Abstract
Accurate rupture risk assessment is essential for optimizing treatment decisions in patients with cerebral aneurysms. While computational fluid dynamics (CFD) has provided critical insights into aneurysmal hemodynamics, most analyses focus on blood flow patterns, neglecting the biomechanical properties of the aneurysm wall. To address this limitation, we applied Fluid-Structure Interaction (FSI) analysis, an integrative approach that simulates the dynamic interplay between hemodynamics and wall mechanics, offering a more comprehensive risk assessment. In this study, we used advanced FSI techniques to investigate the rupture risk of middle cerebral artery bifurcation (MCA) aneurysms, analyzing a cohort of 125 patients treated for a MCA aneurysm at Kepler University Hospital, Linz, Austria. Multivariate analysis identified two significant rupture predictors: High Equivalent Stress Area (HESA; p = 0.049), which quantifies stress distribution relative to the aneurysm surface, and Gaussian curvature (GLN; p = 0.031), which captures geometric complexity. We also introduce the HGD index, a novel composite metric combining HESA, GLN, and Maximum Wall Displacement, designed to enhance predictive accuracy. With a threshold of 0.075, the HGD index exhibited excellent diagnostic performance; in internal validation, 24 of 25 ruptured aneurysms surpassed this threshold, yielding a sensitivity of 0.96. In a 5-fold cross validation the reliability of results was confirmed. Our findings demonstrate that the HGD index provides superior rupture risk stratification compared to conventional single-parameter models, offering a more robust tool for the assessment of complex aneurysmal structures. Further multicenter studies are warranted to refine and validate the HGD index, advancing its potential for clinical application and improving patient outcomes.