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Ruptured abdominal aortic aneurysms (rAAAs) are life-threatening and require emergent surgical therapy. Endovascular aortic repair for rupture (rEVAR) has become the leading strategy due to its minimal invasive approach with expected lower morbidity and mortality, especially in patients presenting with hemodynamic instability and relevant comorbidities. Following rEVAR, intraoperative angiography or early postinterventional computed tomography angiography have to exclude early type 1 or 3 endoleaks requiring immediate reintervention. Persistent type 2 endoleaks (T2ELs) after rEVAR, in contrast to elective cases, can cause possibly lethal situations due to continuing extravascular blood loss through the remaining aortic aneurysm rupture site. Therefore, early identification of relevant persistent T2ELs associated with continuous bleeding and hemodynamic instability and immediate management is mandatory in the acute postoperative setting following rEVAR. Different techniques and concepts for the occlusion of T2ELs after rEVAR are available, and most of them are also used for relevant T2ELs after elective EVAR. In addition to various interventional embolization procedures for persistent T2ELs, some patients require open surgical occlusion of T2EL-feeding arteries, abdominal compartment decompression or direct surgical patch occlusion of the aneurysm rupture site after rEVAR. So far, in the acute situation of rAAAs, indications for preemptive or intraoperative T2EL embolization during rEVAR have not been established. In the long term, persistent T2ELs after rEVAR can lead to continuous aneurysm expansion with the possible development of secondary proximal type I endoleaks and an increased risk of re-rupture requiring regular follow-up and early consideration for reintervention. To date, only very few studies have investigated T2ELs after rEVAR or compared outcomes with those from elective EVAR regarding the special aspects of persisting T2ELs. This narrative review is intended to present the current knowledge on the incidence, natural history, relevance and strategies for T2EL management after rEVAR.

UNASSIGNED: Treating wide-neck bifurcated cerebral aneurysms (WNBAs) using various techniques and new devices has shown favorable outcomes. However, endovascular coiling can be technically challenging when the aneurysm neck is incorporated into the parent vessel. Furthermore, although recent research has reported favorable outcomes of Neuroform Atlas stent (NAS)-assisted coiling, broad inclusion criteria have hampered precise evaluations of their effectiveness and safety for treating complex WNBAs. Therefore, this study evaluated whether the use of a single NAS is a safe and effective approach for treating complex WNBAs.
UNASSIGNED: We treated 76 complex WNBAs (unruptured, n = 49; ruptured, n = 27) using single NAS-assisted coil embolization and retrospectively analyzed the clinical and angiographic outcomes.
UNASSIGNED: In a cohort of 68 patients (mean age, 58.3 ± 11.6 years; males n = 20, 29.4%; females, n = 48, 70.6%), 76 stents were successfully delivered to the target aneurysms, yielding a technical success rate of 98.6%. Complete occlusion was evident in 59 (77.6%) of 76 aneurysms, with neck remnants found in 16 (21.1%) and partial occlusion in 1 (1.3%). Treatment-related morbidities comprised one branch occlusion and one parenchymal hemorrhage. However, no new neurological symptoms of unruptured aneurysms were evident at discharge. The outcomes of 20 of the 27 ruptured aneurysms were favorable (Glasgow Outcome Scale scores of 4 or 5) at the final follow-up assessment (mean 12.2 [6-29] months), except for one initial subarachnoid hemorrhage. Post-treatment angiography revealed complete occlusion in 89.1%, neck remnants in 7.8%, and incomplete occlusion in 3.1% of the aneurysms. Approximately 88.2% of the patients were assessed at least once by follow-up diagnostic or magnetic resonance angiography (mean, 12.5 ± 4.3 [range, 6-29] months), with five (7.8%) minor and two (3.1%) major recurrences.
UNASSIGNED: A single NAS is safe and effective for treating WNBAs incorporated into parent vessels.

OBJECTIVE: To study associations of clinical characteristics and treatment choice with functional outcome, mortality, and time to death in a national sample of aneurysmal subarachnoidal hemorrhage (aSAH) patients.
METHODS: Data were extracted from a prospective nationwide multicenter study performed in September 2014 to March 2018. Glasgow Outcome Scale Extended (GOSE) grade, 1-year mortality, and survival probability were assessed at one year after ictus. Logistic univariate, multivariate, and Cox regression analyses were used to study the variables\' associations with the outcomes.
RESULTS: Unfavorable dichotomized GOSE (dGOSE; grades 1-4) was observed in 35.4% of patients. Microsurgery was preferred for middle cerebral artery aneurysms and Fisher grade 4. Treatment modality was not associated with any outcome measure. Dichotomized World Federation of Neurosurgical Societies (dWFNS), age, and delayed ischemic neurological deficit (DIND) showed significant correlations with dGOSE and 1-year mortality in multivariate regression analyses. Pupil dilatation was associated with 1-year mortality outcome. Cox regression analysis showed lower survival probability for pupil dilatation (hazard ratio (HR) 3.546), poor dWFNS (HR 3.688), higher age (HR 1.051), and DIND occurrence (HR 2.214).
CONCLUSIONS: The patient selection in Sweden after aSAH showed similar values for dGOSE, 1-year mortality, and survival probability between patients treated with microsurgery or endovascular technique. Poor dWFNS, higher age, and DIND were significantly associated with unfavorable dGOSE, mortality, and survival probability. Pupil dilatation was significantly associated with mortality and survival probability.

BACKGROUND: Arachnoid cysts are cerebrospinal fluid-filled spaces that are typically congenital and treated conservatively or with fenestration when symptomatic. Chronic subdural hematomas (cSDHs) can arise in the presence of arachnoid cysts due to fragile leptomeningeal vessels or veins within the cyst wall or cyst lumen, leading to bleeding and subsequent hematoma formation. Middle meningeal artery (MMA) embolization is regularly used for the treatment of cSDH as an alternative to craniotomy and evacuation.
METHODS: Here, the authors present the first known report of the simultaneous resolution of an arachnoid cyst and cSDH following MMA embolization in an adult. A 24-year-old male presented to the emergency department with 1 month of worsening headaches. Imaging revealed the presence of a cSDH and ipsilateral arachnoid cyst. The cSDH was treated with MMA embolization using coils exclusively. Follow-up imaging 4 months after embolization demonstrated simultaneous resolution of both the hematoma and the arachnoid cyst.
CONCLUSIONS: MMA embolization has been used for the treatment of cSDH. In cases in which the hematoma is related to an arachnoid cyst, MMA embolization can also lead to the concurrent resolution of both pathologies. https://thejns.org/doi/10.3171/CASE24192.

Aneurysmal subarachnoid hemorrhage (aSAH) is a rare but devastating complication with increased morbidity and mortality. It is still unclear whether the incidence is increased during pregnancy and in the peripartum period. However, the incidence of cerebral aneurysmal rupture is higher during the third trimester than in the first trimester. The risk of aneurysmal rupture and subarachnoid hemorrhage (SAH) during general anesthesia or spinal anesthesia is unclear. We report a case of left supraclinoid aneurysm rupture after spinal anesthesia for Low Segment Caesarean Section (LSCS) in the immediate postpartum period causing high-grade aSAH.

BACKGROUND: Endovascular options for the treatment of basilar apex aneurysms (BAAs) are heterogeneous, and evidence is limited to retrospective cohorts and case series. We seek to evaluate the efficacy and complications associated with various endovascular treatment methods of BAAs.
METHODS: Systematic review of PubMed, Embase, and Web of Science adhering to the PRISMA guidelines. Retrospective and prospective studies evaluating endovascular treatment of BAAs between January 2010 and July 2024 were included. Relevant information including occlusion rates, aneurysm recurrence, retreatment rates, and complications were subjected to meta-analysis.
RESULTS: Fifteen studies with 1,049 BAAs were included. The median aneurysm diameter was 8.5 mm (range 4.6-19.75), with a median follow-up of 33.7 months (range 6.0-117.6). Residual aneurysm filling occurred in 24% after primary coiling (95% CI=0.16-0.32), 25% after single stent-assisted coiling (s-SAC; 95% CI=0.04-0.46), 25% after Y-stenting (95% CI=0.12-0.37), and 23% after flow diverter stenting (FDS; 95% CI=0.11-0.35). Recurrence rates were high for primary coiling (27%, 95% CI=0.18-0.36) and s-SAC (19%, 95% CI=0.13-0.26), but significantly lower for Y-stenting (9%, 95% CI=0.03-0.15) and FDS (4%, 95% CI=-0.04-0.11). Retreatment rates were 19% for primary coiling (95% CI=0.12-0.26), 17% for s-SAC (95% CI=0.07-0.27), 5% for Y-stenting (95% CI=-0.03-0.12), and 13% for FDS (95% CI=-0.01-0.27). Meta-regression indicated larger aneurysms had higher complication rates (p=0.02). Thromboembolic events were most frequent with FDS and Y-stenting (12%).
CONCLUSIONS: Occlusion rates were similar across treatments, but recurrence rates were significantly lower after Y-stenting and FDS treatments compared to primary coiling, although they carried a higher number of thromboembolic complications.

UNASSIGNED: Direct carotid-cavernous fistulas (CCF) are primarily caused by head trauma. Some cases have also been attributed to iatrogenic injuries during endovascular procedures. However, the reports of functional endoscopic sinus surgery (FESS) associated with direct CCFs are extremely rare.
METHODS: A 52-year-old male worker, who suffered from chronic sinusitis and underwent functional endoscopic sinus surgery (FESS) performed by an otolaryngologist. Intra-operative finding indicated a left sphenoid sinus wall injury without internal carotid artery bleeding, which was repaired using mucosa and tissue glue. One month after discharge, he began experiencing tinnitus, headache and swelling in his left eye. Cerebral angiography revealed a direct carotid-cavernous fistula (CCF) on the left side. The patient underwent transarterial and transvenous stent-assisted coiling using detachable coils and Onyx, which alleviated his symptoms.
UNASSIGNED: A cavernous-carotid fistula following FESS is an exceedingly rare occurrence first reported by Karaman et al. in 2009. The incidence of internal carotid artery injury during FESS or endonasal endoscopic surgery (EES) is estimated to be between 0 and 0.1 %. Currently, there is no definitive explanation for the development of a carotid-cavernous fistula (CCF) post-FESS. Previous studies suggest that procedures like transsphenoidal surgery and EES can induce pseudoaneurysms in the internal carotid artery. If the cavernous pseudoaneurysm ruptures, it could lead to the formation of a CCF.
CONCLUSIONS: A direct cavernous-carotid fistula following functional endoscopic sinus surgery is a very rare. Consequently, when encountering patients with a carotid-cavernous fistula, relevant procedure history should be considered.

This report describes the case of a frail 36-year-old patient who underwent an endovascular treatment of a right subclavian artery pseudoaneurysm (SAP) associated with an arteriovenous fistula secondary to a traumatic central venous catheter insertion. The deployment of a covered stent from the innominate to the right common carotid artery combined with coiling of the SAP and the internal mammary artery was performed. Two additional covered stents were deployed from the vertebral artery to the distal subclavian artery to preserve right upper extremity circulation. This case highlights the feasibility of an endovascular treatment of a complex SAP in a candidate unsuitable for open surgery.

BACKGROUND: The fetal-type posterior cerebral artery (PCA) is defined as a variant anatomy in which the posterior communicating artery (PCOM) is larger than the hypoplastic or aplastic P1 segment of the PCA. The authors present the novel case of a patient with a duplicated right PCA in parallel with fetal-type and conventional PCAs supplying adjacent components of the PCA cerebral territory.
METHODS: A 59-year-old woman presented with a modified Fisher Scale score 4 subarachnoid hemorrhage. A right irregular PCOM aneurysm that measured 9.5 mm × 4.5 mm × 4.5 mm arose from the base of a variant branch supplying a portion of the PCA, rather than a conventional PCOM, and was found on digital subtraction angiography. Following endovascular coil embolization, the patient was discharged home.
CONCLUSIONS: The fetal-type variant has implications for thromboembolic events. If an embolism occludes the anterior circulation in a patient with a fetal-type PCA, it may result in an infarct in the PCA territory. Awareness of cerebral arterial anatomy, including an atypical collateral supply, informs a treating team\'s latitude in tolerance of which sites must be preserved and which can be safely sacrificed. https://thejns.org/doi/10.3171/CASE23735.