery phase.
Cerebrovascular Circulation ; Cross-Over Studies ; Healthy Volunteers ; Hemodynamics ; Middle Cerebral Artery ; Posture ; Ultrasonography, Doppler, Transcranial

Subarachnoid hemorrhage (SAH) usually occurs due to aneurysmal rupture of intracranial arteries and its typical computed tomography (CT) findings are increased attenuation of cisterns and subarachnoid spaces. However, several CT findings mimicking SAH are feasible in diverse conditions. They are so-called as pseudo-SAH, and this report is a case of pseudo-SAH which is misdiagnosed as aneurysm rupture accompanied by bilateral chronic subdural hematoma (cSDH). A 42-year-old male with severe headache visited our institute. Non-contrast brain CT images showed increased attenuation on basal cistern, and cSDH on both fronto-temporo-parietal convexity with midline shifting. Trans-femoral cerebral angiography was done and we confirmed small aneurysm at right M1 portion of middle cerebral artery. Under diagnosis of SAH, we planned an operation in order to clip aneurysmal neck and remove cSDH. cSDH was removed as planned, however, there was no SAH and we also couldn't find the rupture point of aneurysm. Serial follow-up CT showed mild cumulative cSDH recurrence, but the patient was tolerant and had no neurologic deficit during hospitalization. We have checked the patient via out-patient department for 6 months, there are no significant changes in volume and density of cSDH and the patient also have no neurologic complications.
Adult ; Aneurysm ; Arteries ; Brain ; Brain Edema ; Cerebral Angiography ; Diagnosis ; Follow-Up Studies ; Headache ; Hematoma, Subdural, Chronic ; Hemorrhage ; Hospitalization ; Humans ; Intracranial Hypertension ; Male ; Middle Cerebral Artery ; Neck ; Neurologic Manifestations ; Outpatients ; Recurrence ; Rupture ; Subarachnoid Hemorrhage ; Subarachnoid Space

PURPOSE: Horizontal visual field defects are generally caused by lesions before the optic chiasm, but we report a case with bilateral inferior altitudinal defects secondary to bilateral occipital lobe infarction. CASE SUMMARY: A 57-year-old male with a history of diabetes and hypertension presented with a month of blurring in the inferior visual field. His corrected visual acuity was 1.0 in the right eye and 0.63 in the left eye, and the intraocular pressure was normal in each eye. Pupillary response, ocular movement, and color vision tests were normal in both eyes. There was no specific finding of the optic disc and macula on fundus examination. Visual field examination revealed an inferior congruous homonymous hemianopia with horizontal meridian sparing and a left incongruous homonymous quadrantanopia. Optical coherence tomography for peripapillary retinal nerve fiber layer thickness revealed a mild decrease in the inferior disc of both eyes. Brain magnetic resonance imaging confirmed the presence of an acute infarction confined with upper medial calcarine fissures of bilateral occipital lobe and the right splenium of the corpus callosum, which were consistent with inferior altitudinal hemianopia and left superior incongruous quadrantanopia, respectively. Brain magnetic resonance angiography showed multiple stenosis of bilateral posterior cerebral arteries. CONCLUSIONS: The altitudinal visual field defects could be caused by the occipital lesion medial to the calcarine fissure, and unusual visual defects could be due to a combination of multiple lesions.
Brain ; Color Vision ; Constriction, Pathologic ; Corpus Callosum ; Hemianopsia ; Humans ; Hypertension ; Infarction ; Infarction, Posterior Cerebral Artery ; Intraocular Pressure ; Magnetic Resonance Angiography ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Nerve Fibers ; Occipital Lobe ; Optic Chiasm ; Posterior Cerebral Artery ; Retinaldehyde ; Tomography, Optical Coherence ; Visual Acuity ; Visual Fields

OBJECTIVE: To determine the correlation between cerebral blood flow (CBF) on arterial spin labeling (ASL) MRI and the degree of postoperative revascularization assessed on digital subtraction angiography in children with moyamoya disease (MMD). MATERIALS AND METHODS: Twenty-one children (9 boys and 12 girls; mean age, 8.4 ± 3.6 years; age range, 3–16 years) with MMD who underwent both pseudocontinuous ASL MRI at 1.5T and catheter angiography before and after superficial temporal artery encephaloduroarteriosynangiosis were included in this retrospective study. The degree of revascularization in the middle cerebral artery (MCA) territory was evaluated on external carotid angiography and was graded on a 3-point scale. On ASL CBF maps, regions of interest were manually drawn over the MCA territory of the operated side at the level of the centrum semi-ovale and over the cerebellum. The normalized CBF (nCBF) was calculated by dividing the CBF of the MCA territory by the CBF of the cerebellum. Changes in nCBFs were calculated by subtracting the preoperative nCBF values from the postoperative nCBF values. The correlation between nCBF changes measured with ASL and the revascularization grade from direct angiography was evaluated. RESULTS: The nCBF value on the operated side increased after the operation (p = 0.001). The higher the degree of revascularization, the greater the nCBF change was: poor revascularization (grade 1), −0.043 ± 0.212; fair revascularization (grade 2), 0.345 ± 0.176; good revascularization (grade 3), 0.453 ± 0.182 (p = 0.005, Jockheere-Terpstra test). The interobserver agreement was excellent for the measured CBF values of the three readers (0.91–0.97). CONCLUSION: The nCBF values of the MCA territory obtained from ASL MRI increased after the revascularization procedure in children with MMD, and the degree of nCBF change showed a significant correlation with the degree of collateral formation evaluated via catheter angiography.
Angiography ; Angiography, Digital Subtraction ; Catheters ; Cerebellum ; Cerebral Revascularization ; Cerebrovascular Circulation ; Child ; Female ; Humans ; Magnetic Resonance Imaging ; Middle Cerebral Artery ; Moyamoya Disease ; Perfusion ; Retrospective Studies ; Temporal Arteries

OBJECTIVE: Coiled aneurysms are known to recanalize over time, making follow-up evaluations mandatory. Although de novo intracranial aneurysms (DNIAs) are occasionally detected during routine patient monitoring, such events have not been thoroughly investigated to date. Herein, we generated estimates of DNIA development during long-term observation of coiled cerebral aneurysms, focusing on incidence and the risk factors involved. MATERIALS AND METHODS: In total, 773 patients undergoing coil embolization of intracranial aneurysms between 2008 and 2010 were reviewed retrospectively. Their medical records and radiologic data accrued over the extended period (mean, 52.7 ± 29.7 months) were analyzed. For the detection of DNIA, follow-up magnetic resonance angiography and/or conventional angiography were used. The incidence of DNIAs and related risk factors were analyzed using Cox proportional hazards regression and Kaplan-Meier product-limit estimator. RESULTS: In 19 (2.5%) of the 773 patients with coiled aneurysms, DNIAs (0.56% per patient-year) developed during continued long-term monitoring (3395.3 patient-years). Of these, 9 DNIAs (47.4%) were detected within 60 months, with 10 (52.6%) emerging thereafter. The most common site involved was the posterior communicating artery (n = 6), followed by the middle cerebral artery (n = 5) and the basilar top (n = 4). Multivariate analysis indicated that younger age (< 50 years) (hazard ratio [HR] = 1.045; p = 0.010) and recanalization of coiled aneurysms (HR = 2.560; p = 0.047) were significant factors in DNIA formation, whereas female sex, smoking, and hypertension fell short of statistical significance. Cumulative survival rates without DNIA were significantly higher in older subjects (> 60 years; p < 0.001) and in the absence of post-coiling aneurysm recurrence (p = 0.006). CONCLUSION: In most patients with coiled aneurysms, development of DNIAs during long-term monitoring is rare. However, younger patients (< 50 years) or patients with recurring aneurysms appear to be predisposed to DNIAs.
Aneurysm ; Angiography ; Arteries ; Embolization, Therapeutic ; Female ; Follow-Up Studies ; Humans ; Hypertension ; Incidence ; Intracranial Aneurysm ; Magnetic Resonance Angiography ; Medical Records ; Middle Cerebral Artery ; Monitoring, Physiologic ; Multivariate Analysis ; Recurrence ; Retrospective Studies ; Risk Factors ; Smoke ; Smoking ; Survival Rate

Direct puncture and embolization of the transverse sinus (TS) for treatment of dural arteriovenous fistula (DAVF) is typically performed with coils with or without glue. We report a case of DAVF at the left TS that was treated with Onyx embolization via direct puncture of the TS. A 75-year-old woman presented with tremor, festinating gait, and dysarthria. A left TS-DAVF with retrograde superior sagittal sinus and cortical venous reflux (Cognard type IIa+b) was identified on cerebral angiography, and both TSs were occluded with thrombi. We considered that achieving complete cure by transvenous embolization via the femoral vein or transarterial embolization via occipital feeders would be difficult. Thus, we performed a small craniotomy at the occipital bone to puncture the TS. The midportion of the TS was directly punctured with a 21-G microneedle under fluoroscopic guidance. We inserted a 5-F sheath into the TS. A microcatheter was then navigated into the affected sinus. Coils were placed through the microcatheter to support Onyx formation by reducing the pressure of shunting flow. Onyx embolization was performed with the same microcatheter. The DAVF was almost completely occluded except for the presence of minimal shunting flow to the proximal TS. After 1 week, time-of-flight magnetic resonance angiography showed complete resolution of DAVF. The patient showed resolved tremor and markedly improved mental status at 1-month follow up. Direct puncture and embolization of the TS using coils and Onyx is effective and feasible method for the treatment of DAVF when other approaches seem difficult.
Adhesives ; Aged ; Central Nervous System Vascular Malformations ; Cerebral Angiography ; Craniotomy ; Dysarthria ; Female ; Femoral Vein ; Follow-Up Studies ; Gait Disorders, Neurologic ; Humans ; Magnetic Resonance Angiography ; Methods ; Occipital Bone ; Punctures ; Superior Sagittal Sinus ; Tremor