Transvenous embolization of noncavernous dural arteriovenous fistulas (dAVFs): A systematic review and meta-analysis.

BACKGROUND: Intracranial dural arteriovenous fistulas (dAVFs) are abnormal connections between arteries and veins within the dura mater. Various treatment modalities, such as surgical ligation, endovascular intervention, and radiosurgery, aim to close the fistulous connection. Although transvenous embolization (TVE) is the preferred method for carotid-cavernous fistulas, its description and outcomes for noncavernous dAVFs vary. This has prompted a systematic review and meta-analysis to comprehensively assess the effectiveness of TVE in treating noncavernous dAVFs, addressing variations in outcomes and techniques. METHODS: We searched PubMed and Embase, spanning from the earliest records to December 2022, to identify pertinent English-language articles detailing the utilization of TVE. We focused on specific procedural details, outcomes, and complications in patients older than 18 years. The data collected and analyzed comprised the sample size, number of fistulas, publication specifics, presenting symptoms, fistula grades, and pooled rates of embolizations, outcomes, follow-up information, and complications. RESULTS: From a total of 565 screened articles, 15 retrospective articles encompassing 166 patients spanning across seven countries met the inclusion criteria. Their Newcastle-Ottawa scores ranged from 6 to 8. Intraprocedural complication rate was 10% (95% confidence interval [CI] = 5.9-17.1) and in-hospital postprocedural complication rate was 5.4% (95% CI = 2.8-10.6). Prevalence of in-hospital mortality was 5.5% (95% CI = 2.9-10.6). Complication rate during follow-up was 8.6% (95% CI = 4.7-15.7) with fistula rupture occurring in 5.5% (95% CI = 2.6-11.6) of patients. Complete obliteration rate at final angiographic follow-up was 94.9% (95% CI = 90.3-99.9). Symptoms improved in 95% (95% CI = 89.8-100) of patients at final follow-up. CONCLUSION: To our knowledge, we present the first meta-analysis assessing obliteration rates, outcomes, and complications of TVE for dAVFs. Our analysis highlights the higher (>90%) complete obliteration rates. Large prospective multicenter studies are needed to better define the utility of TVE for noncavernous dAVFs.

Vertebral Bone Quality Score as a Predictor of Adjacent Segment Disease After Lumbar Interbody Fusion.

BACKGROUND AND OBJECTIVE: With lumbar spine fusion being one of the most commonly performed spinal surgeries, investigating common complications such as adjacent segment disease (ASD) is a high priority. To the authors' knowledge, there are no previous studies investigating the utility of the preoperative magnetic resonance imaging-based vertebral bone quality (VBQ) score in predicting radiographic and surgical ASD after lumbar spine fusion. We aimed to investigate the predictive factors for radiographic and surgical ASD, focusing on the predictive potential of the VBQ score. METHODS: A single-center retrospective analysis was conducted of all patients who underwent 1-3 level lumbar or lumbosacral interbody fusion for lumbar spine degenerative disease between 2014 and 2021 with a minimum 12 months of clinical and radiographic follow-up. Demographic data were collected, along with patient medical, and surgical data. Preoperative MRI was assessed in the included patients using the VBQ scoring system to identify whether radiographic ASD or surgical ASD could be predicted. RESULTS: A total of 417 patients were identified (mean age, 59.8 ± 12.4 years; women, 54.0%). Eighty-two (19.7%) patients developed radiographic ASD, and 58 (13.9%) developed surgical ASD. A higher VBQ score was a significant predictor of radiographic ASD in univariate analysis (2.4 ± 0.5 vs 3.3 ± 0.4; P < .001) and multivariate analysis (odds ratio, 1.601; 95% CI, 1.453-1.763; P < .001). For surgical ASD, a significantly higher VBQ score was seen in univariate analysis (2.3 ± 0.5 vs 3.3 ± 0.4; P < .001) and served as an independent risk factor in multivariate analysis (odds ratio, 1.509; 95% CI, 1.324-1.720; P < .001). We also identified preoperative disk bulge and preoperative existence of adjacent segment disk degeneration to be significant predictors of both radiographic and surgical ASD. Furthermore, 3-level fusion was also a significant predictor for surgical ASD. CONCLUSION: The VBQ scoring system might be a useful adjunct for predicting radiographic and surgical ASD.

Association of area deprivation index (ADI) with demographics and postoperative outcomes in pediatric brain tumor patients.

PURPOSE: Although social determinants of health (SDOH) have been associated with adverse surgical outcomes, cumulative effects of multiple SDOH have never been studied. The area deprivation index (ADI) assesses cumulative impact of SDOH factors on outcomes. We analyzed the relationship between ADI percentile and postoperative outcomes in pediatric patients diagnosed with brain tumors. METHODS: A retrospective, observational study was conducted on our consecutive series of pediatric brain tumor patients presenting between January 1, 1999, and May 31, 2022. Demographics and outcomes were collected, identifying SDOH factors influencing outcomes found in the literature. ADI percentiles were identified based on patient addresses, and patients were stratified into more (ADI 0-72%) and less (ADI 73-100%) disadvantaged cohorts. Univariate and multivariate logistic regression analyses were completed for demographics and outcomes. RESULTS: A total of 272 patients were included. Demographics occurring frequently in the more disadvantaged group were Black race (13.1% vs. 2.8%; P = .003), public insurance (51.5% vs. 27.5%; P < .001), lower median household income ($64,689 ± $19,254 vs. $46,976 ± $13,751; P < .001), and higher WHO grade lesions (15[11.5%] grade III and 8[6.2%] grade IV vs. 8[5.6%] grade III and 5[3.5%] grade IV; P = .11). The more disadvantaged group required adjunctive chemotherapy (25.4% vs. 12.05%; P = .007) or radiation therapy (23.9% vs. 12.7%; P = .03) more frequently and had significantly greater odds of needing adjunctive chemotherapy (odds ratio [OR], 1.11; confidence interval [CI], 1.01-1.22; P = .03) in a multivariate model, which also identified higher WHO tumor grades at presentation (OR, 1.20; CI, 1.14-1.27; P < .001). CONCLUSION: These findings are promising for use of ADI to represent potential SDOH disadvantages that pediatric patients may face throughout treatment. Future studies should pursue large multicenter collaborations to validate these findings.

Social Determinants of Health and Associations With Outcomes in Pediatric Patients With Brain Tumors.

BACKGROUND AND OBJECTIVES: Social determinants of health (SDOH) are nonmedical factors that affect health outcomes. Limited investigation has been completed on the potential association of these factors to adverse outcomes in pediatric populations. In this study, the authors aimed to analyze the effects of SDOH disparities and their relationship with outcomes after brain tumor resection or biopsy in children. METHODS: The authors retrospectively reviewed the records of their center's pediatric patients with brain tumor. Black race, public insurance, median household income, and distance to hospital were the investigated SDOH factors. Univariate analysis was completed between number of SDOH factors and patient demographics. Multivariate linear regression models were created to identify coassociated determinants and outcomes. RESULTS: A total of 272 patients were identified and included in the final analysis. Among these patients, 81 (29.8%) had no SDOH disparities, 103 (37.9%) had 1, 71 (26.1%) had 2, and 17 (6.2%) had 3. An increased number of SDOH disparities was associated with increased percentage of missed appointments ( P = .002) and emergency room visits ( P = .004). Univariate analysis demonstrated increased missed appointments ( P = .01), number of postoperative imaging ( P = .005), and number of emergency room visits ( P = .003). In multivariate analysis, decreased median household income was independently associated with increased length of hospital stay ( P = .02). CONCLUSION: The SDOH disparities are prevalent and impactful in this vulnerable population. This study demonstrates the need for a shift in research focus toward identifying the full extent of the impact of these factors on postoperative outcomes in pediatric patients with brain tumor.

Residual In-Stent Carotid Stenosis and Cigarette Smoking are Independent Predictors of Carotid Restenosis After Carotid Artery Stenting-Results from 738 Carotid Artery Stenting Procedures at a Single Center.

BACKGROUND AND OBJECTIVES: Carotid artery stenting (CAS) has become a viable alternative to carotid endarterectomy for the management of carotid stenosis. Our aim was to determine the rate of radiographic restenosis after CAS and clinical, radiographic, and procedural predictors of in-stent restenosis. METHODS: Our single-center, prospectively maintained database was retrospectively reviewed for CAS procedures performed in symptomatic and asymptomatic patients over 12 years (2010-2022). Baseline demographic data, procedural characteristics, and preprocedural and postprocedural radiographic and clinical details were noted. Baseline characteristics of patients with and without carotid restenosis were compared using the χ2 test for categorical variables and the Student t-test for continuous variables. Univariate and multivariate analyses were performed to determine risk factors associated with restenosis, defined as >70% on digital subtraction angiography. RESULTS: A total of 1017 consecutive CAS procedures were performed in 905 patients during the 12-year period, with 738 in 632 patients included in our study. Our cohort's overall restenosis rate was 17%, with a 14% restenosis rate at 2 years. On multivariate regression analysis, former or current smoking status (odds ratio [OR] = 2.3, 95% CI 1.2-4.1), plaque irregularity (OR 0.55, 95% CI 0.33-0.91), moderate (50.1%-75%) contralateral stenosis (OR 3.2, 95% CI 1.4-7.2), severe (75.1%-99.9%) contralateral stenosis (OR 2.8, 95% CI 1.3-6.0), and residual (>70%) in-stent stenosis after initial stenting (OR 433, 95% CI 80-2346) were significantly associated with carotid restenosis. Area under the curve for the multivariate regression model analysis was 0.78. Patients with <28.6% initial (residual) in-stent stenosis (45/517 cases) had a 9% restenosis rate, whereas those with >28.6% initial in-stent stenosis (77/221 cases) had a 35% restenosis rate. CONCLUSION: In this large, single-center study of carotid artery stenosis treated with CAS, residual in-stent carotid stenosis of approximately 30% and smoking status were independent predictors for restenosis. Maximizing treatment of initial stenosis and smoking cessation education are important steps in preventing future carotid restenosis.

The first decade of flow diversion for intracranial aneurysms with the Pipeline embolization device.

OBJECTIVE: Flow diverter devices have revolutionized the treatment of intracranial aneurysms (IAs) since their approval in 2011 and have continued to evolve. The devices have been widely adopted across institutions and centers over the past decade; however, long-term follow-up after treatment with the Pipeline embolization device (PED) is not well described in the literature. The authors' institution was among the first to begin using PEDs, allowing them to report their series of patients treated with flow diverters ≥ 10 years ago. In this study, the authors aimed to evaluate the long-term angiographic and clinical outcomes of these patients and review lessons learned along the way. METHODS: The authors performed a retrospective review of their institution's IA database from January 2007 to July 2012. All patients with IAs treated with a PED prior to July 2012 were included. Clinical and angiographic characteristics were extracted. Available angiographic follow-up at 1, 3, 5, and 10 years was reported. RESULTS: A total of 83 patients with 92 aneurysms treated with a PED ≥ 10 years ago were identified and included in the study. The mean aneurysm dome diameter was 9.2 (SD 5.7) mm, the mean aneurysm height was 10.4 (SD 6.8) mm, and the mean neck width was 4.1 (SD 2.4) mm. Only 1 (1.1%) aneurysm was ruptured at presentation. Eight (8.7%) aneurysms were recurrences of previous treatment modalities. The morphology was saccular in 77 (83.7%) aneurysms, fusiform in 14 (15.2%), and blister-like in 1 (1.1%). Among saccular aneurysms, 60 (77.9%) were wide-necked. Seventy-five (81.5%) aneurysms were in the internal carotid artery, 12 (13.0%) were vertebrobasilar, 3 (3.3%) were in the middle cerebral artery, and 2 (2.2%) were in the posterior cerebral artery. Angiographic follow-up at 1, 3, 5, and 10 years was available for 75, 59, 50, and 15 patients, respectively. The complete occlusion rates at 1, 3, 5, and 10 years were 94.7%, 96.6%, 96.0%, and 100%, respectively. The retreatment rates at 1, 3, 5, and 10 years were 8.0%, 6.8%, 8.0%, and 6.7%, respectively. CONCLUSIONS: The authors provide their single-institution series of IA patients treated with a PED ≥ 10 years ago, with the first report of 10-year follow-up for the available patients.

Pretreatment and Posttreatment Factors Associated with Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis.

BACKGROUND: Hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to evaluate novel preoperative and postoperative risk factors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis. METHODS: A systematic search was conducted using PubMed and Embase databases for studies pertaining to aSAH and SDHC. Articles were assessed by meta-analysis if the number of risk factors for SDHC was reported by >4 studies and could be extracted separately for patients who did or did not develop SDHC. RESULTS: Thirty-seven studies were included, comprising 12,667 patients with aSAH (SDHC 2214 vs. non-SDHC 10,453). In a primary analysis of 15 novel potential risk factors, 8 were identified to be significantly associated with increased prevalence of SDHC after aSAH, including high World Federation of Neurological Surgeons grades (odds ratio [OR], 2.43), hypertension (OR, 1.33), anterior cerebral artery (OR, 1.36), middle cerebral artery (OR, 0.65), and vertebrobasilar artery (2.21) involvement, decompressive craniectomy (OR, 3.27), delayed cerebral ischemia (OR, 1.65), and intracerebral hematoma (OR, 3.91). CONCLUSIONS: Several new factors associated with increased odds of developing SDHC after aSAH were found to be significant. By providing evidence-based risk factors for shunt dependency, we describe an identifiable list of preoperative and postoperative prognosticators that may influence how surgeons recognize, treat, and manage patients with aSAH at high risk for developing SDHC.

Acute isolated posterior cerebral artery stroke treated with mechanical thrombectomy: A single-center experience and review of the literature.

BACKGROUND: Acute isolated posterior cerebral artery (PCA) occlusions account for 5-10% of all ischemic events. Due to peculiar patient presentation, the potential benefit of mechanical thrombectomy (MT) remains controversial. We evaluated the safety, feasibility, and effectiveness of MT in our patients and compared our results with the literature review conducted. METHODS: Charts were reviewed retrospectively for consecutive patients diagnosed with acute PCA stroke who underwent MT. Demographics, procedural, and follow-up details were noted. For the literature review, a systematic search of PubMed, MEDLINE, and EMBASE databases was conducted for the keywords "posterior cerebral artery" and "thrombectomy" for articles published between January 1, 2010 and June 30, 2021. Estimated rates for recanalization, favorable outcomes (modified Rankin Scale [mRS] score 0-2), symptomatic intracerebral hemorrhage (sICH), and mortality were extracted. RESULTS: Our cohort included 21 patients. Mean age was 71.2 years (standard deviation [SD] ± 10.2). Median National Institutes of Health Stroke Scale (NIHSS) presentation score was 9 (interquartile range [IQR] 5-15), with visual symptoms reported in 12(57.1%) patients. Overall, final modified thrombolysis in cerebral infarction (mTICI) 2b-3 was achieved in 17 patients (80.9%) with first-pass mTICI 2b-3 attained in 8 (38.1%). Postprocedure sICH occurred in 1 (4.8%) patient. Fifteen (71.4%) patients had a 0-2 mRS score at 90 days. Visual symptoms resolved in 10 of 12(83.3%) patients. Mortality occurred in 2 (9.5%) patients. For the systematic review, cohorts from 4 articles plus ours were included, totaling 222 patients. The estimated rate of successful recanalization was 85.25% (95% confidence interval[CI], 73.05%-97.45%), sICH was 3.60% (95% CI, 1.11%-6.09%), and mortality was 10.51% (95% CI, 5.88%-15.15%). CONCLUSION: The results of our series and systematic review indicate MT as a potentially safe and effective treatment modality for acute PCA stroke. These results also indicate that patient selection and assessment may be the key in obtaining favorable outcomes.

Statins versus Nonstatin Use in Patients with Chronic Subdural Hematomas Treated with Middle Meningeal Artery Embolization Alone - A Single-Center Experience.

BACKGROUND: Statins have been reported to reduce the rates of recurrence and improve the resolution of chronic subdural hematomas (cSDHs) treated surgically or conservatively. No studies have investigated the effect of statins in patients treated with middle meningeal artery embolization. METHODS: We performed a retrospective search of our cSDH database to identify patients treated with middle meningeal artery embolization alone. Only patients with at least 1 noncontrast computed tomography scan obtained 3-12 weeks after embolization were included. Hematoma volumes were measured at baseline and last noncontrast computed tomography available. The volumes, volume reduction, speed of resolution, and recurrence were compared between patients already receiving statin therapy when admitted and those who were not. RESULTS: Forty-six patients with 50 cSDHs were included (statins, 17 patients with 18 cSDHs vs. nonstatins, 29 patients with 32 cSDHs). The statin group had a significantly higher rate of hyperlipidemia (statin, 64.7% vs. nonstatin, 31%, P = 0.03) but similar demographics, remaining comorbidities, medications, and hematoma thickness, axial and coronal lengths, and baseline volumes. The time between procedure and last noncontrast computed tomography scan was similar between groups. There were no differences between the groups regarding volume reduction, final volume, speed of resolution, complete resolution, and recurrence. CONCLUSIONS: Patients treated with middle meningeal artery embolization alone who were on statin therapy had no differences in cSDH resolution or recurrence compared to those who were not on statin therapy. It is possible that the anti-inflammatory effects of statins may not be relevant when supply to the dura is interrupted by treatment with embolization.

Loss of XBP1 Leads to Early-Onset Retinal Neurodegeneration in a Mouse Model of Type I Diabetes.

Retinal neuronal injury and degeneration is one of the primary manifestations of diabetic retinopathy, a leading cause of vision loss in working age adults. In pathological conditions, including diabetes and some physiological conditions such as aging, protein homeostasis can become disrupted, leading to endoplasmic reticulum (ER) stress. Severe or unmitigated ER stress can lead to cell death, which in retinal neurons results in irreversible loss of visual function. X-box binding protein 1 (XBP1) is a major transcription factor responsible for the adaptive unfolded protein response (UPR) to maintain protein homeostasis in cells undergoing ER stress. The purpose of this study is to determine the role of XBP1-mediated UPR in retinal neuronal survival and function in a mouse model of type 1 diabetes. Using a conditional retina-specific XBP1 knockout mouse line, we demonstrate that depletion of XBP1 in retinal neurons results in early onset retinal function decline, loss of retinal ganglion cells and photoreceptors, disrupted photoreceptor ribbon synapses, and Müller cell activation after induction of diabetes. Our findings suggest an important role of XBP1-mediated adaptive UPR in retinal neuronal survival and function in diabetes.