Enhanced Treatment Options for Dural Arteriovenous Fistulas at the Craniocervical Junction: Endovascular Embolization Versus Microsurgery? A Single-Center 23-Year Experience.

OBJECTIVE: The occurrence of dural arteriovenous fistulas (DAVFs) at the craniocervical junction (CCJ) is an uncommon vascular malformation. The diagnosis and treatment of CCJ DAVFs present a formidable challenge. This study aims to investigate the effect of endovascular embolization and microsurgery on improving patient prognosis. METHODS: This retrospective study included patients diagnosed with CCJ DAVFs who received treatment at the First Affiliated Hospital of Fujian Medical University between January 2000 and January 2023. The clinical records, imaging data, and treatment methods were obtained from the hospital's medical record system. The patients were classified into microsurgery and embolization groups based on the surgical technique employed for treatment. The primary outcome measures were surgical-associated neurological dysfunction (SAND) and long-term neurological outcomes. The Cox proportional hazard regression was utilized to determine hazard ratios and 95% confidence intervals (CI) to assess the relationship between treatment methods and prognosis. Kaplan-Meier survival analysis was employed to evaluate the incidence of SAND in both cohorts. RESULTS: This study recruited 46 patients with an average age of 53.72 ± 13.83 years. In the microsurgery group, there were 12 cases (26.1%) observed. While in the embolization group, there were 34 cases (73.9%). Of these patients, 16 (34.8%) experienced SAND after treatment. In the microsurgery group, there were 8 cases (75.0%), while in the embolization group, only 8 cases (23.5%) were reported. Specifically, the embolization group exhibited a significantly lower risk of SAND [adjusted hazard ratio = 0.259, 95% CI = 0.096-0.700; P = 0.008)] compared to the microsurgery group. Additionally, the combined Borden grade 2-3 was found to be significantly associated with SAND (adjusted hazard ratio = 3.150, 95% CI = 1.132-8.766; P = 0.028). The results of the Kaplan-Meier survival analysis indicated a statistically significant difference in the occurrence of favorable functional outcomes between the 2 groups (log-rank P = 0.0081). CONCLUSIONS: CCJ DAVFs are uncommon disorders characterized by a diverse range of clinical manifestations. The functional prognosis of endovascular treatment may be superior to microsurgery.

Microcatheter-guided compartment packing of acutely ruptured complex intracerebral aneurysms (ARCIAs): Preliminary experience and technical note.

Objective: We present our initial experience using the microcatheter-guided compartment packing (MCP) technique for endovascular embolization of acutely ruptured complex intracerebral aneurysms (ARCIAs) and evaluate the safety, feasibility, and efficiency of this technique. Methods: This retrospective, single-center study included 28 patients who underwent coil embolization using the MCP technique for ARCIAs at our institution between January 2021 and January 2022. The MCP technique was the placement of microcatheters in different compartments within the aneurysm to deploy the coils simultaneously or sequentially. Patient demographics, aneurysm characteristics, procedural parameters, grade of occlusion, complications, and clinical results were analyzed. The clinical outcomes were evaluated with modified Rankin Scale (mRS) scores. Results: Of the 28 patients successfully treated with the MCP technique, 24 (85.7%) aneurysms were considered as complete occlusions (Raymond I) based on the immediate postembolization angiogram results. Complications occurred in 2/28 treatments, including guidewire perforation with subarachnoid hemorrhage and cerebral vasospasm-related cerebral infarction. An angiography follow-up demonstrated complete occlusion in 25/28 aneurysms. Twenty-six (92.9%) patients had favorable 90-day outcomes (mRS 0-2) after the endovascular coil embolization. Conclusion: The MCP technique is simple, safe, and effective, achieving good packing density and initial occlusion rate when used to treat ARCIAs.

Altered hippocampal functional connectivity after the rupture of anterior communicating artery aneurysm.

Background and purpose: Aneurysmal subarachnoid hemorrhage (SAH) predisposes hippocampal injury, a major cause of follow-up cognitive impairment. Our previous study has revealed an abnormal resting-state brain network in patients after the rupture of anterior communicating artery (ACoA) aneurysm. However, the functional connectivity (FC) characteristics of the hippocampus and its relationship with cognitive performance in these patients remain unknown. Methods: This study ultimately included 26 patients and 19 age- and sex-matched controls who completed quality control for resting-state functional magnetic resonance imaging (fMRI). The mean time series for each side of the hippocampus was extracted from individuals and then a seed-to-voxel analysis was performed. We compared the difference in FC strength between the two groups and subsequently analyzed the correlations between abnormal FC and their cognitive performance. Results: The results of bilateral hippocampus-based FC analysis were largely consistent. Compared with the healthy controls, patients after the rupture of ACoA aneurysm exhibited significantly decreased FC between the hippocampus and other brain structures within the Papez circuit, including bilateral anterior and middle cingulate cortex (MCC), bilateral medial superior frontal gyrus, and left inferior temporal gyrus (ITG). Instead, increased FC between the hippocampus and bilateral insula was observed. Correlation analyses showed that more subjective memory complaints or lower total cognitive scores were associated with decreased connectivity in the hippocampus and several brain regions such as left anterior cingulate cortex (ACC) and frontotemporal cortex. Conclusion: These results extend our previous findings and suggest that patients with ruptured ACoA aneurysm exist hypoconnectivity between the hippocampus and multiple brain regions within the Papez circuit. Deactivation of the Papez circuit may be a crucial neural mechanism related to cognitive deficits in patients after the rupture of ACoA aneurysm.

Mechanical Thrombectomy with Tandem Double Stent Retriever in Combination with Intermediate Catheter Aspiration for Refractory Severe Hemorrhagic Cerebral Venous Sinus Thrombosis.

OBJECTIVE: We aimed to describe the initial experience of mechanical thrombectomy using tandem double stent retrievers combined with intermediate catheter aspiration to treat refractory severe hemorrhagic (SH)-cerebral venous sinus thrombosis (CVST). METHODS: All refractory SH-CVST patients treated with mechanical thrombectomy using tandem double stent retriever (SR) combined with intermediate catheter aspiration (MT-TDSA) in our institution were retrospectively reviewed. MT-TDSA is a technique that fully engages the clot with double SRs and retrieves the clot using a double SR in combination with aspiration from an intermediate catheter. Demographics, clinical manifestation, medical history, the location of the occluded venous sinus, intraoperative details, procedure-related complications, and modified Rankin Scale (1, 6, 12 months postoperatively) were collected and analyzed. RESULTS: Fourteen patients (median age, 43 years) with refractory SH-CVST were treated with MT-TDSA between January 2016 and January 2020. Ten of 14 (71.4%) had a successful intraoperative recanalization rate (>90%) using MT-TDSA. No procedure-related complications occurred. Eleven patients had good clinical outcomes (modified Rankin Scale score 0-2 at 12 months postoperatively). CONCLUSIONS: MT-TDSA for refractory SH-CVST might improve clot-capturing ability and remove blood clots from cerebral venous sinuses effectively and safely, achieving good clinical outcomes.

Altered functional connectivity within default mode network after rupture of anterior communicating artery aneurysm.

Background: Rupture of anterior communicating artery (ACoA) aneurysm often leads to cognitive impairment, especially memory complaints. The medial superior frontal gyrus (SFGmed), a node of the default mode network (DMN), has been extensively revealed to participate in various cognitive processes. However, the functional connectivity (FC) characteristics of SFGmed and its relationship with cognitive performance remain unknown after the rupture of the ACoA aneurysm. Methods: Resting-state functional MRI (fMRI) and cognitive assessment were acquired in 27 eligible patients and 20 controls. Seed-based FC between unilateral SFGmed and the rest of the brain was calculated separately, and then compared their intensity differences between the two groups. Furthermore, we analyzed the correlation between abnormal FC and cognitive function in patients with ruptured ACoA aneurysm. Results: Cognitive impairment was confirmed in 51.9% of the patients. Compared with the controls, patients suffering from ruptured ACoA aneurysm exhibited a similar FC decline between each side of SFGmed and predominant nodes within DMN, including the precuneus, angular gyrus, cingulate cortex, left hippocampus, left amygdala, left temporal pole (TPO), and left medial orbitofrontal cortex (mOFC). Besides, significantly decreased FC of left SFGmed and left insula, right middle temporal gyrus (MTG), as well as right mOFC, were also found. In addition, only enhanced insular connectivity with right SFGmed was determined, whereas increased FC of the left SFGmed was not observed. Correlation analyses showed that lower total cognitive performance or stronger subjective memory complaints were related to reduced connectivity in the SFGmed and several cortical regions such as the angular gyrus and middle cingulate cortex (MCC). Conclusion: Our results suggest that patients with ruptured ACoA aneurysm exist long-term cognitive impairment and intrinsic hypoconnectivity of cognition-related brain regions within DMN. Deactivation of DMN may be a potential neural mechanism leading to cognitive deficits in these patients.

Isolated Cervical Ruptured Radiculomedullary Artery Aneurysm Predominantly Presenting as Supratentorial Subarachnoid Hemorrhage: Case Report and Review of the Literature.

A spinal artery aneurysm originating from the branch of the extracranial vertebral artery is uncommon. Most of them were finally diagnosed due to the evidence of infratentorial or spinal subarachnoid hemorrhage (SAH). Herein, we report an extremely rare case of a ruptured spinal artery aneurysm which predominantly presented with supratentorial SAH. A 68-year-old woman was initially revealed cranial computed tomographic angiographically negative SAH with a Hunt-Hess grade of 3, while the digital subtraction angiography confirmed an isolated radiculomedullary aneurysm arising from the medial ascending branch of V2 segment at C2 level. The patient underwent surgery in a hybrid operating room. She was originally attempted with coil embolization, but successful clipping of the aneurysm was achieved through unilateral laminectomy at last. Regrettably, the current case suffered a poor clinical outcome due to the complications caused by progressive cerebral vasospasm. In summary, angiogram is of great value for this rare kind of aneurysmal definitive diagnosis. A hybrid operating room may be a feasible choice for the ruptured spinal artery aneurysm.

Early Deterioration and Long-Term Prognosis of Patients With Intracerebral Hemorrhage Along With Hematoma Volume More Than 20 ml: Who Needs Surgery?

Background and Purpose: The treatment of patients with intracerebral hemorrhage along with moderate hematoma and without cerebral hernia is controversial. This study aimed to explore risk factors and establish prediction models for early deterioration and poor prognosis. Methods: We screened patients from the prospective intracerebral hemorrhage (ICH) registration database (RIS-MIS-ICH, ClinicalTrials.gov Identifier: NCT03862729). The enrolled patients had no brain hernia at admission, with a hematoma volume of more than 20 ml. All patients were initially treated by conservative methods and followed up ≥ 1 year. A decline of Glasgow Coma Scale (GCS) more than 2 or conversion to surgery within 72 h after admission was defined as early deterioration. Modified Rankin Scale (mRS) ≥ 4 at 1 year after stroke was defined as poor prognosis. The independent risk factors of early deterioration and poor prognosis were determined by univariate and multivariate regression analysis. The prediction models were established based on the weight of the independent risk factors. The accuracy and value of models were tested by the receiver operating characteristic (ROC) curve. Results: After screening 632 patients with ICH, a total of 123 legal patients were included. According to statistical analysis, admission GCS (OR, 1.43; 95% CI, 1.18-1.74; P < 0.001) and hematoma volume (OR, 0.9; 95% CI, 0.84-0.97; P = 0.003) were the independent risk factors for early deterioration. Hematoma location (OR, 0.027; 95% CI, 0.004-0.17; P < 0.001) and hematoma volume (OR, 1.09; 95% CI, 1.03-1.15; P < 0.001) were the independent risk factors for poor prognosis, and island sign had a trend toward significance (OR, 0.5; 95% CI, 0.16-1.57; P = 0.051). The admission GCS and hematoma volume score were combined for an early deterioration prediction model with a score from 2 to 5. ROC curve showed an area under the curve (AUC) was 0.778 and cut-off point was 3.5. Combining the score of hematoma volume, island sign, and hematoma location, a long-term prognosis prediction model was established with a score from 2 to 6. ROC curve showed AUC was 0.792 and cutoff point was 4.5. Conclusions: The novel early deterioration and long-term prognosis prediction models are simple, objective, and accurate for patients with ICH along with a hematoma volume of more than 20 ml.

Non-contrast CT image characteristics on admission predict the 3-month outcome of cerebral venous sinus thrombosis: an observational study in a single institution.

BACKGROUND: Various computed tomography (CT) appearances of cerebral venous sinus thrombosis (CVST) were associated with different prognosis and the patients with large intracranial hematoma will have adverse outcomes, but no in-depth study of non-contrast CT image appearances was carried out. We aimed to test the hypothesis that non-contrast CT image characteristics on admission are associated with and predict the outcome of CVST at 3 months. METHODS: Three hundred and six patients with CVST between 2008 and 2017 were collected. Age, sex, onset of CVST(acute, subacute, or chronic), etiology, clinical manifestations, midline shift, occluded venous sinus, location of infarction, non-contrast CT image characteristics, and the 3-month outcome were recorded. In addition, we established a non-contrast CT image-based classification and grading system to test the hypothesis; the CVST patients were classified into four grades (namely non-contrast CT image-based classification): grade I, no obvious abnormality; grade II, simple vein infarction without hemorrhage or with subarachnoid hemorrhage; grade III, cerebral venous infarction with subarachnoid hemorrhage; and grade IV, cerebral vein infarction with hematoma. All enrolled patients had received subcutaneous injections of low molecular weight heparin subcutaneous injection for 14 days. Thereafter, oral anticoagulant therapy with warfarin was continued. Patients with epilepsy were given antiepileptic drugs, and patients with cerebral herniation received decompressive craniotomy. RESULTS: Our observational findings revealed that midline shift (> 5 mm), location of lesion (frontal lobe and temporal lobe), and cerebral venous infarction with subarachnoid or hematoma (grade III and IV) were associated with 3-month poor outcome (p < 0.05); the respective increased risks were 12.730 [risk ratio (RR) 12.730, 95% confidence interval (CI) 1.680-96.490, p = 0.014], 46.538 (RR 146.538, 95% CI 6.222-348.079, p = 0.000), 32.549 (RR 32.549, 95% CI 2.180-486.104, p = 0.012), 37.725 (RR 37.725, 95% CI 2.051-693.778, p = 0.015), and 93.164-fold (RR 93.164, 95% CI 11.137-779.328, p = 0.000). However, seizure, hemiplegia, location of occluded venous sinus (super sagittal sinus and deep venous systems), location of infarction (parietal lobe), and non-contrast CT image-based classification (I) were not correlated with the adverse outcome (p > 0.05). CONCLUSIONS: Our findings suggested that non-contrast CT image characteristics on admission were associated with and predict the 3-month outcome of CVST. However, the ultimate conclusions need to be confirmed by a large sample of CVST patients at multiple institutions.

Systolic Blood Pressure Variability is a Novel Risk Factor for Rebleeding in Acute Subarachnoid Hemorrhage: A Case-Control Study.

UNLABELLED: Rebleeding of an aneurysm is a major cause of morbidity and mortality after subarachnoid hemorrhage (SAH). Whereas numerous studies have demonstrated predictors of rebleeding and effect of systolic blood pressure variability (SBPV) on stroke, few data on the association between SBPV and rebleeding. Here, we sought to identify the effect of SBPV on rebleeding in acute aneurysmal SAH. Case-control study. From January 2010 to June 2015, 612 patients with aneurysmal SAH were enrolled in our tertiary care medical center. MAIN OUTCOME MEASURES: Consecutive patients with acute (<3 days from ictus) aneurismal rebleeding or repair or death were retrospectively included. Antihypertensive therapy based on a predefined standardized protocol was prescribed to lower and maintain SBP between 120 and 160  mm Hg. SBP was measured hourly until a censoring event occurred. SBPV was determined as standard deviation (SD) and successive variation (SV). Binary logistic regression was used to assess the association between SBPV and rebleeding. Rebleeding occurred in 61 (10.0%) of the 612 patients. We identified 47 acute rebleeding as cases and 382 early repair or early death as controls. On binary logistic regression analysis, rebleeding was associated with the SD of SBP (odds ratio [OR], 1.254; 95% confidence interval [CI], 1.131-1.391; P < 0.001) and the SV of SBP (OR, 1.131; 95% CI, 1.039-1.231; P = 0.004). No significant difference was seen between rebleeding and mean systolic blood pressure (MSBP). SBPV is associated with increased rates of acute aneurysmal rebleeding. Further prospective research is warranted to confirm that SBP stability prevents acute aneurysm rebleeding.