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Abstract BACKGROUND Stress is associated with increased risk of stroke and might predispose to presence and rupture of intracranial aneurysms. OBJECTIVE To study the association of recent and lifelong stress with unruptured intracranial aneurysm (UIA) and aneurysmal subarachnoid hemorrhage (ASAH). METHODS In 227 UIA patients (mean age 61 ± 11 yr), 490 ASAH patients (59 ± 11 yr), and 775 controls (51 ± 15 yr) who were randomly retrieved from the general population, we assessed occurrence of major life events and perceived stress during the preceding 12 mo and the entire life. With multivariable logistic regression analysis, we calculated odds ratios (ORs) with 95% confidence intervals (95% CIs) for 4 categories of life events (financial-related, work-related, children-related, and death of family members) and for periods of perceived stress at home and at work (never vs sometimes, often, or always). We adjusted for sex, age, alcohol consumption, smoking, and hypertension. RESULTS The 4 categories of life events and perceived stress at work had ORs ranging from 0.4 to 1.7, of which financial stress for UIA was statistically significant (95% CI: 1.1-2.5). ORs for chronic perceived stress at home in the previous year were 4.3 (95% CI: 1.8-10.3) for UIA and 2.5 (1.2-5.5) for ASAH, and for lifelong exposure 5.7 (2.2-14.5) for UIA and 3.0 (1.3-7.0) for ASAH. CONCLUSION For some components of stress, there may be a relation with UIA and ASAH. The mechanisms underlying this relation should be unraveled; strategies to improve coping with stress may reduce the risk of rupture in patients with unruptured aneurysms.

This prospective study is designed to detect changes in the treatment of ruptured intracranial aneurysms over a period of 17 years. We compared 361 treated cases of aneurysm occlusion after subarachnoid hemorrhage from 1997 to 2003 with 281 cases from 2006 to 2014. Specialists of neuroradiology and vascular neurosurgery decided over the modality assignment. We established a prospective data acquisition in both groups to detect significant differences within a follow-up time of one year. With this setting we evaluated the treatment methods over time and compared endovascular with microsurgical treatment. When compared to the earlier group, microsurgical treatment was less frequently chosen in the more recent collective because of neck-configuration. Endovascular treatment was chosen more frequently over time (31.9% versus 48.8%). Occurrence of initial symptomatic ischemic stroke was significantly lower in the clipping group compared to the endovascular group and remained stable over time. The number of reinterventions due to refilled treated aneurysms significantly decreased in the endovascular group at one-year follow-up, but the significantly better occlusion- and reintervention-rate of the microsurgical group persisted. The rebleeding rate in the endovascular group at one year follow-up decreased from 6.1% to 2.2% and showed no statistically significant difference to the microsurgical group, anymore (endovascular 2.2% versus microsurgical 0.0%, p = 0.11). Microsurgical clipping still has some advantages, however endovascular treatment is improving rapidly.

Abstract BACKGROUND: Microscope integrated intraoperative near-infrared indocyanine green angiography (ICGA) provides assessment of the cerebral vasculature in the operating field. OBJECTIVE: To prospectively compare the value of ICGA-derived information during cerebral aneurysm surgery with data simultaneously generated from other intraoperative monitoring and vascular imaging techniques. METHODS: Data from 104 patients with 123 cerebral aneurysms who were operated on were prospectively recorded. Results of intraoperative vascular monitoring and descriptions of how this information influenced intraoperative decision making were analyzed. RESULTS: Clip repositioning was necessary in 30 of 123 aneurysms (24.4%) treated. Parent artery occlusion was documented by microvascular Doppler ultrasound in 4 aneurysms. ICGA disclosed parent artery stenoses not detected by sonography in 7 cases. Neuroendoscopy was used in 13 cases of midline aneurysms to confirm perforator patency after clipping, and disclosed aneurysm misclipping undetected by ICGA and digital subtraction angiography in 1 aneurysm. The information from DSA and ICGA corresponded in 120 of 123 aneurysms operated on (97.5 %). In 1 patient, ICGA underestimated a relevant parent artery stenosis detected by digital subtraction angiography. In 2 patients with relevant aneurysmal misclipping, digital subtraction angiography and ICGA led to conflicting results that could be clarified only when both methods were used and interpreted together. CONCLUSION: The intraoperative monitoring and vascular imaging methods compared were complementary rather than competitive in nature. None of the devices used were absolutely reliable when used as a stand-alone method. Correct intraoperative assessment of aneurysm occlusion, perforating artery patency, and parent artery reconstruction was possible in all patients when these techniques were used in combination.

To compare the risk of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms by clipping versus coiling. We analyzed 596 patients prospectively added to our database from July of 1999 to November of 2005 concerning the risk of shunt dependency after clipping versus coiling. Factors analyzed included age; sex; Hunt and Hess grade; Fisher grade; acute hydrocephalus; intraventricular hemorrhage; angiographic vasospasm; and number, size, and location of aneurysms. In addition, a meta-analysis of available data from the literature was performed identifying four studies with quantitative data on the frequency of clip, coil, and shunt dependency. The institutional series revealed Hunt and Hess grade, Fisher grade, acute hydrocephalus, intraventricular hemorrhage, and angiographic vasospasm as significant (P < 0.05) risk factors for shunt dependency after a univariate analysis. In a multivariate logistic regression analysis, we isolated intraventricular hemorrhage, acute hydrocephalus, and angiographic vasospasm as independent, significant risk factors for shunt dependency. The meta-analysis, including the current data, revealed a significantly higher risk for shunt dependency after coiling than after clipping (P = 0.01). Clipping of a ruptured aneurysm may be associated with a lower risk for developing shunt dependency, possibly by clot removal. This might influence long-term outcome and surgical decision making.

Background Aneurysmal rebleed is the most dreaded complication following subarachnoid hemorrhage. Being a cause of devastating outcome, the stratification of risk factors can be used to prioritize patients, especially at high volume centers. Method A total of 99 patients with aneurysmal rebleed were analyzed in this study both prospectively and retrospectively from August 2010 to July 2014. In the control group, 100 patients were selected randomly from the patient registry. A total of 25 variables from the demographic, historical, clinical and radiological data were compared and analyzed by univariate and multivariate logistic regression analysis. Results Significant independent predictors of aneurysm rebleed were the presence of known hypertension (p = 0.023), diastolic blood pressure of >90 mmHg on admission (p = 0.008); presence of loss of consciousness (p = 0.013) or seizures (p = 0.002) at first ictus; history of warning headaches (p = 0.005); higher Fisher grade (p < 0.001); presence of multiple aneurysms (p = 0.021); irregular aneurysm surface (0.002). Conclusions Identification of high risk factors can help in stratifying patients in the high risk group. The risk stratification strategy with early intervention can prevent rebleeds. This in turn may translate into better outcomes of patients with intracranial aneurysms.

Background：Nontraumatic spontaneous subarachnoid hemorrhage （SAH） is associated with a high mortality.This study was conducted to investigate the epidemiological features of nontraumatic spontaneous SAH in China.Methods：From January 2006 to December 2008,the clinical data of patients with nontraumatic SAH from 32 major neurosurgical centers of China were evaluated.Emergent digital subtraction angiography （DSA） was performed for the diagnosis of SAH sources in the acute stage of SAH （≤3 days）.The results and complications of emergent DSA were analyzed.Repeated DSA or computed tomography angiography （CTA） was suggested 2 weeks later if initial angiographic result was negative.Results：A total of 2562 patients were enrolled,including 81.4% of aneurysmal SAH and 18.6% of nonaneurysmal SAH.The total complication rate of emergent DSA was 3.9% without any mortality.Among the patients with aneurysmal SAH,321 cases （15.4%） had multiple aneurysms,and a total of 2435 aneurysms were detected.The aneurysms mostly originated from the anterior communicating artery （30.1%）,posterior commtmicating artery （28.7%）,and middle cerebral artery （15.9%）.Among the nonaneurysmal SAH cases,76.5% （n =365） had negative initial DSA,including 62 cases with peri-mesencephalic nonaneurysmal SAH （PNSAH）.Repeated DSA or CTA was performed in 252 patients with negative initial DSA,including 45 PNSAH cases.Among them,the repeated angiographic results remained negative in 45 PNSAH cases,but 28 （13.5%） intracranial aneurysms were detected in the remaining 207 cases.In addition,brain arteriovenous malformation （AVM,7.5%）,Moyamoya disease （7.3%）,stenosis or sclerosis of the cerebral artery （2.7%）,and dural arteriovenous fistula or carotid cavernous fistula （2.3%） were the major causes of nonaneurysmal SAH.Conclusions：DSA can be performed safely for pathological diagnosis in the acute stage of SAH.Ruptured intracranial aneurysms,AVM,and Moyamoya disease are the major causes of SAH detected by emergent DSA in China.

Introduction Endovascular treatment of cerebral aneurysms includes follow-up imaging to identify aneurysms that may need retreatment. The aim of this study was to determine predictors of incomplete aneurysm occlusion at 1 year after endovascular coiling for ruptured cerebral aneurysms. Methods In 129 patients of the Prospective Registry of Subarachnoid Aneurysms Treatment cohort, ruptured aneurysms were coiled within 14 days of onset and both initial post-coiling and 1-year follow-up digital subtraction angiography or magnetic resonance angiography were obtained. Factors predicting 1-year incomplete aneurysm occlusion (retreatment within 1-year or residual aneurysms at 1 year) were determined using multivariate logistic regression analyses. Results One-year incomplete aneurysm occlusion was identified in 59 patients, including ten patients who were retreated within 1-year post-coiling. Dome size ≥7.5 mm ( P  = 0.007, odds ratio (OR) = 5.00, 95% confidence interval (CI) = 1.55–16.15), pre-treatment aneurysm re-rupture ( P  = 0.023, OR = 3.50, 95% CI = 1.19–10.31), non-small size/small neck aneurysm (dome size, ≥10 mm or neck size, ≥4 mm; P  = 0.022, OR = 3.26, 95% CI = 1.19–8.96), and residual aneurysms on immediate post-coiling angiograms ( P  = 0.017, OR = 1.43, 95% CI = 1.07–1.93) significantly predicted incomplete aneurysm occlusion at 1-year post-coiling. Conclusions In addition to the characteristics of aneurysm and initially incomplete aneurysm occlusion, this study showed pre-treatment aneurysm re-rupture to be a predictor that favors closer imaging follow-ups for coiled aneurysms.

Background Aneurysmal subarachnoid hemorrhage (aSAH) is a neurologic emergency that typically warrants initial monitoring in a critical care setting. The aim of this study is to identify clinical and radiologic features on admission that predict a protracted critical care admission following aSAH. Methods Exploratory posthoc analysis was performed on the 413 patients enrolled in Clazosentan to Overcome Neurological iSChemia and Infarction OccUrring after Subarachnoid hemorrhage (CONSCIOUS-1), a prospective randomized control trial of clazosentan for the prevention of vasospasm after aSAH. The association between potential clinical and radiographic covariates, and the length of stay (LOS) in a critical care unit after aSAH was determined using a Cox proportional hazards model. Covariates with a significance level of p  < 0.20, on univariate analysis, were entered into a multivariate forward conditional analysis to identify independent predictors of prolonged LOS. Results The mean LOS was 12.6 ± 10.6 days. On multivariate analysis, age (hazard ratio [HR] 1.01, 95 % confidence interval [CI] 1.00–1.02; p  = 0.032), a history of hypertension (HR 1.30, CI 1.01–1.67; p  = 0.045), and a World Federation of Neurosurgical Societies Score of IV–V on admission (HR 1.38, CI 1.05–1.81; p  = 0.02) were the clinical features associated with a greater critical care LOS following aSAH. Intracerebral hemorrhage (HR 1.50, CI 1.03–2.21; p  = 0.004) and increasing intraventricular clot burden (HR 1.08, CI 1.03–1.14; p  = 0.037) on admission computed tomography were the radiologic features associated with prolonged LOS. Conclusions We have identified several early risk factors associated with a prolonged critical care stay following aSAH.

The decision of whether to treat incidental intracranial saccular aneurysms is complicated by limitations in current knowledge of their natural history. We combined individual patient data from prospective cohort studies to determine predictors of aneurysm rupture and to construct a risk prediction chart to estimate 5-year aneurysm rupture risk by risk factor status. We did a systematic review and pooled analysis of individual patient data from 8382 participants in six prospective cohort studies with subarachnoid haemorrhage as outcome. We analysed cumulative rupture rates with Kaplan-Meier curves and assessed predictors with Cox proportional-hazard regression analysis. Rupture occurred in 230 patients during 29 166 person-years of follow-up. The mean observed 1-year risk of aneurysm rupture was 1·4% (95% CI 1·1–1·6) and the 5-year risk was 3·4% (2·9–4·0). Predictors were age, hypertension, history of subarachnoid haemorrhage, aneurysm size, aneurysm location, and geographical region. In study populations from North America and European countries other than Finland, the estimated 5-year absolute risk of aneurysm rupture ranged from 0·25% in individuals younger than 70 years without vascular risk factors with a small-sized (<7 mm) internal carotid artery aneurysm, to more than 15% in patients aged 70 years or older with hypertension, a history of subarachnoid haemorrhage, and a giant-sized (>20 mm) posterior circulation aneurysm. By comparison with populations from North America and European countries other than Finland, Finnish people had a 3·6-times increased risk of aneurysm rupture and Japanese people a 2·8-times increased risk. The PHASES score is an easily applicable aid for prediction of the risk of rupture of incidental intracranial aneurysms. Netherlands Organisation for Health Research and Development.

Intracranial saccular or berry aneurysms are common, occurring in about 1–2% of the population. Unruptured intracranial aneurysms are increasingly being detected as cross-sectional imaging techniques are used more frequently in clinical practice. Once an unruptured intracranial aneurysm is detected, decisions regarding optimum management are made on the basis of careful comparison of the short-term and long-term risks of aneurysmal rupture with the risk associated with the intervention, whether that be surgical clipping or endovascular management. Several factors need to be carefully considered, including aneurysm size and location, the patient's family history and medical history, and the availability of an interventional option that has an acceptable risk. The patient's knowledge that they have an unruptured intracranial aneurysm can lead to substantial stress and anxiety, and their perspective regarding treatment, after hearing an unbiased appraisal of the rupture risks and the risk of interventional treatment, is of the utmost importance. Controversy remains regarding optimum management, and thorough assessments of the risks and benefits of contemporary management options, specific to aneurysm size, location, and many other aneurysm and patient factors, are needed.