Several case reports and studies suggest that partially thrombosed large and giant aneurysms are potential sources of distal embolic events. However, there are limited data on small thrombosed aneurysms as a possible cause of ischemic events. Three patients are reported who presented with acute ischemic stroke and in whom the initial imaging studies showed a small (<10 mm), unruptured, partially thrombosed aneurysm. In each case, the aneurysm location was confirmed by a conventional angiogram. In all cases, the aneurysms were found on the proximal middle cerebral artery, in the territory corresponding to the clinical symptoms of the stroke. The mechanism of middle cerebral artery embolic event was thought to be related to the thrombus within the aneurysm, causing subsequent embolization into distal related vascular territory. Two of these patients had craniotomy for aneurysm clipping; one was managed conservatively with medical therapy alone. Thrombosis of small, unruptured intracranial aneurysms should be considered as a possible cause of acute-onset stroke symptoms in patients with acute ischemic stroke. It is under-recognized in the current literature, and no guidelines currently exist for medical or surgical treatment of such aneurysms. Medical management is often decided on an individual basis. Surgical treatment mostly involves aneurysmal clipping rather than coiling.
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Competing interests MJB, ZD and MM have no financial conflicts of interest. EIL receives research grant support (principal investigator: Stent-Assisted Recanalization in acute Ischemic Stroke, SARIS), other research support (devices) and an honorarium from Boston Scientific and research support from Codman & Shurtleff, Inc and ev3/Covidien Vascular Therapies; has ownership interests in Intratech Medical Ltd. and Mynx/Access Closure; serves as a consultant on the board of Scientific Advisors to Codman & Shurtleff, Inc; serves as a consultant per project and/or per hour for Codman & Shurtleff, Inc, ev3/Covidien Vascular Therapies and TheraSyn Sensors, Inc; and receives fees for carotid stent training from Abbott Vascular and ev3/Covidien Vascular Therapies. EIL has no consulting salary agreements. All consulting is per project and/or per hour. AHS has received research grants from the National Institutes of Health (co-investigator: NINDS 1R01NS064592-01A1, Hemodynamic induction of pathologic remodeling leading to intracranial aneurysms) and the University at Buffalo (Research Development Award); holds financial interests in Hotspur, Intratech Medical, StimSox and Valor Medical; serves as a consultant to Codman & Shurtleff, Inc, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting and Penumbra; belongs to the speakers' bureaus of Codman & Shurtleff, Inc and Genentech; serves on an advisory board for Codman & Shurtleff; and has received honoraria from the American Association of Neurological Surgeons' courses, an Emergency Medicine Conference, Genentech, Neocure Group LLC and from Abbott Vascular and Codman &Shurtleff, Inc for training other neurointerventionists in carotid stenting and for training physicians in endovascular stenting for aneurysms. He has no consulting salary agreements. All consulting is per project and/or per hour.
Ethics approval Health Sciences Institutional Review Board, University at Buffalo, State University of New York.
Provenance and peer review Not commissioned; externally peer reviewed.
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