The influence of morphological characteristics of intracranial aneurysms in rupture risk assessment using three dimensional digital subtraction angiography

Intrakranijalne aneurizme su lokalna proširenja moždanih arterija i prema podacima iz literature 2-5% populacije ima aneurizmu na nekom od intrakranijalnih krvnih sudova. Procenjuje se da će u toku života prokrvariti 15-20% ovih aneurizmi. Oko 30-40% bolesnika umire neposredno po rupturi, a od onih koji prežive i budu tretirani u specijalizovanoj neurohirurškoj ustanovi, samo trećina se potpuno oporavi, trećina ostane sa lakšim ili težim posledicama, a kod preostale trećine pacijenata lečenje se ipak završi letalnim ishodom. Rizik za rerupturu netretirane aneurizme iznosi 50% u prvih šest meseci, a potom do 3% godišnje. Do sada je nekoliko socio-demografskih, kliničkih, ali i morfoloških parametara pokazano kao povezano sa rupturom intrakranijalnih aneurizmi. Razvojem savremenih dijagnostičkih procedura i njihovom većom dostupnošću, analiza morfoloških karakteristika intrakranijalnih aneurizmi radi procene rizika od rupture se sve češće koristi. U dosadašnjim većim studijama pokazano je da su veličina aneurizme i lokalizacija aneurizme najčešće povezane sa rizikom za rupturu. Ove dve karakteristike se tako najšire koriste u proceni rizika za rupturu intrakranijalnih aneurizmi. Pokazano je da aneurizme manje od 5 mm ređe rupturiraju, a da je rizik za rupturu najveći kod aneurizmi veličine preko 7 mm. Aneurizme lokalizovane na račvama velikih intrakranijalnih krvnih sudova, naročito srednje velikomoždane arterije, prednje komunikantne arterije i bazilarne arterije, su češće povezivane sa većim rizikom za rupturu. Ipak, nekoliko kompleksnijih izvedenih morfoloških parametara koji uzimaju u obzir odnos veličine aneurizme i vrata aneurizme, odnos veličine aneurizme i matičnog krvnog suda, kao i uticaj smera toka krvne struje, su se pokazali kao mnogo značajniji i precizniji u proceni rizika od rupture u odnosu na samo veličinu i lokalizaciju aneurizme. Određivanje morfoloških karakteristika intrakranijalnih aneurizmi kao prediktora rupture je od izuzetnog značaja, kako sa dijagnostičkog, tako i sa terapijskog stanovišta. Ova saznanja bi imala veliku praktičnu vrednost jer bi se na taj način odredila upravo ona grupa pacijenata kojima je potreban sveobuhvatan pristup. Protokoli bazirani na dobroj kliničkoj praksi i referentnim studijama mogu značajno da doprinesu adekvatnom lečenju i savetovanju ovih pacijenata. MATERIJAL I METODE Ovo je studija slučajeva i kontrola kojom su obuhvaćeni svi pacijenti kojima je u petogodišnjem periodu, od januara 2016. godine do decembra 2020. godine, urađena trodimenzionalna digitalna suptrakciona angiografija na Odseku invazivne i interventne neuroradiologije Univerzitetskog Kliničkog centra Srbije i tom prilikom dijagnostikovana ili potvrđena intrakranijalna aneurizma. Pacijenti su podeljeni u dve grupe: pacijenti sa krvarećim i pacijenti sa nekrvarećim aneurizmama. Nakon primene kriterijuma studije, 604 pacijenata (316 sa krvarećim aneurizmama i 288 sa nekrvarećim aneurizmama) sa 818 aneurizmi (318 rupturiranih i 500 nerupturiranih) je uključeno u studiju. Iz medicinskih istorija bolesti analizirane su demografske i kliničke karakteristike pacijenata, a morfološki parametri mereni na trodimenzionalnoj digitalnoj suptrakcionoj angiografiji uključuju 13 varijabli. Svi dobijeni podaci su potom statistički obrađeni i analizirani...Intracranial aneurysms are pathological dilatations of cerebral arteries. They are present in 2-5% of the general population, and it is estimated that 15-20% of them will rupture during lifetime. About 30-40% of patients die immediately after the rupture, and of those who survive and are treated in a specialized neurosurgical institution, only 1/3 recover completely, 1/3 remain with mild or severe deficits, and the remaining third of patients have a lethal outcome. The risk of a new rupture is 50% in the first six months followed by an increase of 3% for every year. So far, several socio-demographic, clinical, and morphological parameters have shown to be associated with rupture of intracranial aneurysms. With the development of novel diagnostic procedures and their greater availability, the analysis of morphological characteristics of intracranial aneurysms in order to assess the risk of rupture is increasingly used. Studies showed that the size of the aneurysm and the location of the aneurysm are most often associated with the risk of rupture. These two characteristics are thus most widely used in assessing the risk of aneurysm rupture. Aneurysms smaller than 5 mm are less likely to rupture, and the risk of rupture is greatest with aneurysms larger than 7 mm. Aneurysms located at the bifurcations of large intracranial vessels, especially the middle cerebral artery, anterior communicating artery and basilar artery are most often associated with a higher risk of rupture. However, several more complex derived morphological parameters that take into account the aneurysm-to-neck size ratio, the aneurysm-to-parent vessel size ratio, and the influence of blood flow direction, have proven to be much more significant and accurate in rupture risk assessment than only the size and location of the aneurysm. Thus, knowledge of risk factors for rupture is crucial for counseling and managing patients with intracranial aneurysms. Protocols based on good clinical practice, knowledge and reference studies can significantly contribute to adequate treatment and management of these patients. MATERIAL AND METHODS This is a case-control study that included all patients who underwent three-dimensional digital subtraction angiography in the five-year period, from January 2016 to December 2020, at the Department of Interventional Neuroradiology of the University Clinical Center of Serbia, and were diagnosed with intracranial aneurysms. Patients were divided into two groups: patients with bleeding and patients with non-bleeding aneurysms. Following the application of the study criteria, 604 patients (316 with bleeding and 288 with non-bleeding aneurysms) with 818 aneurysms (318 ruptured and 500 non-ruptured) were included in the study. From the medical records, the demographic and clinical characteristics of the patients were analyzed. The morphological parameters were measured on three-dimensional digital subtraction angiography and included 13 variables. All obtained data were statistically processed and analyzed..

Povezanost kliničkih karakteristika i morfoloških parametara s rupturom aneurizme prednje komunikacijske arterije

We analyzed aneurysm morphology, demographic and clinical characteristics in patients with anterior communicating artery (ACoA) aneurysms to investigate the risk factors contributing to aneurysm rupture. A total of 219 patients with ACoA aneurysms were admitted to our hospital between January 2016 and December 2020, and morphological and clinical characteristics were analyzed retrospectively in 153 patients (112 ruptured and 41 unruptured). Medical records were reviewed to obtain demographic and clinical data on age, gender, presence of hemorrhage, history of hypertension, diabetes, heart disease, and kidney disease. Morphological parameters examined on 3-dimensional digital subtraction angiography included aneurysm size, neck diameter, aspect ratio, size ratio, bottleneck ratio, height/width ratio, aneurysm angle, (in)flow angle, branching angle, number of aneurysms per patient, shape of the aneurysm, aneurysm wall morphology, variation of the A1 segment, and direction of the aneurysm. Male gender, aspect ratio, height/width ratio, non-spherical and irregular shape were associated with higher odds of rupture, whilst controlled hypertension was associated with lower odds of rupture, when tested using univariate logistic regression model. In multivariate model, controlled hypertension, presence of multiple aneurysms, and larger neck diameter reduced the odds of rupture, while irregular wall morphology increased the risk of rupture. Regulated hypertension represented a significant protective factor from ACoA aneurysm rupture. We found that ACoA aneurysms in male patients and those with greater aspect ratios and height/width ratios, larger aneurysm angles, presence of daughter sacs and irregular and non-spherical shapes were at a higher risk of rupture.Analizirali smo morfologiju aneurizme, demografske i kliničke karakteristike u bolesnika s aneurizmom prednje komunikacijske arterije (ACoA) kako bismo istražili čimbenike rizika koji doprinose rupturi aneurizme. Ukupno je 219 bolesnika s aneurizmom ACoA primljeno u našu bolnicu u razdoblju od siječnja 2016. do prosinca 2020. godine, a morfološke i kliničke karakteristike analizirane su retrospektivno u 153 bolesnika (112 puknutih i 41 neprekinuta). Pregledani su medicinski zapisi kako bi se dobili demografski i klinički podaci za dob, spol, prisutnost krvarenja, povijest hipertenzije, dijabetes, srčane bolesti i bolesti bubrega. Morfološki parametri ispitani na trodimenzionalnoj digitalnoj subtrakcijskoj angiografiji uključivali su veličinu aneurizme, promjer vrata, odnos između normalne visine aneurizme i širine vrata aneurizme (aspect ratio), odnos između visine aneurizme i prosječnog promjera svih krvnih žila povezanih s aneurizmom (size ratio), odnos između širine fundusa aneurizme i širine vrata aneurizme (bottleneck ratio), odnos između najveće normalne visine aneurizme i širine aneurizme (height/width ratio), kut aneurizme, ugao ulaska tijeka krvne struje u fundus aneurizme (inflow angle), kut grananja, broj aneurizma po bolesniku, oblik aneurizme, morfologiju stijenke aneurizme, varijaciju segmenta A1 i smjer aneurizme. Muški spol, odnos između normalne visine aneurizme i širine vrata aneurizme, odnos između najveće normalne visine aneurizme i širine aneurizme, nesferičan i nepravilan oblik bili su povezani s većim izgledima za puknuće, dok je kontrolirana hipertenzija bila povezana s manjom vjerojatnosti puknuća kada je testirano primjenom modela s univarijatnom logističkom regresijom. U multivarijatnom modelu su kontrolirana hipertenzija, prisutnost više aneurizma i veći promjer vrata smanjili izglede za puknuće, dok je nepravilna morfologija stijenke povećala rizik od puknuća. Regulirana hipertenzija predstavlja značajan zaštitni čimbenik od pucanja aneurizme ACoA. Utvrdili smo da su aneurizme ACoA u muških bolesnika i one s većim odnosom između normalne visine aneurizme i širine vrata aneurizme te one s većim odnosom između najveće normalne visine aneurizme i širine aneurizme, većim kutovima aneurizme, prisutnošću kćeri vrećica te nepravilnim i nesferičnim oblicima u većem riziku od puknuća

Razvojna venska anomalija kao drenažna vena arteriovenske malformacije mozga

Developmental venous anomalies are cerebral vascular malformations that present normal venous drainage of cerebral tissue. With increased and accessible usage of modern diagnostic tools, they are now one of the most commonly diagnosed cerebral vascular malformations. Although developmental venous anomalies are considered to be benign lesions, association with arteriovenous malformation renders malignant potential to this combined pathology. In the case presented, these malformations were clinically silent and diagnosed accidentally, so they were not treated either with surgery, endovascular surgery or radiosurgery, considering the possible complications such as venous infarction of the brain, and because there was no obvious neurologic deficit related to this pathology. The patient presents for regular neurosurgical follow up examinations and has been free from symptoms that were present on admission.Razvojne venske anomalije predstavljaju cerebrovaskularne malformacije koje čine vensku drenažu moždanog tkiva. S povećanom i dostupnijom upotrebom modernih dijagnostičkih postupaka one su sada među najčešće dijagnosticiranim cerebrovaskularnim malformacijama. Iako se razvojne venske anomalije smatraju benignim lezijama, udruženost s arteriovenskom malformacijom daje ovoj mješovitoj patologiji maligni potencijal. U slučaju koji predstavljamo ove malformacije bile su klinički nijeme i dijagnosticirane su slučajno, tako da nisu liječene kirurški, endovaskularno niti radioterapijom, imajući u vidu moguće komplikacije kao što su venski infarkti, kao i zato što nije bilo očitog neurološkog defi cita povezanog s ovom patologijom. Naš bolesnik redovito dolazi na neurokirurške kontrole i sada nema simptoma koji su bili prisutni kod prijma

Liječenje projektilnih ozljeda brahijalnog pleksusa

Missile injuries are among the most devastating injuries in general traumatology. Traumatic brachial plexus injuries are the most difficult injuries in peripheral nerve surgery, and most complicated to be surgically treated. Nevertheless, missile wounding is the second most common mechanism of brachial plexus injury. The aim was to evaluate functional recovery after surgical treatment of these injuries. Our series included 68 patients with 202 nerve lesions treated with 207 surgical procedures. Decision on the treatment modality (exploration, neurolysis, graft repair, or combination) was made upon intraoperative finding. Results were analyzed in 60 (88.2%) patients with 173 (85.6%) nerve lesions followed-up for two years. Functional recovery was evaluated according to functional priorities. Satisfactory functional recovery was achieved in 90.4% of cases with neurolysis and 85.7% of cases with nerve grafting. Insufficient functional recovery was verified in ulnar and radial nerve lesions after neurolysis, and in median and radial nerve lesions when graft repair was done. We conclude that the best time for surgery is between two and four months after injury, except for the gunshot wound associated with injury to the surrounding structures, which requires immediate surgical treatment. The results of neurolysis and nerve grafting were similar.Ozljede projektilima su među najrazornijim ozljedama u općoj traumatologiji. Traumatske ozljede brahijalnog pleksusa najteže su ozljede perifernog živčanog sustava, a najkompliciranije se liječe kirurški. Ipak, projektilno ranjavanje je drugi najčešći mehanizam ozljede brahijalnog pleksusa. Cilj je bio procijeniti funkcionalni oporavak nakon kirurškog liječenja ovih ozljeda. Naša studija je obuhvatila 68 bolesnika s 202 ozljede živaca liječenih u 207 kirurških zahvata. Odluka o načinu liječenja (eksploracija, neuroliza, direktna reparacija graftom ili kombinacija) donesena je na osnovi intraoperacijskog nalaza. Rezultati su analizirani u 60 (88,2%) bolesnika sa 173 (85,6%) lezije živaca nakon kojih je slijedilo razdoblje praćenja u trajanju od dvije godine. Funkcionalni oporavak ocijenjen je prema funkcionalnim prioritetima. Zadovoljavajući funkcionalni oporavak postignut je u 90,4% neuroliza i 85,7% reparacija graftom. Slučajevi s nedovoljnim funkcionalnim oporavkom bili su povezani s neurolizom ulnarnog i radijalnog živca ili reparacijom graftom srednjih i proksimalnih lezija. Zaključujemo da je najbolje vrijeme za kirurški zahvat između dva i četiri mjeseca nakon ozljede, osim kada postoje udružene ozljede okolnih struktura, što zahtijeva neodložno kirurško liječenje. Rezultati neurolize i reparacije graftom bili su slični

The influence of morphological characteristics of intracranial aneurysms in rupture risk assessment using three dimensional digital subtraction angiography

Intrakranijalne aneurizme su lokalna proširenja moždanih arterija i prema podacima iz literature 2-5% populacije ima aneurizmu na nekom od intrakranijalnih krvnih sudova. Procenjuje se da će u toku života prokrvariti 15-20% ovih aneurizmi. Oko 30-40% bolesnika umire neposredno po rupturi, a od onih koji prežive i budu tretirani u specijalizovanoj neurohirurškoj ustanovi, samo trećina se potpuno oporavi, trećina ostane sa lakšim ili težim posledicama, a kod preostale trećine pacijenata lečenje se ipak završi letalnim ishodom. Rizik za rerupturu netretirane aneurizme iznosi 50% u prvih šest meseci, a potom do 3% godišnje. Do sada je nekoliko socio-demografskih, kliničkih, ali i morfoloških parametara pokazano kao povezano sa rupturom intrakranijalnih aneurizmi. Razvojem savremenih dijagnostičkih procedura i njihovom većom dostupnošću, analiza morfoloških karakteristika intrakranijalnih aneurizmi radi procene rizika od rupture se sve češće koristi. U dosadašnjim većim studijama pokazano je da su veličina aneurizme i lokalizacija aneurizme najčešće povezane sa rizikom za rupturu. Ove dve karakteristike se tako najšire koriste u proceni rizika za rupturu intrakranijalnih aneurizmi. Pokazano je da aneurizme manje od 5 mm ređe rupturiraju, a da je rizik za rupturu najveći kod aneurizmi veličine preko 7 mm. Aneurizme lokalizovane na račvama velikih intrakranijalnih krvnih sudova, naročito srednje velikomoždane arterije, prednje komunikantne arterije i bazilarne arterije, su češće povezivane sa većim rizikom za rupturu. Ipak, nekoliko kompleksnijih izvedenih morfoloških parametara koji uzimaju u obzir odnos veličine aneurizme i vrata aneurizme, odnos veličine aneurizme i matičnog krvnog suda, kao i uticaj smera toka krvne struje, su se pokazali kao mnogo značajniji i precizniji u proceni rizika od rupture u odnosu na samo veličinu i lokalizaciju aneurizme. Određivanje morfoloških karakteristika intrakranijalnih aneurizmi kao prediktora rupture je od izuzetnog značaja, kako sa dijagnostičkog, tako i sa terapijskog stanovišta. Ova saznanja bi imala veliku praktičnu vrednost jer bi se na taj način odredila upravo ona grupa pacijenata kojima je potreban sveobuhvatan pristup. Protokoli bazirani na dobroj kliničkoj praksi i referentnim studijama mogu značajno da doprinesu adekvatnom lečenju i savetovanju ovih pacijenata. MATERIJAL I METODE Ovo je studija slučajeva i kontrola kojom su obuhvaćeni svi pacijenti kojima je u petogodišnjem periodu, od januara 2016. godine do decembra 2020. godine, urađena trodimenzionalna digitalna suptrakciona angiografija na Odseku invazivne i interventne neuroradiologije Univerzitetskog Kliničkog centra Srbije i tom prilikom dijagnostikovana ili potvrđena intrakranijalna aneurizma. Pacijenti su podeljeni u dve grupe: pacijenti sa krvarećim i pacijenti sa nekrvarećim aneurizmama. Nakon primene kriterijuma studije, 604 pacijenata (316 sa krvarećim aneurizmama i 288 sa nekrvarećim aneurizmama) sa 818 aneurizmi (318 rupturiranih i 500 nerupturiranih) je uključeno u studiju. Iz medicinskih istorija bolesti analizirane su demografske i kliničke karakteristike pacijenata, a morfološki parametri mereni na trodimenzionalnoj digitalnoj suptrakcionoj angiografiji uključuju 13 varijabli. Svi dobijeni podaci su potom statistički obrađeni i analizirani...Intracranial aneurysms are pathological dilatations of cerebral arteries. They are present in 2-5% of the general population, and it is estimated that 15-20% of them will rupture during lifetime. About 30-40% of patients die immediately after the rupture, and of those who survive and are treated in a specialized neurosurgical institution, only 1/3 recover completely, 1/3 remain with mild or severe deficits, and the remaining third of patients have a lethal outcome. The risk of a new rupture is 50% in the first six months followed by an increase of 3% for every year. So far, several socio-demographic, clinical, and morphological parameters have shown to be associated with rupture of intracranial aneurysms. With the development of novel diagnostic procedures and their greater availability, the analysis of morphological characteristics of intracranial aneurysms in order to assess the risk of rupture is increasingly used. Studies showed that the size of the aneurysm and the location of the aneurysm are most often associated with the risk of rupture. These two characteristics are thus most widely used in assessing the risk of aneurysm rupture. Aneurysms smaller than 5 mm are less likely to rupture, and the risk of rupture is greatest with aneurysms larger than 7 mm. Aneurysms located at the bifurcations of large intracranial vessels, especially the middle cerebral artery, anterior communicating artery and basilar artery are most often associated with a higher risk of rupture. However, several more complex derived morphological parameters that take into account the aneurysm-to-neck size ratio, the aneurysm-to-parent vessel size ratio, and the influence of blood flow direction, have proven to be much more significant and accurate in rupture risk assessment than only the size and location of the aneurysm. Thus, knowledge of risk factors for rupture is crucial for counseling and managing patients with intracranial aneurysms. Protocols based on good clinical practice, knowledge and reference studies can significantly contribute to adequate treatment and management of these patients. MATERIAL AND METHODS This is a case-control study that included all patients who underwent three-dimensional digital subtraction angiography in the five-year period, from January 2016 to December 2020, at the Department of Interventional Neuroradiology of the University Clinical Center of Serbia, and were diagnosed with intracranial aneurysms. Patients were divided into two groups: patients with bleeding and patients with non-bleeding aneurysms. Following the application of the study criteria, 604 patients (316 with bleeding and 288 with non-bleeding aneurysms) with 818 aneurysms (318 ruptured and 500 non-ruptured) were included in the study. From the medical records, the demographic and clinical characteristics of the patients were analyzed. The morphological parameters were measured on three-dimensional digital subtraction angiography and included 13 variables. All obtained data were statistically processed and analyzed..

Developmental Venous Anomaly Serving as a Draining Vein of Brain Arteriovenous Malformation

Developmental venous anomalies are cerebral vascular malformations that present normal venous drainage of cerebral tissue. With increased and accessible usage of modern diagnostic tools, they are now one of the most commonly diagnosed cerebral vascular malformations. Although developmental venous anomalies are considered to be benign lesions, association with arteriovenous malformation renders malignant potential to this combined pathology. In the case presented, these malformations were clinically silent and diagnosed accidentally, so they were not treated either with surgery, endovascular surgery or radiosurgery, considering the possible complications such as venous infarction of the brain, and because there was no obvious neurologic deficit related to this pathology. The patient presents for regular neurosurgical follow up examinations and has been free from symptoms that were present on admission

Iatrogenic Peripheral Nerve Injuries—Surgical Treatment and Outcome: 10 Years' Experience

Background Iatrogenic nerve injuries are nerve injuries caused by medical interventions or inflicted accidentally by a treating physician. Methods We describe and analyze iatrogenic nerve injuries in a total of 122 consecutive patients who received surgical treatment at our Institution during a period of 10 years, from January 1, 2003, to December 31, 2013. The final outcome evaluation was performed 2 years after surgical treatment. Results The most common causes of iatrogenic nerve injuries among patients in the study were the operations of bone fractures (23.9%), lymph node biopsy (19.7%), and carpal tunnel release (18%). The most affected nerves were median nerve (21.3%), accessory nerve (18%), radial nerve (15.6%), and peroneal nerve (11.5%). In 74 (60.7%) patients, surgery was performed 6 months after the injury, and in 48 (39.3%) surgery was performed within 6 months after the injury. In 80 (65.6%) patients, we found lesion in discontinuity, and in 42 (34.4%) patients lesion in continuity. The distribution of surgical procedures performed was as follows: autotransplantation (51.6%), neurolysis (23.8%), nerve transfer (13.9%), direct suture (8.2%), and resection of neuroma (2.5%). In total, we achieved satisfactory recovery in 91 (74.6%), whereas the result was dissatisfactory in 31 (25.4%) patients. Conclusions Patients with iatrogenic nerve injuries should be examined as soon as possible by experts with experience in traumatic nerve injuries, so that the correct diagnosis can be reached and the appropriate therapy planned. The timing of reconstructive surgery and the technique used are the crucial factors for functional recovery