While isolated internal iliac artery aneurysms (IIIAAs) are rare entities, they are associated with a high mortality rate if ruptured. IIAAs are usually asymptomatic and can be discovered accidentally during imaging for any other causes. The treatment options vary according to the signs, symptoms, size of the aneurysm, and the patient\'s general condition. While surgery used to be the first option of treatment earlier, with the advances in the field of endovascular intervention, endovascular repair of IIIAA has emerged as the first option of treatment if applicable.

OBJECTIVE: Heparin-induced thrombocytopenia is a known complication of heparin exposure with potentially life-threatening sequelae. Direct thrombin inhibitors can be substituted for heparin in patients with heparin-induced thrombocytopenia that require anticoagulation. However, the use of direct thrombin inhibitors as a substitute for heparin has not been widely reported in the neuroendovascular literature.
METHODS: Here we report the first use of the direct thrombin inhibitor bivalirudin in a neuroendovascular procedure as a substitute for heparin in a patient with a ruptured pseudoaneurysm and heparin-induced thrombocytopenia, and review the literature on the use of bivalirudin and argatroban for such patients.
RESULTS: Bivalirudin was safely and effectively used in the case reported, with no thrombotic or hemorrhagic complications. Our literature review revealed a paucity of studies on the use of heparin alternatives, including bivalirudin, in neuroendovascular procedures in patients with heparin-induced thrombocytopenia.
CONCLUSIONS: Heparin-induced thrombocytopenia is an important iatrogenic disease process in patients undergoing neuroendovascular procedures, and developing protocols to diagnose and manage heparin-induced thrombocytopenia is important for healthcare systems. While further research needs to be done to establish the full range of anticoagulation options to substitute for heparin, our case indicates bivalirudin as a potential candidate.

Cerebral aneurysm is a life-threatening condition, which requires high precision during the neurosurgical procedures. Increasing progress of evaluating modern devices in medicine have led to common usage of robotic systems in many fields, including cranial aneurysm operations. However, currently no systematic review describes up-to date knowledge of this topic. Following PRISMA guidelines, we have independently screened and extracted works from seven databases. Only studies fulfilling inclusion criteria were presented in this study. Device used, operation time, complications, aneurysm type and patient demographics were extracted from each work. We identified a total of 995 articles from databases. We have found six original works and one supplementary article eligible for this synthesis. Majority of works (4/6) have implemented CorPath GRX in cerebral aneurysm procedures. The procedures involved diverse aneurysm locations, utilizing flow diverters, stents, or coiling. One study described implementation of robot-assist on 117 patients and compared results to randomized clinical trials. One work with a small patient cohort described use of the magnetically-controlled microguidewire in the coiling procedures, without any complications. Additionally, one case-series study described use of a robotic arm for managing intraoperative aneurysm rupture. Currently, robotical devices for cerebral aneurysm treatment mainly lack jailing and haptic feedback feature. Further development of these devices will certainly be beneficial for operators and patients, allowing for more precise and remote surgeries.

Endoscopic third ventriculostomy (ETV) is a well-established neurosurgical procedure. However, it carries risks of intraoperative complications, among which major vascular injury is the most dangerous. Reportedly, prominent bleeding during ETV has been noted in <1% of cases. Herein, we describe a case of a 34-year-old woman with occlusive hydrocephalus caused by a quadrigeminal cistern arachnoid cyst, who developed a pseudoaneurysm after injury of the basilar artery apex during ETV. Complete obliteration of the pseudoaneurysm with endovascular balloon-assisted coiling was done on the first postoperative day, and the patient demonstrated gradual recovery, but approximately 4 weeks later, she suffered massive rebleeding, seemingly due to rupture of the weak pseudoaneurysm wall, which resulted in her death. Careful evaluation of sagittal T2-weighted magnetic resonance images before ETV may be invaluable for assessment of the basilar artery position in relation to the third ventricle floor. In addition, use of a blunt surgical instrument (instead of a sharp one or cautery) for fenestration may be safer for prevention of arterial injury. Finally, special care should be applied in cases with an opaque third ventricle floor and inability to visualize the basilar artery during ETV.

UNASSIGNED: Paraophthalmic aneurysms present a challenge to surgeons and their ideal management remains up for debate. We studied recent outcomes of these lesions in a single center.
UNASSIGNED: A retrospective chart review of all patients undergoing treatment for paraophthalmic aneurysms from 2017-2019 was performed. Factors including patient demographics, aneurysm characteristics, treatment modality, radiographic treatment outcome, clinical outcome, and length of stay were collected, and bivariate analysis was performed.
UNASSIGNED: In total 84.5% (82/97) of aneurysms were treated endovascularly and 15.5% (15/97) surgically. In the surgery cohort, there were three transient perioperative complications (20%) and one minor postoperative complication (6.7%). Complete aneurysm occlusion or near complete (<2mm residual) was achieved in 100% (15/15). All but one patient had mRS ≤1 at the last follow-up. In the endovascular group, 78.1% (64/82) underwent flow diversion alone. Endovascular treatment was associated with a 4.9% (4/82) rate of periprocedural complications: 3 transient events, and 1 death, and a 3.7% (3/82) rate of delayed complications: 2 transient vision changes, and one death. Rate of total occlusion was 87.8% (72/82). 76 patients (92.7%) had mRS ≤1 at the last follow-up. Length of stay was significantly shorter in the endovascular group (3.4 days vs. 7.0 days) [p < 0.001].
UNASSIGNED: This series demonstrates similar safety to previously reported series as well as the efficacy of both surgical clipping and endovascular embolization of paraophthalmic aneurysms. Rate of complications and treatment efficacy were similar in both groups although this represents a single institution series not generalizable to all centers.

Wide-neck aneurysms (WNA) often require advanced open surgical and endovascular techniques to achieve adequate aneurysm occlusion. Microsurgical treatment often requires advanced clip configurations. Occasionally, more complex open surgical techniques are required. Advancements in endovascular therapies (EVT) and devices have expanded endovascular treatment options for WNAs and have improved aneurysm occlusion rates compared with primary coiling. Certain EVT require dual antiplatelet therapy, limiting their use in the ruptured setting. Evidence suggests that microsurgical treatment should remain a consideration for treatment of ruptured WNAs, but perhaps with novel endovascular techniques and devices, EVT should be first-line treatment in the unruptured setting.

Pediatric intracranial aneurysms (PIA) are very rare and can be fatal if left untreated. There are many treatment strategies including microsurgical and endovascular techniques. We feel that endovascular treatment using trans-radial access (TRA) is safe and convenient for PIA compared to the trans-femoral access (TFA), which is commonly employed in this population. We present the case of the youngest patient in the world whose ruptured aneurysm was treated with endovascular coiling via the TRA. The seven-year-old patient was brought to the ER with a severe headache. He had several episodes of vomiting and an episode of seizure as well. Computerized tomography (CT) of the brain showed subarachnoid hemorrhage. A magnetic resonance angiogram (MRA) showed an aneurysm at the bifurcation of the right internal carotid artery (ICA). An intermediate catheter/microcatheter system was used to navigate up into the ICA and then into the aneurysm. Two coils were deployed with good packing. The patient had a good clinical recovery and is currently doing good without any neurological deficits. With the availability of newer devices, we believe the TRA will be widely used in the coming years. We need to have larger randomized controlled trials to really understand the advantages of TRA in this patient population.

Pancreaticoduodenal arterial arcade aneurysms are rare but are prone to rupture. We report the case of a 60-year-old woman with an asymptomatic pancreaticoduodenal artery aneurysm and concomitant celiac trunk occlusion that was treated using an endovascular approach. After percutaneous transfemoral access and superior mesenteric artery cannulation, intraoperative cone-beam computed tomography angiography was performed to better understand the aneurysm morphology and provide image guidance. On selecting the optimal working projection, the aneurysm and distal parent vessel were cannulated and treated by braided stent (low-profile visualized intraluminal support; MicroVention)-assisted coil embolization. Completion angiography and cone-beam computed tomography confirmed successful exclusion of the aneurysm sac and a patent pancreaticoduodenal arcade with a well-apposed stent.

Basilar artery fenestrations (BAF) are rare vascular anomalies. Surgical intervention for aneurysms in this vascular segment is exceptionally arduous because of the complexity of the neurovascular structures in the vicinity of the brainstem. Endovascular therapy (ET) is the treatment of choice because of its safety and efficacy. Here, we report a 62-year-old female presenting with a two-day history of sudden onset severe headache, vomiting, and altered sensorium. A computed tomography (CT) and subsequent CT angiogram (CTA) revealed subarachnoid hemorrhage (SAH) and BAF with an aneurysm on each arm of the fenestration. Digital subtraction angiogram (DSA) with a three-dimensional rotational angiogram (3DRA) was employed before initiating ET. We used coiling and flow diversion to exclude the aneurysms from circulation. A six-month follow-up angiography reconfirmed the complete obliteration of the aneurysms. There was no focal neurological deficit.

BACKGROUND: Wide-necked middle cerebral artery bifurcation aneurysms pose specific challenges to endovascular management. Surgical clipping remains the standard treatment approach for these aneurysms in many centers. While recent data suggests the endovascular treatment may be comparable, a prospective datapoint has been lacking.
METHODS: The Penumbra SMART registry, a prospective, multi-center, single-arm outcomes registry of Penumbra coil-treated aneurysms, was queried for endovascularly treated MCA bifurcation aneurysms with wide necks (dome:neck ratio <2 or neck >4 mm). Safety and efficacy outcomes were summarized for ruptured and unruptured aneurysms, including rupture, complication rate, and 1-year occlusion outcomes.
RESULTS: Seventy-two aneurysms across 31 sites were enrolled. Of these, a total of 15 presented as ruptured aneurysms. Serious adverse events were reported in 21 (29.2%) of patients, with 8 (11.1%) attributed to the device/procedure. Immediately postoperatively, 75.0% of cases achieved \"adequate\" Raymond Roy Class I (40.3%) or II (34.7%) occlusion outcomes. Of the 72 patients treated, 60 (83.3%) underwent follow-up angiography at 1 year, and among these, 95.0% had 1-year occlusion outcomes of Raymond Roy Class I (71.7%) or II (23.3%). A total of 6 aneurysms (10.0%) were required or were planned for retreatment at the last follow-up.
CONCLUSIONS: This study represents the most significant prospective sample of endovascularly treated wide-neck MCA bifurcation aneurysms conducted to date. It supports the safety and efficacy of endovascular treatment of these aneurysms.