A1 asynchrony, a potential risk factor for the rupture of anterior communicating artery aneurysms: A computational fluid dynamics study

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true "cabecera" => "Clinical Research" "titulo" => "A1 asynchrony, a potential risk factor for the rupture of anterior communicating artery aneurysms: A computational fluid dynamics study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "207" "paginaFinal" => "214" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "José Luis Thenier-Villa, Antonio Riveiro Rodríguez, Rosa María Martínez-Rolán, Miguel Gelabert-González, Pedro Miguel González-Vargas, Lourdes Calero-Félix, Raúl Alejandro Galarraga Campoverde, Adolfo Ramón De La Lama Zaragoza, Juan Pou, Cesáreo Conde Alonso" "autores" => array:10 [ 0 => array:4 [ "nombre" => "José Luis" "apellidos" => "Thenier-Villa" "email" => array:1 [ 0 => "jose.luis.thenier.villa@sergas.es" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 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Alejandro" "apellidos" => "Galarraga Campoverde" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 7 => array:3 [ "nombre" => "Adolfo Ramón" "apellidos" => "De La Lama Zaragoza" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 8 => array:3 [ "nombre" => "Juan" "apellidos" => "Pou" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 9 => array:3 [ "nombre" => "Cesáreo Conde" "apellidos" => "Alonso" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Neurosurgery, University Hospital Complex of Vigo, Estrada de Clara Campoamor, 341, Vigo 36312, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Surgery, University of Santiago de Compostela, Rúa de San Francisco, s/n, 15782 Santiago de Compostela, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Galicia Sur Health Research Institute (IIS Galicia Sur) SERGAS-UVIGO, Estrada de Clara Campoamor, 341, Vigo 36312, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Applied Physics Department, EEI, University of Vigo, Lagoas-Marcosende, s/n, Vigo 36310, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Asincronía de A1, un factor de riesgo potencial para la rotura de aneurismas de la arteria comunicante anterior: un estudio de dinámica de fluidos computacional" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2896 "Ancho" => 2925 "Tamanyo" => 646530 ] ] "descripcion" => array:1 [ "en" => "Low shear area (white) in anterior communicating aneurysms in synchrony and asynchrony conditions. Upper row: left figure shows a dominant A1/A2 angle of 88.62 degrees in synchronic conditions, right figure shows the same aneurysm in asynchrony conditions; LSA decreased from 31.64 to 26.06. Lower row: left figure shows a dominant A1/A2 angle of 46.45 degrees in synchronic conditions, right figure shows the same aneurysm in asynchrony; LSA increased from 27.69 to 36.95." ] ] ] "textoCompleto" => "IntroductionIntracranial aneurysms are pathological dilatations of the cerebral arteries, the estimated prevalence of cerebral aneurysms in the general population has been reported as high as 7%.<a class="elsevierStyleCrossRef" href="#bib0120">1</a> The rupture of an intracranial aneurysm produces severe intracranial haemorrhages, among the survivors who reach hospital care, 27% will die despite modern intensive and surgical measures.<a class="elsevierStyleCrossRef" href="#bib0125">2</a>Anterior communicating complex aneurysms are one the most frequent locations for intracranial aneurysms. A prevalence of 3.6% is described in prospective autopsy studies,<a class="elsevierStyleCrossRef" href="#bib0130">3</a> and anterior communicating artery (AcoA) aneurysms are responsible of about 39% of aneurysmal subarachnoid haemorrhage cases.<a class="elsevierStyleCrossRef" href="#bib0135">4</a> Previous studies showed certain features that could contribute to the formation of aneurysms in this location such as the hypoplasia of the A1 segment and the angulation of the arteries.<a class="elsevierStyleCrossRefs" href="#bib0140">5,6</a> Also, certain common concepts in general aneurysm literature such as the relationship of the size and aspect ratio and rupture seems not to behave similarly in this location, for example, in a recent study, 86.9% of the ruptured anterior communicating aneurysms had a size lower than 5mm,<a class="elsevierStyleCrossRef" href="#bib0150">7</a> and ruptured AcoA aneurysms with a size lower than 7mm are found two times more frequent compared with other locations in anterior cerebral circulation.<a class="elsevierStyleCrossRef" href="#bib0155">8</a>Anterior communicating artery aneurysms receive blood from the carotid circulation, and is the first point in which both left and right circulations met after its early bifurcation in the aortic arch. Each carotid artery has its own geometry, including diameter, elongations, tortuosity and atherosclerotic changes,<a class="elsevierStyleCrossRef" href="#bib0160">9</a> as a consequence, four pulsatile waves reach the brain in an asynchronous fashion,<a class="elsevierStyleCrossRef" href="#bib0165">10</a> this phenomena is also documented from non-selective arteriography using aortic injections of contrast.<a class="elsevierStyleCrossRef" href="#bib0170">11</a>We have not found previous studies analysing the implications of the asynchrony of the carotid pulse in the haemodynamics of the anterior communicating aneurysms. The objective of this study is to compare conditions of asynchrony in the pulse of the A1 artery and its effects in the haemodynamic environment of naturally occurred aneurysms using computational fluid dynamics.Materials and methodsStudy populationFrom January 2008 to December 2017, 652 intracranial aneurysms were diagnosed by digital subtraction arteriography (DSA) in our centre, of these, 122 patients (18.71%) had anterior communicating aneurysms. For this study, patients with multiple aneurysms, A1 segment agenesis, suboptimal quality or absent CT angiography were excluded.The study population of this retrospective study corresponds to 54 anterior complex circulations. The design of this study was approved by the Galician Clinical Research Ethics Committee. Informed written consent was obtained from patients still alive.Computational fluid dynamics analysisModel geometryFor the treatment of the geometry, anterior communicating artery complex was selected, starting from the first segment of the A1 artery to at least 3mm of the A2 segment. 3D sequences were obtained from 3D computed tomography angiogram (CTA) of cerebral arteries with a voxel resolution of 0.4×0.4×0.6mm. Digital subtraction angiography studies were not considered because of their vessel selectivity requiring registration/fusion procedures from 2 internal carotid angiograms to obtain a model, unsuitable for this retrospective study.Segmentation and generation of STL surfaces were performed using the software Slicer3D (Harvard Medical School, Boston, MA, USA). These surfaces were processed in Meshlab (Visual Computing Lab, Pisa, Italy) and FreeCAD (Juergen Riegel, Werner Mayer, Yorik van Havre, OpenSource, <a href="http://freecadweb.org/">http://freecadweb.org/</a>), to create meshes with ≈100,000 tetrahedral elements into the CFD software ANSYS Fluent 17.0 (Ansys, Canonsburg, PA, USA). A viscous layer of 0.1D (D=diameter of the vessel lumen), adjacent to the vessel walls, was created to capture the boundary layer effects.Governing equations and numerical simulationThe CFD software was used to solve the Navier–Stokes and mass conservation equations under the assumption of laminar, incompressible, and non-Newtonian blood flow. The corresponding governing equations are given as:<elsevierMultimedia ident="eq0005"></elsevierMultimedia><elsevierMultimedia ident="eq0010"></elsevierMultimedia>where u→ and p are the fluid velocity and the pressure, respectively ρ is the density (1060kg/m3), and μ is the dynamic viscosity of blood. Dynamic viscosity is modelled using a Carreau model.<a class="elsevierStyleCrossRef" href="#bib0215">20</a> This is given as:<elsevierMultimedia ident="eq0015"></elsevierMultimedia>where μ is the effective viscosity depending upon the shear rate γ˙, μ0 the viscosity at zero shear rate (0.056Pas), μ∞ the viscosity at infinite shear rate (0.0035Pas), Γ the time constant (3.313s) and n the power law index (0.3568).Boundary conditionsTransient pulsatile simulations averaged over several cardiac cycles were performed. Regarding the entrance boundary, the input condition was a sinusoidal profile with a peak speed of 0.5m/s and a minimum speed of 0.1m/s. The pulse length was 0.125s, and the period 0.5s. The output boundaries were defined as constant pressure outlets, with a pressure close to the mean arterial pressure of a normal individual (100mmHg). Dominancy was defined as the A1 artery with the largest diameter.The experiment was conducted with 2 profiles in each case, introducing a delay of 0.2s (asynchrony condition) and a second profile assuming complete synchrony of both A1 inlets.Output variablesThe wall shear stress (WSS) describes the viscous stress exerted by the blood on the walls of the artery. This magnitude is calculated as:<elsevierMultimedia ident="eq0020"></elsevierMultimedia>where ni is the normal vector to the surface and τij the viscous stress tensor. The time-averaged magnitude corresponding to the wall shear stress (TAWSS) is calculated as follows:<elsevierMultimedia ident="eq0025"></elsevierMultimedia>where T denotes the period of the cardiac cycle (assumed T=0.5s).Time-averaged WSS and pressure were considered. Low shear area WSS (LSA), was defined as the percentage of the aneurysmal area with a WSS below 10% of the TAWSS measured in the parent artery (dominant A1) of each case.<a class="elsevierStyleCrossRef" href="#bib0175">12</a>Geometric analysisThe geometry of the aneurysm, regarding its shape and size was measured from 3D reconstructions, the definitions of these variables are well described by previous studies.<a class="elsevierStyleCrossRef" href="#bib0180">13</a>The diameter of the 4 vessels A1L, A1R, A2L and A2R were measured. Aneurysm lateralization was defined as the direction on the left-right axis of the height vector. A1 dominance was defined as the side of the largest of both A1 arteries (diameter measured in mm). Symmetry index was defined as the quotient between the non-dominant and the dominant A1 diameters independently from the side, in a scale from 0 to 1, where 1 corresponds to fully symmetric A1 arteries.We also include in the analysis 3 angles, left A1/A2 angle, right A1/A2 angle and A1–A1 angle, methods of this measurements were described elsewhere.<a class="elsevierStyleCrossRef" href="#bib0185">14</a>StatisticsAll output variables from case-by-case simulations were registered for statistical analysis. For these analyses, SPSS software version 20 for MacOS was used. The inferential analysis was made from nonparametric tests for paired samples when comparing among comparisons between synchronic and asynchrony conditions, and tests for independent samples when considering grouped nominal variables. A p-value less than 0.05 is assumed to be significant. Rupture event or status of the aneurysm was not assessed in the analysis because of the imbalance of the distribution in this variable, risk was assumed according to the WSS changes.ResultsPopulation characteristicsFifty-four cases were analyzed in this study, 31 cases (57.4%) were male and 23 cases (42.7%) were female. The mean age at diagnosis was 56.14 years (SD=14.09). 45 cases presented as ruptured aneurysms with subarachnoid haemorrhage (83.3%) and 9 cases as unruptured aneurysms (16.7%). Considering only the subarachnoid haemorrhage cases (n=45), the distribution of Fisher's radiological grade was grade 2 in 10 cases (22.22%), grade 3 in 16 cases (35.56%) and grade 4 in 19 cases (42.22%). In SAH cases the clinical severity in the WFNS scale was grade 1 in 22 cases (48.89%), grade 2 in 9 cases (20%), grade 3 in 1 case (2.22%), grade 4 in 7 cases (15.56%) and grade 5 in 6 cases (13.33%). Baseline characteristics of the population are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Geometry characteristicsMeasurements of the dimensions of the aneurysm were obtained, including height and neck and aspect ratio. We also measured the diameter of both A1 and A2 arteries, the right and left A1/A2 angles, and the A1–A1 angle. These measurements are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. There is a tendency to lateralization of the aneurysm towards the side with the smaller A1/A2 angle, in left lateralization aneurysms the A1/A2 angles had an average of 101 and 74 degrees for the left and right sides respectively; and in right lateralization aneurysms, these angles were 79 and 82 degrees for the left and right sides, respectively.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Haemodynamic characteristics in synchronous and asynchronous conditionsA significant difference exists in TAWSS in asynchrony conditions. Mean TAWSS was 1.25Pa and 1.34Pa in asynchrony and synchrony conditions respectively (p=0.04, paired samples T-test), mean time-averaged pressure was 13,205Pa and 13,495Pa in asynchrony and synchrony conditions respectively (p=0.004). The difference produced in the LSA in synchronous and asynchronous conditions resulted in a broad range including positive and negative values (from −35.68 to 27.34), for this reason the population was grouped owing to this variable into “LSA increased in asynchrony” and “LSA decreased in asynchrony” groups. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows a summary of the effect of different geometric variables over this phenomenon in a univariate analysis. In this analysis, the symmetry index and A1/A2 angle on the dominant artery were related to changes in LSA.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>The effects of asynchrony on the pressure measured in the aneurysm were mainly negative with a mean of −289.68Pa (range of −4755.84 to 218.10Pa, SD=717.16Pa).DiscussionAs a result of the anatomical configuration of the arterial system, four different pulse waves reach the Willis complex at different times. The first aortic branch comprises the brachiocephalic trunk that branches off into the right common carotid and subclavian arteries, while the left common carotid and subclavian arteries emerges independently from the aortic arch. This particular asymmetric configuration and other anatomical and pathological variabilities such as the existence of atherosclerotic plaques in the lumen of large vessels are determinants of cerebral pulse asynchrony.<a class="elsevierStyleCrossRef" href="#bib0165">10</a>Geometry of the anterior communicating artery complexThe anterior communicating artery is a complex site due to its anatomical features. It receives flow from two independent circulations; it is also known that the diameters of both anterior cerebral arteries are usually different in patients with aneurysms, several previous studies have shown that this configuration is a risk factor for both the development and rupture of the aneurysm and increases the risk of complications of the treatment of aneurysms in this location.<a class="elsevierStyleCrossRefs" href="#bib0190">15–17</a>In our study, asymmetry is present in virtually all cases, a symmetry index of less than 0.80 is present in 72% of cases and an index lower than 0.5 is present in up to 20% of cases. We did not find statistical differences in ruptured and unruptured aneurysms in our series, although our sample of unruptured aneurysms is small.Zhang et al.<a class="elsevierStyleCrossRef" href="#bib0145">6</a> analysing 665 patients with aneurysms in various locations described that the A1/A2 angle is lower in individuals with aneurysms of anterior communicant artery, with an average of 106 degrees compared to 120 degrees in the group without aneurysms in this location. In our study, A1/A2 angle is smaller, approaching a mean of 82 degrees. The previously cited author also finds that there is a lateralization of the anterior communicating aneurysm to the side that offers a lower A1/A2 angle, this finding is comparable in our study.Lin et al.<a class="elsevierStyleCrossRef" href="#bib0205">18</a> analysing 79 anterior communicating artery aneurysms described lower dominant A1/A2 angles in patients with ruptured aneurysms in this location, other studies found the same results.<a class="elsevierStyleCrossRefs" href="#bib0210">19,20</a> In our study, we did not find a significant association with this variable, we must consider that in our series only nine unruptured aneurysms were analyzed.Haemodynamic characteristics of aneurysms in conditions of synchrony and asynchronyHaemodynamic conditions play an indisputable role in the pathophysiology of the formation, growth and rupture of aneurysms. The most described variable is the wall shear stress (WSS), defined as the frictional force exerted by the flowing blood tangentially on the vessel lumen.<a class="elsevierStyleCrossRef" href="#bib0220">21</a> This variable is usually diminished in ruptured aneurysms highlighting its potential role in the event of rupture.<a class="elsevierStyleCrossRef" href="#bib0225">22</a> Low shear area is also described in most studies as a variable; LSA is defined as the percentage of the aneurysm wall with a WSS lower than the 10% of the WSS measured in the parent vessel for most authors.<a class="elsevierStyleCrossRef" href="#bib0230">23</a>In our study, there is a significant direct influence of the asynchrony of the pulse in the A1 artery in the haemodynamic conditions of the aneurysm, including a reduction of the total pressure, and changes in the TAWSS that are reflected in two different groups: some aneurysms had an increase and some had a decrease in TAWSS, and in LSA in an inverse way. In the univariate analysis, we found greater symmetry indexes and lower A1/A2 angles in patients in whom asynchrony conditions induced an increase in LSA, potentially increasing the theoretical risk of bleeding.The effect of the asynchronous pulse may produce a decrease in TAWSS when there is less or none A1 asymmetry, two significant flows that produce a complex interaction resulting in an additive effect in the TAWSS over the complete cardiac cycle. This effect is not achieved when there is a second asynchronous pulse, the result is the decrease of the TAWSS, and in consequence the increase of the LSA.In the presence of lower A1/A2 angles in the dominant artery, more volume of blood is directed to A2 arteries bypassing the aneurysm, synchrony may play a role in stabilizing the intra-aneurysmal flow; if asynchrony is assumed, TAWSS could be decreased and in consequence, LSA increased. In higher A1/A2 angles, the blood influx to the aneurysm is greater, the second asynchronous pulse may therefore induce an increase in the TAWSS.In addition to the geometric characteristics described previously as associated with an increased incidence of aneurysms in this location, asynchrony could play an important role in the formation and growth of aneurysms, it is therefore advisable to include this variable in further studies to address haemodynamics of this complex location.We conclude from our findings that in cases of mild or no asymmetry and/or low A1/A2 angles, asynchrony of A1 arteries may potentially increase LSA, increasing the theoretical risk of aneurysm rupture. Two representative cases are illustrated in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>LimitationsFor this theoretical study, we have considered various conditions as true, in real conditions they may not be absolutely certain. Limitations inherent to out method are the absence of a specific velocity profile for each patient, the absence of data on the physical characteristics of the arterial wall, the geometric changes produced in the aneurysm after rupture, among others. Although DSA is the gold standard for brain vessels studies, only CTA were included in this study. CTA is highly accessible and is performed in all cases in our centre. Moreover, compared with DSA, CTA allows to represent AcomA geometry in only one step, DSA studies from AcomA needs two vessel catheterizations (both ICA) and registration/fusion procedures making this unaffordable for retrospective studies. Although low WSS is the most frequently described condition in ruptured aneurysms, the discussion about the role of low WSS and high WSS in the pathophysiology of a brain aneurysm remains open. The interpretation of our results assume a relevant role of low WSS in aneurysm rupture; more research is warranted in the pathobiology of this phenomena.ConclusionThe asynchrony of the flow in A1 arteries produces significant haemodynamic changes in anterior communicating artery aneurysms, low shear area is increased in the absence of A1 asymmetry and low A1/A2 angles, potentially increasing the risk of rupture of aneurysms in this location.FundingThis work was partially supported by Xunta de Galicia – Plan I2C Grant ProgramPOS-A/2013/161, ED481B 2016/047-0, ED481D 2017/010).The contents of this manuscript were not presented or published before.Conflict of interestsThe authors declare no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1239277" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1150146" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1239276" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1150145" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study population" ] 1 => array:3 [ "identificador" => "sec0020" "titulo" => "Computational fluid dynamics analysis" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Model geometry" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Governing equations and numerical simulation" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Boundary conditions" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Output variables" ] ] ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Geometric analysis" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Statistics" ] ] ] 6 => array:3 [ "identificador" => "sec0055" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Population characteristics" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Geometry characteristics" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Haemodynamic characteristics in synchronous and asynchronous conditions" ] ] ] 7 => array:3 [ "identificador" => "sec0075" "titulo" => "Discussion" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Geometry of the anterior communicating artery complex" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "Haemodynamic characteristics of aneurysms in conditions of synchrony and asynchrony" ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Limitations" ] ] ] 8 => array:2 [ "identificador" => "sec0095" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0100" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0105" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-01-13" "fechaAceptado" => "2019-04-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1150146" "palabras" => array:5 [ 0 => "Anterior communicating artery aneurysm" 1 => "Subarachnoid haemorrhage" 2 => "Computational fluid dynamics" 3 => "Asynchrony" 4 => "Brain aneurysm" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1150145" "palabras" => array:5 [ 0 => "Aneurisma de la arteria comunicante anterior" 1 => "Hemorragia subaracnoidea" 2 => "Dinámica de fluidos computacional" 3 => "Asincronía" 4 => "Aneurisma cerebral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Introduction and objectivesThe anterior communicating complex is one the most common locations for aneurysm development. It receives blood from both carotid circulations and the effect of synchrony on the arrival of blood flow has not been previously studied. The objective of this study was to compare the asynchrony conditions of the A1 pulse and its effects on the haemodynamic conditions of anterior communicating artery (ACoA) aneurysms. Materials and methodsFrom 2008 to 2017, 54 anterior communicating artery aneurysms treated at our centre were included in the study. Computational fluid dynamics (CFD) techniques were employed and simulations consisted of complete conditions of synchrony and introducing a delay of 0.2s in the non-dominant A1 artery. Time-averaged wall shear stress (TAWSS), low shear area (LSA), A1 diameter and ACoA angles were measured. ResultsThe difference in the LSA in conditions of synchrony and asynchrony resulted in a broad range of positive and negative values. The symmetry index (p=0.04) and A1/A2 angle on the dominant artery (p=0.04) were associated with changes in LSA. ConclusionsIn asynchrony, LSA increased in the absence of A1 asymmetry and low A1/A2 angles, potentially increasing the risk of aneurysm rupture in this location." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Introducción y objetivosEl complejo comunicante anterior es una de las localizaciones más frecuentes para el desarrollo de aneurismas; recibe sangre de ambas circulaciones carotídeas y el efecto de la sincronía en la llegada de sangre no ha sido estudiado previamente. El objetivo de este estudio es comparar las condiciones de asincronía del pulso de A1 y sus efectos en las condiciones hemodinámicas de los aneurismas de la arteria comunicante anterior (ACoA). Materiales y métodosDesde 2008 hasta 2017, 54 aneurismas de la ACoA tratados en nuestro centro se incluyeron en el estudio. Se emplearon técnicas de dinámica de fluidos computacional y las simulaciones consistieron en condiciones de completa sincronía y en la introducción de un retraso de 0,2s en la arteria A1 no dominante. Se realizaron mediciones del TAWSS, área de bajo cizallamiento (LSA), diámetros de A1 y ángulos de la AcoA. ResultadosLa diferencia producida en el LSA en condiciones de sincronía y asincronía resultó en un amplio rango de valores positivos y negativos. El índice de simetría (p=0,04) y el ángulo A1/A2 en la arteria dominante (p=0,04) se relacionan con los cambios en el LSA. ConclusionesEn asincronía, el LSA se incrementó en ausencia de asimetría A1 y ángulos A1/A2 menores, incrementando potencialmente el riesgo de rotura de aneurismas en esta localización." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:10 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2917 "Ancho" => 2917 "Tamanyo" => 572461 ] ] "descripcion" => array:1 [ "en" => "Low shear area (white) in anterior communicating aneurysms in synchrony and asynchrony conditions. Upper row: left figure shows a right A1 hypoplasia with a symmetry index of 0.39 in synchrony conditions, right figure shows the same in asynchrony conditions; LSA decreased from 50.93 to 26.40 considering asynchrony condition. Lower row: left figure shows a right dominant A1 segment, symmetry index is 0.9, right figure shows the same aneurysm in asynchrony conditions, LSA increased from 25.03 to 36.78." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2896 "Ancho" => 2925 "Tamanyo" => 646530 ] ] "descripcion" => array:1 [ "en" => "Low shear area (white) in anterior communicating aneurysms in synchrony and asynchrony conditions. Upper row: left figure shows a dominant A1/A2 angle of 88.62 degrees in synchronic conditions, right figure shows the same aneurysm in asynchrony conditions; LSA decreased from 31.64 to 26.06. Lower row: left figure shows a dominant A1/A2 angle of 46.45 degrees in synchronic conditions, right figure shows the same aneurysm in asynchrony; LSA increased from 27.69 to 36.95." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Percentage \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender (n=54)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rupture status (n=54)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SAH cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83.3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Incidental cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment in SAH cases (n=45)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Endovascular treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61.1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A1 dominance (n=54)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left A1 dominant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61.11% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right A1 dominant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.89% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aneurysm axis lateralization</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left lateralization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.93% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right lateralization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74.07% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2117589.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "2 cases were not treated due to the severe haemorrhage with brainstem dysfunction signs." ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of the population." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Minimum \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Maximum \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aneurysm height (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aneurysm neck (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aspect ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.68 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left A1 diameter (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.47 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right A1 diameter (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left A2 diameter (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right A2 diameter (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left A1–A2 angle (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">159.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right A1–A2 angle (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">160.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.47 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A1–A1 angle (degrees) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">176.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">136.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symmetry index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2117587.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Geometric characteristics of the arteries studied." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LSA increased (n=31) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LSA decreased (n=23) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-value (Mann Whitney-U test) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean aneurysm height (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.99 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean aneurysm neck (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.55 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean aspect ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.28 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean A1–A1 angle (degrees) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">139.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">137.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dominant side A1–A2 angle (degrees) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean symmetry index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2117588.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Univariate analysis of low shear area changes in relation to geometric characteristics." ] ] 5 => array:6 [ "identificador" => "eq0005" "etiqueta" => "(1)" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "ρ(u→⋅∇u→+∇p−μ∇u→=0)" "Fichero" => "STRIPIN_si1.jpeg" "Tamanyo" => 1509 "Alto" => 16 "Ancho" => 170 ] ] 6 => array:6 [ "identificador" => "eq0010" "etiqueta" => "(2)" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "∇⋅u→=0" "Fichero" => "STRIPIN_si2.jpeg" "Tamanyo" => 631 "Alto" => 13 "Ancho" => 59 ] ] 7 => array:6 [ "identificador" => "eq0015" "etiqueta" => "(3)" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "μ−μ∞μ0−μ∞=(1+(Γγ˙))n−12" "Fichero" => "STRIPIN_si4.jpeg" "Tamanyo" => 1794 "Alto" => 31 "Ancho" => 161 ] ] 8 => array:5 [ "identificador" => "eq0020" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "WSS=ni⋅τij" "Fichero" => "STRIPIN_si8.jpeg" "Tamanyo" => 848 "Alto" => 15 "Ancho" => 87 ] ] 9 => array:5 [ "identificador" => "eq0025" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "TAWSS=1T∫0T|WSS| dt" "Fichero" => "STRIPIN_si11.jpeg" "Tamanyo" => 1876 "Alto" => 39 "Ancho" => 170 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of unruptured cerebral aneurysms in Chinese adults aged 35 to 75 years: a cross-sectional study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.H. 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Clinical Research

A1 asynchrony, a potential risk factor for the rupture of anterior communicating artery aneurysms: A computational fluid dynamics study

Asincronía de A1, un factor de riesgo potencial para la rotura de aneurismas de la arteria comunicante anterior: un estudio de dinámica de fluidos computacional

José Luis Thenier-Villaa,b,c,

Autor para correspondencia

jose.luis.thenier.villa@sergas.es

Corresponding author.

, Antonio Riveiro Rodríguezd, Rosa María Martínez-Rolána,c, Miguel Gelabert-Gonzálezb, Pedro Miguel González-Vargasa, Lourdes Calero-Félixa, Raúl Alejandro Galarraga Campoverdea,c, Adolfo Ramón De La Lama Zaragozaa,c, Juan Poud, Cesáreo Conde Alonsoa,c

a Department of Neurosurgery, University Hospital Complex of Vigo, Estrada de Clara Campoamor, 341, Vigo 36312, Spain

b Department of Surgery, University of Santiago de Compostela, Rúa de San Francisco, s/n, 15782 Santiago de Compostela, Spain

c Galicia Sur Health Research Institute (IIS Galicia Sur) SERGAS-UVIGO, Estrada de Clara Campoamor, 341, Vigo 36312, Spain

d Applied Physics Department, EEI, University of Vigo, Lagoas-Marcosende, s/n, Vigo 36310, Spain

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        "titulo" => "Asincron&#237;a de A1&#44; un factor de riesgo potencial para la rotura de aneurismas de la arteria comunicante anterior&#58; un estudio de din&#225;mica de fluidos computacional"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Low shear area &#40;white&#41; in anterior communicating aneurysms in synchrony and asynchrony conditions&#46; Upper row&#58; left figure shows a dominant A1&#47;A2 angle of 88&#46;62 degrees in synchronic conditions&#44; right figure shows the same aneurysm in asynchrony conditions&#59; LSA decreased from 31&#46;64 to 26&#46;06&#46; Lower row&#58; left figure shows a dominant A1&#47;A2 angle of 46&#46;45 degrees in synchronic conditions&#44; right figure shows the same aneurysm in asynchrony&#59; LSA increased from 27&#46;69 to 36&#46;95&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Intracranial aneurysms are pathological dilatations of the cerebral arteries&#44; the estimated prevalence of cerebral aneurysms in the general population has been reported as high as 7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> The rupture of an intracranial aneurysm produces severe intracranial haemorrhages&#44; among the survivors who reach hospital care&#44; 27&#37; will die despite modern intensive and surgical measures&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Anterior communicating complex aneurysms are one the most frequent locations for intracranial aneurysms&#46; A prevalence of 3&#46;6&#37; is described in prospective autopsy studies&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> and anterior communicating artery &#40;AcoA&#41; aneurysms are responsible of about 39&#37; of aneurysmal subarachnoid haemorrhage cases&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> Previous studies showed certain features that could contribute to the formation of aneurysms in this location such as the hypoplasia of the A1 segment and the angulation of the arteries&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5&#44;6</span></a> Also&#44; certain common concepts in general aneurysm literature such as the relationship of the size and aspect ratio and rupture seems not to behave similarly in this location&#44; for example&#44; in a recent study&#44; 86&#46;9&#37; of the ruptured anterior communicating aneurysms had a size lower than 5<span class="elsevierStyleHsp" style=""></span>mm&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> and ruptured AcoA aneurysms with a size lower than 7<span class="elsevierStyleHsp" style=""></span>mm are found two times more frequent compared with other locations in anterior cerebral circulation&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Anterior communicating artery aneurysms receive blood from the carotid circulation&#44; and is the first point in which both left and right circulations met after its early bifurcation in the aortic arch&#46; Each carotid artery has its own geometry&#44; including diameter&#44; elongations&#44; tortuosity and atherosclerotic changes&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> as a consequence&#44; four pulsatile waves reach the brain in an asynchronous fashion&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> this phenomena is also documented from non-selective arteriography using aortic injections of contrast&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We have not found previous studies analysing the implications of the asynchrony of the carotid pulse in the haemodynamics of the anterior communicating aneurysms&#46; The objective of this study is to compare conditions of asynchrony in the pulse of the A1 artery and its effects in the haemodynamic environment of naturally occurred aneurysms using computational fluid dynamics&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0025" class="elsevierStylePara elsevierViewall">From January 2008 to December 2017&#44; 652 intracranial aneurysms were diagnosed by digital subtraction arteriography &#40;DSA&#41; in our centre&#44; of these&#44; 122 patients &#40;18&#46;71&#37;&#41; had anterior communicating aneurysms&#46; For this study&#44; patients with multiple aneurysms&#44; A1 segment agenesis&#44; suboptimal quality or absent CT angiography were excluded&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study population of this retrospective study corresponds to 54 anterior complex circulations&#46; The design of this study was approved by the Galician Clinical Research Ethics Committee&#46; Informed written consent was obtained from patients still alive&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Computational fluid dynamics analysis</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Model geometry</span><p id="par0035" class="elsevierStylePara elsevierViewall">For the treatment of the geometry&#44; anterior communicating artery complex was selected&#44; starting from the first segment of the A1 artery to at least 3<span class="elsevierStyleHsp" style=""></span>mm of the A2 segment&#46; 3D sequences were obtained from 3D computed tomography angiogram &#40;CTA&#41; of cerebral arteries with a voxel resolution of 0&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;6<span class="elsevierStyleHsp" style=""></span>mm&#46; Digital subtraction angiography studies were not considered because of their vessel selectivity requiring registration&#47;fusion procedures from 2 internal carotid angiograms to obtain a model&#44; unsuitable for this retrospective study&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Segmentation and generation of STL surfaces were performed using the software Slicer3D &#40;Harvard Medical School&#44; Boston&#44; MA&#44; USA&#41;&#46; These surfaces were processed in Meshlab &#40;Visual Computing Lab&#44; Pisa&#44; Italy&#41; and FreeCAD &#40;Juergen Riegel&#44; Werner Mayer&#44; Yorik van Havre&#44; OpenSource&#44; <a href="http://freecadweb.org/">http&#58;&#47;&#47;freecadweb&#46;org&#47;</a>&#41;&#44; to create meshes with &#8776;100&#44;000 tetrahedral elements into the CFD software ANSYS Fluent 17&#46;0 &#40;Ansys&#44; Canonsburg&#44; PA&#44; USA&#41;&#46; A viscous layer of 0&#46;1<span class="elsevierStyleItalic">D</span> &#40;<span class="elsevierStyleItalic">D</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>diameter of the vessel lumen&#41;&#44; adjacent to the vessel walls&#44; was created to capture the boundary layer effects&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Governing equations and numerical simulation</span><p id="par0045" class="elsevierStylePara elsevierViewall">The CFD software was used to solve the Navier&#8211;Stokes and mass conservation equations under the assumption of laminar&#44; incompressible&#44; and non-Newtonian blood flow&#46; The corresponding governing equations are given as&#58;<elsevierMultimedia ident="eq0005"></elsevierMultimedia><elsevierMultimedia ident="eq0010"></elsevierMultimedia>where u&#8594; and <span class="elsevierStyleItalic">p</span> are the fluid velocity and the pressure&#44; respectively <span class="elsevierStyleItalic">&#961;</span> is the density &#40;1060<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">3</span>&#41;&#44; and <span class="elsevierStyleItalic">&#956;</span> is the dynamic viscosity of blood&#46; Dynamic viscosity is modelled using a Carreau model&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> This is given as&#58;<elsevierMultimedia ident="eq0015"></elsevierMultimedia>where <span class="elsevierStyleItalic">&#956;</span> is the effective viscosity depending upon the shear rate &#947;&#729;&#44; <span class="elsevierStyleItalic">&#956;</span><span class="elsevierStyleInf">0</span> the viscosity at zero shear rate &#40;0&#46;056<span class="elsevierStyleHsp" style=""></span>Pa<span class="elsevierStyleHsp" style=""></span>s&#41;&#44; &#956;&#8734; the viscosity at infinite shear rate &#40;0&#46;0035<span class="elsevierStyleHsp" style=""></span>Pa<span class="elsevierStyleHsp" style=""></span>s&#41;&#44; &#915; the time constant &#40;3&#46;313<span class="elsevierStyleHsp" style=""></span>s&#41; and <span class="elsevierStyleItalic">n</span> the power law index &#40;0&#46;3568&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Boundary conditions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Transient pulsatile simulations averaged over several cardiac cycles were performed&#46; Regarding the entrance boundary&#44; the input condition was a sinusoidal profile with a peak speed of 0&#46;5<span class="elsevierStyleHsp" style=""></span>m&#47;s and a minimum speed of 0&#46;1<span class="elsevierStyleHsp" style=""></span>m&#47;s&#46; The pulse length was 0&#46;125<span class="elsevierStyleHsp" style=""></span>s&#44; and the period 0&#46;5<span class="elsevierStyleHsp" style=""></span>s&#46; The output boundaries were defined as constant pressure outlets&#44; with a pressure close to the mean arterial pressure of a normal individual &#40;100<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46; Dominancy was defined as the A1 artery with the largest diameter&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The experiment was conducted with 2 profiles in each case&#44; introducing a delay of 0&#46;2<span class="elsevierStyleHsp" style=""></span>s &#40;asynchrony condition&#41; and a second profile assuming complete synchrony of both A1 inlets&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Output variables</span><p id="par0060" class="elsevierStylePara elsevierViewall">The wall shear stress &#40;WSS&#41; describes the viscous stress exerted by the blood on the walls of the artery&#46; This magnitude is calculated as&#58;<elsevierMultimedia ident="eq0020"></elsevierMultimedia>where ni is the normal vector to the surface and &#964;ij the viscous stress tensor&#46; The time-averaged magnitude corresponding to the wall shear stress &#40;TAWSS&#41; is calculated as follows&#58;<elsevierMultimedia ident="eq0025"></elsevierMultimedia>where <span class="elsevierStyleItalic">T</span> denotes the period of the cardiac cycle &#40;assumed <span class="elsevierStyleItalic">T</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>s&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Time-averaged WSS and pressure were considered&#46; Low shear area WSS &#40;LSA&#41;&#44; was defined as the percentage of the aneurysmal area with a WSS below 10&#37; of the TAWSS measured in the parent artery &#40;dominant A1&#41; of each case&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Geometric analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">The geometry of the aneurysm&#44; regarding its shape and size was measured from 3D reconstructions&#44; the definitions of these variables are well described by previous studies&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The diameter of the 4 vessels A1L&#44; A1R&#44; A2L and A2R were measured&#46; Aneurysm lateralization was defined as the direction on the left-right axis of the height vector&#46; A1 dominance was defined as the side of the largest of both A1 arteries &#40;diameter measured in mm&#41;&#46; Symmetry index was defined as the quotient between the non-dominant and the dominant A1 diameters independently from the side&#44; in a scale from 0 to 1&#44; where 1 corresponds to fully symmetric A1 arteries&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We also include in the analysis 3 angles&#44; left A1&#47;A2 angle&#44; right A1&#47;A2 angle and A1&#8211;A1 angle&#44; methods of this measurements were described elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistics</span><p id="par0085" class="elsevierStylePara elsevierViewall">All output variables from case-by-case simulations were registered for statistical analysis&#46; For these analyses&#44; SPSS software version 20 for MacOS was used&#46; The inferential analysis was made from nonparametric tests for paired samples when comparing among comparisons between synchronic and asynchrony conditions&#44; and tests for independent samples when considering grouped nominal variables&#46; A <span class="elsevierStyleItalic">p</span>-value less than 0&#46;05 is assumed to be significant&#46; Rupture event or status of the aneurysm was not assessed in the analysis because of the imbalance of the distribution in this variable&#44; risk was assumed according to the WSS changes&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Population characteristics</span><p id="par0090" class="elsevierStylePara elsevierViewall">Fifty-four cases were analyzed in this study&#44; 31 cases &#40;57&#46;4&#37;&#41; were male and 23 cases &#40;42&#46;7&#37;&#41; were female&#46; The mean age at diagnosis was 56&#46;14 years &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#46;09&#41;&#46; 45 cases presented as ruptured aneurysms with subarachnoid haemorrhage &#40;83&#46;3&#37;&#41; and 9 cases as unruptured aneurysms &#40;16&#46;7&#37;&#41;&#46; Considering only the subarachnoid haemorrhage cases &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45&#41;&#44; the distribution of Fisher&#39;s radiological grade was grade 2 in 10 cases &#40;22&#46;22&#37;&#41;&#44; grade 3 in 16 cases &#40;35&#46;56&#37;&#41; and grade 4 in 19 cases &#40;42&#46;22&#37;&#41;&#46; In SAH cases the clinical severity in the WFNS scale was grade 1 in 22 cases &#40;48&#46;89&#37;&#41;&#44; grade 2 in 9 cases &#40;20&#37;&#41;&#44; grade 3 in 1 case &#40;2&#46;22&#37;&#41;&#44; grade 4 in 7 cases &#40;15&#46;56&#37;&#41; and grade 5 in 6 cases &#40;13&#46;33&#37;&#41;&#46; Baseline characteristics of the population are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Geometry characteristics</span><p id="par0095" class="elsevierStylePara elsevierViewall">Measurements of the dimensions of the aneurysm were obtained&#44; including height and neck and aspect ratio&#46; We also measured the diameter of both A1 and A2 arteries&#44; the right and left A1&#47;A2 angles&#44; and the A1&#8211;A1 angle&#46; These measurements are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; There is a tendency to lateralization of the aneurysm towards the side with the smaller A1&#47;A2 angle&#44; in left lateralization aneurysms the A1&#47;A2 angles had an average of 101 and 74 degrees for the left and right sides respectively&#59; and in right lateralization aneurysms&#44; these angles were 79 and 82 degrees for the left and right sides&#44; respectively&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Haemodynamic characteristics in synchronous and asynchronous conditions</span><p id="par0100" class="elsevierStylePara elsevierViewall">A significant difference exists in TAWSS in asynchrony conditions&#46; Mean TAWSS was 1&#46;25<span class="elsevierStyleHsp" style=""></span>Pa and 1&#46;34<span class="elsevierStyleHsp" style=""></span>Pa in asynchrony and synchrony conditions respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#44; paired samples <span class="elsevierStyleItalic">T</span>-test&#41;&#44; mean time-averaged pressure was 13&#44;205<span class="elsevierStyleHsp" style=""></span>Pa and 13&#44;495<span class="elsevierStyleHsp" style=""></span>Pa in asynchrony and synchrony conditions respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#46; The difference produced in the LSA in synchronous and asynchronous conditions resulted in a broad range including positive and negative values &#40;from &#8722;35&#46;68 to 27&#46;34&#41;&#44; for this reason the population was grouped owing to this variable into &#8220;LSA increased in asynchrony&#8221; and &#8220;LSA decreased in asynchrony&#8221; groups&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows a summary of the effect of different geometric variables over this phenomenon in a univariate analysis&#46; In this analysis&#44; the symmetry index and A1&#47;A2 angle on the dominant artery were related to changes in LSA&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The effects of asynchrony on the pressure measured in the aneurysm were mainly negative with a mean of &#8722;289&#46;68<span class="elsevierStyleHsp" style=""></span>Pa &#40;range of &#8722;4755&#46;84 to 218&#46;10<span class="elsevierStyleHsp" style=""></span>Pa&#44; SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>717&#46;16<span class="elsevierStyleHsp" style=""></span>Pa&#41;&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">As a result of the anatomical configuration of the arterial system&#44; four different pulse waves reach the Willis complex at different times&#46; The first aortic branch comprises the brachiocephalic trunk that branches off into the right common carotid and subclavian arteries&#44; while the left common carotid and subclavian arteries emerges independently from the aortic arch&#46; This particular asymmetric configuration and other anatomical and pathological variabilities such as the existence of atherosclerotic plaques in the lumen of large vessels are determinants of cerebral pulse asynchrony&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a></p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Geometry of the anterior communicating artery complex</span><p id="par0115" class="elsevierStylePara elsevierViewall">The anterior communicating artery is a complex site due to its anatomical features&#46; It receives flow from two independent circulations&#59; it is also known that the diameters of both anterior cerebral arteries are usually different in patients with aneurysms&#44; several previous studies have shown that this configuration is a risk factor for both the development and rupture of the aneurysm and increases the risk of complications of the treatment of aneurysms in this location&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">15&#8211;17</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In our study&#44; asymmetry is present in virtually all cases&#44; a symmetry index of less than 0&#46;80 is present in 72&#37; of cases and an index lower than 0&#46;5 is present in up to 20&#37; of cases&#46; We did not find statistical differences in ruptured and unruptured aneurysms in our series&#44; although our sample of unruptured aneurysms is small&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Zhang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a> analysing 665 patients with aneurysms in various locations described that the A1&#47;A2 angle is lower in individuals with aneurysms of anterior communicant artery&#44; with an average of 106 degrees compared to 120 degrees in the group without aneurysms in this location&#46; In our study&#44; A1&#47;A2 angle is smaller&#44; approaching a mean of 82 degrees&#46; The previously cited author also finds that there is a lateralization of the anterior communicating aneurysm to the side that offers a lower A1&#47;A2 angle&#44; this finding is comparable in our study&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Lin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> analysing 79 anterior communicating artery aneurysms described lower dominant A1&#47;A2 angles in patients with ruptured aneurysms in this location&#44; other studies found the same results&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">19&#44;20</span></a> In our study&#44; we did not find a significant association with this variable&#44; we must consider that in our series only nine unruptured aneurysms were analyzed&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Haemodynamic characteristics of aneurysms in conditions of synchrony and asynchrony</span><p id="par0135" class="elsevierStylePara elsevierViewall">Haemodynamic conditions play an indisputable role in the pathophysiology of the formation&#44; growth and rupture of aneurysms&#46; The most described variable is the wall shear stress &#40;WSS&#41;&#44; defined as the frictional force exerted by the flowing blood tangentially on the vessel lumen&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> This variable is usually diminished in ruptured aneurysms highlighting its potential role in the event of rupture&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> Low shear area is also described in most studies as a variable&#59; LSA is defined as the percentage of the aneurysm wall with a WSS lower than the 10&#37; of the WSS measured in the parent vessel for most authors&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In our study&#44; there is a significant direct influence of the asynchrony of the pulse in the A1 artery in the haemodynamic conditions of the aneurysm&#44; including a reduction of the total pressure&#44; and changes in the TAWSS that are reflected in two different groups&#58; some aneurysms had an increase and some had a decrease in TAWSS&#44; and in LSA in an inverse way&#46; In the univariate analysis&#44; we found greater symmetry indexes and lower A1&#47;A2 angles in patients in whom asynchrony conditions induced an increase in LSA&#44; potentially increasing the theoretical risk of bleeding&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The effect of the asynchronous pulse may produce a decrease in TAWSS when there is less or none A1 asymmetry&#44; two significant flows that produce a complex interaction resulting in an additive effect in the TAWSS over the complete cardiac cycle&#46; This effect is not achieved when there is a second asynchronous pulse&#44; the result is the decrease of the TAWSS&#44; and in consequence the increase of the LSA&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In the presence of lower A1&#47;A2 angles in the dominant artery&#44; more volume of blood is directed to A2 arteries bypassing the aneurysm&#44; synchrony may play a role in stabilizing the intra-aneurysmal flow&#59; if asynchrony is assumed&#44; TAWSS could be decreased and in consequence&#44; LSA increased&#46; In higher A1&#47;A2 angles&#44; the blood influx to the aneurysm is greater&#44; the second asynchronous pulse may therefore induce an increase in the TAWSS&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In addition to the geometric characteristics described previously as associated with an increased incidence of aneurysms in this location&#44; asynchrony could play an important role in the formation and growth of aneurysms&#44; it is therefore advisable to include this variable in further studies to address haemodynamics of this complex location&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">We conclude from our findings that in cases of mild or no asymmetry and&#47;or low A1&#47;A2 angles&#44; asynchrony of A1 arteries may potentially increase LSA&#44; increasing the theoretical risk of aneurysm rupture&#46; Two representative cases are illustrated in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Limitations</span><p id="par0165" class="elsevierStylePara elsevierViewall">For this theoretical study&#44; we have considered various conditions as true&#44; in real conditions they may not be absolutely certain&#46; Limitations inherent to out method are the absence of a specific velocity profile for each patient&#44; the absence of data on the physical characteristics of the arterial wall&#44; the geometric changes produced in the aneurysm after rupture&#44; among others&#46; Although DSA is the gold standard for brain vessels studies&#44; only CTA were included in this study&#46; CTA is highly accessible and is performed in all cases in our centre&#46; Moreover&#44; compared with DSA&#44; CTA allows to represent AcomA geometry in only one step&#44; DSA studies from AcomA needs two vessel catheterizations &#40;both ICA&#41; and registration&#47;fusion procedures making this unaffordable for retrospective studies&#46; Although low WSS is the most frequently described condition in ruptured aneurysms&#44; the discussion about the role of low WSS and high WSS in the pathophysiology of a brain aneurysm remains open&#46; The interpretation of our results assume a relevant role of low WSS in aneurysm rupture&#59; more research is warranted in the pathobiology of this phenomena&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusion</span><p id="par0170" class="elsevierStylePara elsevierViewall">The asynchrony of the flow in A1 arteries produces significant haemodynamic changes in anterior communicating artery aneurysms&#44; low shear area is increased in the absence of A1 asymmetry and low A1&#47;A2 angles&#44; potentially increasing the risk of rupture of aneurysms in this location&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Funding</span><p id="par0175" class="elsevierStylePara elsevierViewall">This work was partially supported by <span class="elsevierStyleGrantSponsor" id="gs1">Xunta de Galicia &#8211; Plan I2C Grant Program</span><span class="elsevierStyleGrantNumber" refid="gs1">POS-A&#47;2013&#47;161</span>&#44; <span class="elsevierStyleGrantNumber" refid="gs1">ED481B 2016&#47;047-0</span>&#44; <span class="elsevierStyleGrantNumber" refid="gs1">ED481D 2017&#47;010</span>&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The contents of this manuscript were not presented or published before&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflict of interests</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests&#46;</p></span></span>"
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              "titulo" => "Haemodynamic characteristics in synchronous and asynchronous conditions"
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              "titulo" => "Geometry of the anterior communicating artery complex"
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              "titulo" => "Haemodynamic characteristics of aneurysms in conditions of synchrony and asynchrony"
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    "fechaRecibido" => "2019-01-13"
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            0 => "Anterior communicating artery aneurysm"
            1 => "Subarachnoid haemorrhage"
            2 => "Computational fluid dynamics"
            3 => "Asynchrony"
            4 => "Brain aneurysm"
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          "palabras" => array:5 [
            0 => "Aneurisma de la arteria comunicante anterior"
            1 => "Hemorragia subaracnoidea"
            2 => "Din&#225;mica de fluidos computacional"
            3 => "Asincron&#237;a"
            4 => "Aneurisma cerebral"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The anterior communicating complex is one the most common locations for aneurysm development&#46; It receives blood from both carotid circulations and the effect of synchrony on the arrival of blood flow has not been previously studied&#46; The objective of this study was to compare the asynchrony conditions of the A1 pulse and its effects on the haemodynamic conditions of anterior communicating artery &#40;ACoA&#41; aneurysms&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">From 2008 to 2017&#44; 54 anterior communicating artery aneurysms treated at our centre were included in the study&#46; Computational fluid dynamics &#40;CFD&#41; techniques were employed and simulations consisted of complete conditions of synchrony and introducing a delay of 0&#46;2<span class="elsevierStyleHsp" style=""></span>s in the non-dominant A1 artery&#46; Time-averaged wall shear stress &#40;TAWSS&#41;&#44; low shear area &#40;LSA&#41;&#44; A1 diameter and ACoA angles were measured&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The difference in the LSA in conditions of synchrony and asynchrony resulted in a broad range of positive and negative values&#46; The symmetry index &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41; and A1&#47;A2 angle on the dominant artery &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41; were associated with changes in LSA&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In asynchrony&#44; LSA increased in the absence of A1 asymmetry and low A1&#47;A2 angles&#44; potentially increasing the risk of aneurysm rupture in this location&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El complejo comunicante anterior es una de las localizaciones m&#225;s frecuentes para el desarrollo de aneurismas&#59; recibe sangre de ambas circulaciones carot&#237;deas y el efecto de la sincron&#237;a en la llegada de sangre no ha sido estudiado previamente&#46; El objetivo de este estudio es comparar las condiciones de asincron&#237;a del pulso de A1 y sus efectos en las condiciones hemodin&#225;micas de los aneurismas de la arteria comunicante anterior &#40;ACoA&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Desde 2008 hasta 2017&#44; 54 aneurismas de la ACoA tratados en nuestro centro se incluyeron en el estudio&#46; Se emplearon t&#233;cnicas de din&#225;mica de fluidos computacional y las simulaciones consistieron en condiciones de completa sincron&#237;a y en la introducci&#243;n de un retraso de 0&#44;2<span class="elsevierStyleHsp" style=""></span>s en la arteria A1 no dominante&#46; Se realizaron mediciones del TAWSS&#44; &#225;rea de bajo cizallamiento &#40;LSA&#41;&#44; di&#225;metros de A1 y &#225;ngulos de la AcoA&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La diferencia producida en el LSA en condiciones de sincron&#237;a y asincron&#237;a result&#243; en un amplio rango de valores positivos y negativos&#46; El &#237;ndice de simetr&#237;a &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41; y el &#225;ngulo A1&#47;A2 en la arteria dominante &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41; se relacionan con los cambios en el LSA&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En asincron&#237;a&#44; el LSA se increment&#243; en ausencia de asimetr&#237;a A1 y &#225;ngulos A1&#47;A2 menores&#44; incrementando potencialmente el riesgo de rotura de aneurismas en esta localizaci&#243;n&#46;</p></span>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Low shear area &#40;white&#41; in anterior communicating aneurysms in synchrony and asynchrony conditions&#46; Upper row&#58; left figure shows a right A1 hypoplasia with a symmetry index of 0&#46;39 in synchrony conditions&#44; right figure shows the same in asynchrony conditions&#59; LSA decreased from 50&#46;93 to 26&#46;40 considering asynchrony condition&#46; Lower row&#58; left figure shows a right dominant A1 segment&#44; symmetry index is 0&#46;9&#44; right figure shows the same aneurysm in asynchrony conditions&#44; LSA increased from 25&#46;03 to 36&#46;78&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Low shear area &#40;white&#41; in anterior communicating aneurysms in synchrony and asynchrony conditions&#46; Upper row&#58; left figure shows a dominant A1&#47;A2 angle of 88&#46;62 degrees in synchronic conditions&#44; right figure shows the same aneurysm in asynchrony conditions&#59; LSA decreased from 31&#46;64 to 26&#46;06&#46; Lower row&#58; left figure shows a dominant A1&#47;A2 angle of 46&#46;45 degrees in synchronic conditions&#44; right figure shows the same aneurysm in asynchrony&#59; LSA increased from 27&#46;69 to 36&#46;95&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Rupture status &#40;n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">54&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SAH cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Incidental cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Treatment in SAH cases &#40;n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">45&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Endovascular treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;52&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left A1 dominant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;11&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right A1 dominant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;89&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left lateralization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;93&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right lateralization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#46;07&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Aneurysm height &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aneurysm neck &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aspect ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left A1 diameter &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right A1 diameter &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left A2 diameter &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right A2 diameter &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left A1&#8211;A2 angle &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">159&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right A1&#8211;A2 angle &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">160&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A1&#8211;A1 angle &#40;degrees&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">176&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Symmetry index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;94&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;15&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LSA increased &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>31&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LSA decreased &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>23&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value &#40;Mann Whitney-<span class="elsevierStyleItalic">U</span> test&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Mean aneurysm height &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Mean aneurysm neck &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean aspect ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean A1&#8211;A1 angle &#40;degrees&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">139&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">137&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Dominant side A1&#8211;A2 angle &#40;degrees&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">63&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean symmetry index&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;72&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;62&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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Información del artículo

ISSN: 11301473
Idioma original: Inglés

DOI:10.1016/j.neucir.2019.04.002

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