OBJECTIVE The aim of this study was to define predictive factors for rupture of middle cerebral artery (MCA) mirror bifurcation aneurysms. METHODS The authors retrospectively analyzed the data in patients with ruptured MCA bifurcation aneurysms with simultaneous presence of an unruptured MCA bifurcation mirror aneurysm treated in two neurosurgical centers. The following parameters were measured and analyzed with the statistical software R: neck, dome, and width of both MCA aneurysms-including neck/dome and width/neck ratios, shape of the aneurysms (regular vs irregular), inflow angle of both MCA aneurysms, and the diameters of the bilateral A and M segments and the frontal and temporal M trunks, as well as the bilateral diameter of the internal carotid artery (ICA). RESULTS The authors analyzed the data of 44 patients (15 male and 29 female, mean age 50.1 years). Starting from the usual significance level of 0.05, the Sidak-corrected significance level is 0.0039. The diameter of the measured vessels was statistically not significant, nor was the inflow angle. The size of the dome was highly significant (p = 0.0000069). The size of the neck (p = 0.0047940) and the width of the aneurysms (p = 0.0056902) were slightly nonsignificant at the stated significance level of 0.0039. The shape of the aneurysms was bilaterally identical in 22 cases (50%). In cases of asymmetrical presentation of the aneurysm shape, 19 (86.4%) ruptured aneurysms were irregular and 3 (13.6%) had a regular shape (p = 0.001). CONCLUSIONS In this study the authors show that the extraaneurysmal flow dynamics in mirror aneurysms are nonsignificant, and the aneurysmal geometry also does not seem to play a role as a predictor for rupture. The only predictors for rupture were size and shape of the aneurysms. It seems as though under the same conditions, one of the two aneurysms suffers changes in its wall and starts growing in a more or less stochastic manner. Newer imaging methods should enable practitioners to see which aneurysm has an unstable wall, to predict the rupture risk. At the moment one can only conclude that in cases of MCA mirror aneurysms the larger one, with or without shape irregularities, is the unstable aneurysm and that this is the one that needs to be treated.

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Background Central drop foot is a common problem in patients with stroke or multiple sclerosis (MS). For decades, it has been treated with orthotic devices, keeping the ankle in a fixed position. It has been shown recently that semi-implantable functional electrical stimulation (siFES) of the peroneal nerve can lead to a greater gait velocity increase than orthotic devices immediately after being switched on. Little is known, however, about long-term outcomes over 12 months, and the relationship between quality of life (QoL) and gait speed using siFES has never been reported applying a validated tool. We provide here a report of short (3 months) and long-term (12 months) outcomes for gait speed and QoL. Methods Forty-five consecutive patients (91% chronic stroke, 9% MS) with central drop foot received siFES (Actigait®). A 10 m walking test was carried out on day 1 of stimulation (T1), in stimulation ON and OFF conditions, and repeated after 3 (T2) and 12 (T3) months. A 36-item Short Form questionnaire was applied at all three time points. Results We found a main effect of stimulation on both maximum ( p < 0.001) and comfortable gait velocity (p < 0.001) and a main effect of time ( p = 0.015) only on maximum gait velocity. There were no significant interactions. Mean maximum gait velocity across the three assessment time points was 0.13 m/s greater with stimulation ON than OFF, and mean comfortable gait velocity was 0.083 m/s faster with stimulation ON than OFF. The increase in maximum gait velocity over time was 0.096 m/s, with post hoc testing revealing a significant increase from T1 to T2 ( p = 0.012 ) , which was maintained but not significantly further increased at T3. QoL scores showed a main effect of time ( p < 0.001), with post hoc testing revealing an increase from T1 to T2 (p < 0.001), which was maintained at T3 (p < 0.001). Finally, overall absolute QoL scores correlated with the absolute maximum and comfortable gait speeds at T2 and T3, and the increase in overall QoL scores correlated with the increase in comfortable gait velocity from T1 to T3. Pain was reduced at T2 (p < 0.001) and was independent of gait speed but correlated with overall QoL (p < 0.001). Conclusions Peroneal siFES increased maximal and comfortable gait velocity and QoL, with the greatest increase in both over the first three months, which was maintained at one year, suggesting that 3 months is an adequate follow-up time. Pain after 3 months correlated with QoL and was independent of gait velocity, suggesting pain as an independent outcome measure in siFES for drop foot.

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