Hydrocephalus is a common complication following aneurysmal subarachnoid hemorrhage (aSAH), associated with increased morbidity and mortality. While its immediate negative impact on cognitive function is well-known, the longitudinal effects, especially in lower-grade aSAH patients, remain unclear. This study aimed to assess these effects. Within the prospective, multicenter “MoCA-DCI study” (ClinicalTrials.gov NCT03032471), patients with a GCS of 13–15 < 72 h post-aSAH underwent serial neuropsychological assessments using the Montreal Cognitive Assessment (MoCA) at baseline (< 72 h post-aSAH), around discharge (14–28 days post-aSAH), and at 3-month follow-up. Standardized MoCA scores were compared to evaluate cognitive outcomes, and the likelihood of a clinically meaningful decline (≥ 2 points) was assessed in patients with and without hydrocephalus. We included 112 patients, mean age 53.9 years (SD 13.9), 66.1

Introduction:Despite advances in cerebral aneurysm treatment, information on detailed outcomes remains limited. We compared complications and multidimensional outcomes in alert aneurysmal subarachnoid hemorrhage (aSAH) patients (GCS ≥13) who received clipping or coiling after individualized decisions were made through multidisciplinary board discussions. Research question:Are there significant differences in multidimensional outcomes between clipping and coiling treatments for alert aSAH patients when treatment selection is individualized? Material and methods:Within the prospective MoCA-DCI study (ClinicalTrials.gov identifier: NCT03032471), patients with a GCS of 13-15 72h post-aSAH in six neurovascular centers underwent neuropsychological (Montreal Cognitive Assessment; MoCA), neurological (National Institutes of Health Stroke Scale; NIHSS), headache (visual analog scale; VAS), disability (modified Rankin Scale; mRS) and health-related quality of life (EuroQol Five Dimensions; EQ5D) assessments within 72h, 14 days and three months after aSAH. We compared these multidimensional outcomes and complications for clipped and coiled patients. Results:Of 126 patients (mean age 53.8 years; 63.9 % female), 84 were coiled and 42 clipped. MoCA scores for clipped vs coiled patients were 23(7) vs 23(8; p = 0.250), 25(8) vs 28(5; p = 0.346), and 27(4) vs 28(5; p = 0.481). Normal cognition (MoCA ≥26) was achieved within 72h by 28.6 % of coiled and 40.5 % of clipped patients (p = 0.179). Complication rates were similar, though surgical patients had higher intraprocedural rupture rates (p = 0.027). Clipped patients reported higher headaches at three months (p = 0.013), while NIHSS, mRS and EQ5D showed no differences. Discussion and conclusion:After interdisciplinary selection of the most appropriate treatment, similar favorable outcomes can be achieved in alert aSAH patients.

The vertebral arteries represent in the adult the main blood supply of the posterior cranial fossa, even if they appear relatively late during the embryological life. We reviewed all the most important steps of the vertebral artery's embryological development and the most common variants that can occur in the adult. The aim of this review is to summarize the main events of the development of this artery and to give an embryological explication for the most common variants of this artery.

The ophthalmic artery has one of the most fascinating embryologic developments among the craniofacial arteries. Most of the ophthalmic artery orbital branches develop from the formation and regression of the stapedial artery and share their origin with dural branches of the ophthalmic artery. The concomitant embryologic development of the ophthalmic artery and middle meningeal artery explains adequately the important varieties of anastomosis between these 2 arteries. It also explains the presence of many dural branches from the ophthalmic artery. In this review, we focused on dural branches of the ophthalmic artery with the description of rare variations possible, in particular the ophthalmic artery origin of the middle meningeal artery and the ophthalmic artery origin of the marginal tentorial artery.

BACKGROUND:Thoracic pial arteriovenous fistulas (pAVFs) are rare vascular malformations that usually consist of a single dilated pial artery connecting directly to an enlarged draining vein. Multiple shunting point thoracic pAVFs are even rarer entities causing progressive myelopathy.METHOD:We present our surgical technique to identify and exclude multiple shunting point thoracic pAVF with appropriate pre-operative planning. This surgical technique is illustrated by an intraoperative video.CONCLUSION:Double injection pre-operative angiography represents a helpful tool to plan the surgery. Intraoperative exposure with pedicle removal and the use of micro-Doppler improve the identification and the exclusion of a multiple shunting thoracic pAVF.

OBJECTIVE:Acute hydrocephalus is a frequent complication after aneurysmal subarachnoid hemorrhage (aSAH). Among patients needing CSF diversion, some cannot be weaned. Little is known about the comparative neurological, neuropsychological, and health-related quality-of-life (HRQOL) outcomes in patients with successful and unsuccessful CSF weaning. The authors aimed to assess outcomes of patients by comparing those with successful and unsuccessful CSF weaning; the latter was defined as occurring in patients with permanent CSF diversion at 3 months post-aSAH.METHODS:The authors included prospectively recruited alert (i.e., Glasgow Coma Scale score 13-15) patients with aSAH in this retrospective study from six Swiss neurovascular centers. Patients underwent serial neurological (National Institutes of Health Stroke Scale), neuropsychological (Montreal Cognitive Assessment), disability (modified Rankin Scale), and HRQOL (EuroQol-5D) examinations at < 72 hours, 14-28 days, and 3 months post-aSAH.RESULTS:Of 126 included patients, 54 (42.9%) developed acute hydrocephalus needing CSF diversion, of whom 37 (68.5%) could be successfully weaned and 17 (31.5%) required permanent CSF diversion. Patients with unsuccessful weaning were older (64.5 vs 50.8 years, p = 0.003) and had a higher rate of intraventricular hemorrhage (52.9% vs 24.3%, p = 0.04). Patients who succeed in restoration of physiological CSF dynamics improve on average by 2 points on the Montreal Cognitive Assessment between 48-72 hours and 14-28 days, whereas those in whom weaning fails worsen by 4 points (adjusted coefficient 6.80, 95% CI 1.57-12.04, p = 0.01). They show better neuropsychological recovery between 48-72 hours and 3 months, compared to patients in whom weaning fails (adjusted coefficient 7.60, 95% CI 3.09-12.11, p = 0.02). Patients who receive permanent CSF diversion (ventriculoperitoneal shunt) show significant neuropsychological improvement thereafter, catching up the delay in neuropsychological improvement between 14-28 days and 3 months post-aSAH. Neurological, disability, and HRQOL outcomes at 3 months were similar.CONCLUSIONS:These results show a temporary but clinically meaningful cognitive benefit in the first weeks after aSAH in successfully weaned patients. The resolution of this difference over time may be due to the positive effects of permanent CSF diversion and underlines its importance. Patients who do not show progressive neuropsychological improvement after weaning should be considered for repeat CT imaging to rule out chronic (untreated) hydrocephalus.

BACKGROUND AND PURPOSE:Internal carotid artery (ICA) agenesis is a rare anatomical variant that can involve different segments of the ICA. Although many authors proposed their own classifications of this variant basing on different criteria, none of these allows to include all the cases described in the literature. The aim of the authors is to propose a new classification that allows to include all cases of ICA agenesis described until now.MATERIALS AND METHODS:The study is based on the review of all the cases of ICA agenesis described in the literature and of the classifications already proposed. After the analysis of these cases, we looked for the limits of each classification to elaborate a new more complete one.RESULTS:We found 228 cases of ICA agenesis. Among them 40 were not includible in the existing classifications. For this reason, we proposed a new classification based on the type of flow compensation and on the embryological events that determine the different variants. The flow is compensated in Type I by the Circle of Willis; in Type II by the non-regression of an embryonic artery; in Type III by the presence of an arterio-arterial anastomosis and in Type IV by external-internal carotid arteries anastomoses.CONCLUSION:After the literature review, we proposed a new comprehensive classification based on the detailed analysis of arterial embryology. Even if all the embryological details that determine this complex variant are not completely understood yet, this classification allows to include all the cases described in literature.

Spinal pial arteriovenous fistulas (spAVFs) are rare, high-flow vascular malformations consisting of a single dilated pial artery connecting directly to an enlarged draining vein. This article describes the anatomic, clinical, and diagnostic features of spAVFs, to help clinicians to select the best treatment option. Both surgical and endovascular treatments are effective; microsurgery has a higher success rate. To maximize the exclusion rate, a multidisciplinary approach and adequate preoperative study are mandatory.