Outcomes of Preoperative Transophthalmic Artery Embolization of Meningiomas: A Systematic Review with a Focus on Embolization Agent.

BACKGROUND: Transophthalmic artery embolization of intracranial meningiomas is thought to be associated with a high complication risk. PURPOSE: With advances in endovascular techniques, we systematically reviewed the current literature to improve our understanding of the safety and efficacy of transophthalmic artery embolization of intracranial meningiomas. DATA SOURCES: We performed a systematic search using PubMed from inception until August 3, 2022. STUDY SELECTION: Twelve studies with 28 patients with intracranial meningiomas embolized through the transophthalmic artery were included. DATA ANALYSIS: Baseline and technical characteristics and clinical and safety outcomes were collected. No statistical analysis was conducted. DATA SYNTHESIS: The average age of 27 patients was 49.5 (SD, 13) years. Eighteen (69%) meningiomas were located in the anterior cranial fossa, and 8 (31%), in the sphenoid ridge/wing. Polyvinyl alcohol particles were most commonly (n = 8, 31%) used to preoperatively embolize meningiomas, followed by n-BCA in 6 (23%), Onyx in 6 (23%), Gelfoam in 5 (19%), and coils in 1 patient (4%). Complete embolization of the target meningioma feeders was reported in 8 (47%) of 17 patients; partial embolization, in 6 (32%); and suboptimal embolization, in 3 (18%). The endovascular complication rate was 16% (4 of 25), which included visual impairment in 3 (12%) patients. LIMITATIONS: Selection and publication biases were limitations. CONCLUSIONS: Transophthalmic artery embolization of intracranial meningiomas is feasible but is associated with a non-negligible complication rate.

Higher Incidence of Unruptured Intracranial Aneurysms among Black and Hispanic Women on Screening MRA in Large Urban Populations.

BACKGROUND AND PURPOSE: Intracranial aneurysms have a reported prevalence of 1%-2% in the general population. Currently, only patients with a strong family history or autosomal dominant polycystic kidney disease are screened for intracranial aneurysms using MRA. The purpose of this study was to determine whether there are other specific patient populations at risk that should be offered screening for intracranial aneurysms. MATERIALS AND METHODS: This is a retrospective case-control study of adult patients who underwent a screening MRA of their brain at our comprehensive stroke center from 2011 to 2020. Patients with a history of a known brain aneurysm were excluded. Data were extracted on patient demographics and medical comorbidities. Bivariate analyses were performed, followed by multivariable logistic regression, to identify factors associated with a positive MRA screen for incidental aneurysms. RESULTS: Of 24,397 patients eligible for this study, 2084 screened positive for a possible intracranial aneurysm. On bivariate analysis, significant differences were present in the following categories: age, sex, race and ethnicity, chronic constipation, and hyperlipidemia. On logistic regression analysis, older age (+10 years: OR = 10.01; 95% CI, 10.01-10.02; P = .001), female sex (OR = 1.37; 95% CI, 1.24-1.51; P = .001), non-Hispanic Black (OR = 1.19; 95% CI, 1.02-1.40; P = .031), and Hispanic ethnicity (OR = 1.35; 95% CI, 1.16-1.58; P = .001) versus non-Hispanic White remained significant when adjusted for other factors. CONCLUSIONS: Targeted screening for high-risk elderly women of Black or Hispanic descent will yield higher positive findings for brain aneurysms, which may mitigate the risk of rupture. Whether this is a cost-effective approach has yet to be determined.

Embolic Agent Choice in Middle Meningeal Artery Embolization as Primary or Adjunct Treatment for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis.

BACKGROUND: Middle meningeal artery embolization is an emerging treatment option for chronic subdural hematomas. PURPOSE: Our aim was to assess outcomes following middle meningeal artery embolization by different techniques, including in comparison with traditional surgical methods. DATA SOURCES: We searched the literature databases from inception to March 2022. DATA SELECTION: We selected studies reporting outcomes after middle meningeal artery embolization as a primary or adjunctive treatment for chronic subdural hematoma. DATA ANALYSIS: We analyzed the risk of recurrence of chronic subdural hematoma, reoperation for recurrence or residual hematoma, complications, and radiologic and clinical outcomes using random effects modeling. Additional analyses were performed on the basis of whether middle meningeal artery embolization was used as the primary or adjunct treatment and by embolic agent type. DATA SYNTHESIS: Twenty-two studies were included with 382 patients with middle meningeal artery embolization and 1373 surgical patients. The rate of subdural hematoma recurrence was 4.1%. Fifty (4.2%) patients underwent a reoperation for a recurrent or residual subdural hematoma. Thirty-six (2.6%) experienced postoperative complications. The rates of good radiologic and clinical outcomes were 83.1% and 73.3%, respectively. Middle meningeal artery embolization was significantly associated with decreased odds of subdural hematoma reoperation (OR = 0.48; 95% CI, 23.4-99.1; P = .047) compared with surgery. The lowest rates of subdural hematoma radiologic recurrence, reoperation, and complications were observed among patients receiving embolization with Onyx, whereas good overall clinical outcome occurred most commonly with combined polyvinyl alcohol and coils. LIMITATIONS: A limitation was the retrospective design of studies included. CONCLUSIONS: Middle meningeal artery embolization is safe and effective, either as a primary or adjunctive treatment. Treatment using Onyx seems to yield lower rates of recurrence, rescue operation, and complications whereas particles and coils produce good overall clinical outcomes.

Use of the Woven EndoBridge Device for Sidewall Aneurysms: Systematic Review and Meta-analysis.

BACKGROUND: The Woven EndoBridge device was originally approved to treat intracranial wide-neck saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of sidewall intracranial aneurysms with variable success. PURPOSE: Our aim was to evaluate the safety and efficacy of the Woven EndoBridge device for sidewall aneurysms using a meta-analysis of the literature. DATA SOURCES: We performed a systematic review of all studies including patients treated with the Woven EndoBridge device for sidewall aneurysms from inception until May 2022 on Scopus, EMBASE, MEDLINE, the Web of Science, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION: Ten studies were selected, and 285 patients with 288 sidewall aneurysms were included. DATA ANALYSIS: A random-effects meta-analysis of proportions using a generalized linear mixed model was performed as appropriate. Statistical heterogeneity across studies was assessed with I2 statistics. DATA SYNTHESIS: The adequate occlusion rate at last follow-up was 89% (95% CI, 81%-94%; I2, = 0%), the composite safety outcome was 8% (95% CI, 3%-17%; I2 = 34%), and the mortality rate was 2% (95% CI, 1%-7%; I2 = 0%). Aneurysm width (OR = 0.5; P = .03) was the only significant predictor of complete occlusion. LIMITATIONS: Given the level of evidence, our results should be interpreted cautiously until confirmation from larger prospective studies is obtained. CONCLUSIONS: The initial evidence evaluating the use of the Woven EndoBridge device for the treatment of wide-neck sidewall intracranial aneurysms has demonstrated high rates of adequate occlusion with low procedural complications. Our findings favor the consideration of the Woven EndoBridge device as an option for the treatment of sidewall aneurysms.

The Impact of COVID-19 on Emergent Large-Vessel Occlusion: Delayed Presentation Confirmed by ASPECTS.

BACKGROUND AND PURPOSE: Our hypothesis is that the COVID-19 pandemic led to delayed presentations for patients with acute ischemic stroke. This study evaluates the impact of the coronavirus disease 2019 pandemic on presentation, treatment, and outcomes of patients with emergent large-vessel occlusion using data from a large health system in the Bronx, New York. MATERIALS AND METHODS: We performed a retrospective cohort study of 2 cohorts of consecutive patients with emergent large-vessel occlusion admitted to 3 Montefiore Health System hospitals in the Bronx from January 1 to February 17, 2020, (prepandemic) and March 1 to April 17, 2020 (pandemic). We abstracted data from the electronic health records on presenting biomarker profiles, admission and postprocedural NIHSS scores, time of symptom onset, time of hospital presentation, time of start of the thrombectomy procedure, time of revascularization, presenting ASPECTS, TICI recanalization score, mRS, functional outcomes, and mortality. RESULTS: Of 179 patients admitted with ischemic stroke during the study periods, 80 had emergent large-vessel occlusion, of whom 36 were in the pandemic group. Patients in the pandemic group were younger (66 versus 72 years, P < .061) and had lower ASPECTS (7 versus 9, P < .001) and took longer to arrive at the hospital (361 versus 152 minutes, P < .004) with no other major differences. There was a decreased rate of thrombolysis administration (22% versus 43%, P < .049) and a decreased number of patients treated with mechanical thrombectomy (33% versus 61%, P < .013). CONCLUSIONS: The pandemic led to delays in patients arriving at hospitals, leading to decreased patients eligible for treatment, while in-hospital evaluation and treatment times remain unchanged.

COVID-19-Associated Carotid Atherothrombosis and Stroke.

We present a radiology-pathology case series of 3 patients with coronavirus disease 2019 (COVID-19) with acute ischemic stroke due to fulminant carotid thrombosis overlying mild atherosclerotic plaque and propose a novel stroke mechanism: COVID-associated carotid atherothrombosis.

Psychosocial factors and hospitalisations for COVID-19: Prospective cohort study based on a community sample.

BACKGROUND: While certain infectious diseases have been linked to socioeconomic disadvantage, mental health problems, and lower cognitive function, relationships with COVID-19 are either uncertain or untested. Our objective was to examine the association of a range of psychosocial factors with hospitalisation for COVID-19. METHODS: UK Biobank, a prospective cohort study, comprises around half a million people who were aged 40-69 years at study induction between 2006 and 2010 when information on psychosocial factors and covariates were captured. Hospitalisations for COVID-19 were ascertained between 16th March and 26th April 2020. RESULTS: There were 908 hospitalisations for COVID-19 in an analytical sample of 431,051 England-based study members. In age- and sex-adjusted analyses, an elevated risk of COVID-19 was related to disadvantaged levels of education (odds ratio; 95% confidence interval: 2.05; 1.70, 2.47), income (2.00; 1.63, 2,47), area deprivation (2.20; 1.86, 2.59), occupation (1.39; 1.14, 1.69), psychological distress (1.58; 1.32, 1.89), mental health (1.50; 1.25, 1.79), neuroticism (1.19; 1.00, 1.42), and performance on two tests of cognitive function - verbal and numerical reasoning (2.66; 2.06, 3.34) and reaction speed (1.27; 1.08, 1.51). These associations were graded (p-value for trend ≤ 0.038) such that effects were apparent across the full psychosocial continua. After mutual adjustment for these characteristics plus ethnicity, comorbidity, and lifestyle factors, only the relationship between lower cognitive function as measured using the reasoning test and risk of the infection remained (1.98; 1.38, 2.85). CONCLUSIONS: A range of psychosocial factors revealed associations with hospitalisation for COVID-19 of which the relation with cognitive function, a marker of health literacy, was most robust.

A randomized trial of endovascular versus surgical management of ruptured intracranial aneurysms: Interim results from ISAT2.

BACKGROUND AND PURPOSE: Appropriate management of ruptured intracranial aneurysm (RIA) in patients eligible for surgical clipping but under-represented in or excluded from previous randomized trials remains undetermined. METHODS: The International Subarachnoid Aneurysm Trial-2 (ISAT-2) is a randomized care trial comparing surgical versus endovascular treatment (EVT) of RIA. All patients considered for surgical clipping but eligible for endovascular treatment can be included. The primary endpoint is death or dependency on modified Rankin score (mRS>2) at 1 year. Secondary endpoints are 1 year angiographic results and length of hospital stay. RESULTS: An interim analysis was performed after 103 patients were treated from November 2012 to July 2017 in 4 active centers. Fifty-two of the 55 patients allocated to surgery were treated by clipping, and 45 of the 48 allocated to EVT were treated by coiling, with 3 crossovers in each arm. The main endpoint (1 year mRS>2), available for 76 patients, was reached in 16/42 patients allocated to clipping (38%; 95%CI: 25%-53%), and 10/34 patients allocated to coiling (29%; 17%-46%). One year imaging results were available in 54 patients: complete aneurysm occlusion was found in 23/27 patients allocated to clipping (85%; 67%-94%), and 18/27 patients allocated to coiling (67%; 47%-81%). Hospital stay exceeding 20 days was more frequent in surgery (26/55 [47%; 34%-60%]) than EVT (9/48 [19%; 10%-31%]). CONCLUSION: Ruptured aneurysm patients for whom surgical clipping may still be best can be managed in a randomized care trial, which is feasible in some centers. More participating centers are needed.

An Exploration of the Relationships Among Facial Dimensions, Age, Sex, Dominance Status, and Personality in Rhesus Macaques (Macaca mulatta).

Aspects of personality in nonhuman primates have been linked to health, social relationships, and life history outcomes. In humans as well as nonhuman primates, facial morphology is associated with assertiveness, aggression, and measures of dominance status. In this study we aimed to examine the relationship among facial morphology, age, sex, dominance status, and ratings on the personality dimensions Confidence, Openness, Assertiveness, Friendliness, Activity, and Anxiety in rhesus macaques (Macaca mulatta). We measured facial width-to-height ratio (fWHR) and lower-height/full-height ratio (fLHFH) using photographs from 109 captive rhesus macaques, which observers also assessed for dominance status and personality, and explored the associations among facial morphology, age, sex, dominance status, and personality. fWHR and fLHFH personality associations depended on age category: Assertiveness was associated with higher fWHR and fLHFH, and Confidence was associated with lower fWHR and fLHFH, but all these associations were consistent only in individuals <8 yr. of age. We found fWHR and fLHFH to not be consistently associated with sex or dominance status; compared to younger individuals, we found few associations with fWHR and fLHFH for individuals older than 8 yr., which may be due to limited sample size. Our results indicate that in macaques <8 yr. old, facial morphology is associated with the Assertiveness and Confidence personality dimensions, which is consistent with results suggesting a relationship between fWHR and trait aggression in humans and assertiveness in brown capuchins, all of which implies that fWHR might be a cue to assertive and aggressive traits.