Factors Associated with Extended Hospitalization in Patients Who Had Adjuvant Middle Meningeal Artery Embolization After Conventional Surgery for Chronic Subdural Hematomas.

BACKGROUND: This study aims to evaluate the length of stay (LOS) in patients who had adjunct middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH) after conventional surgery and determine the factors influencing the LOS in this population. METHODS: A retrospective review of 107 cases with MMAE after conventional surgery between September 2018 and January 2024 was performed. Factors associated with prolonged LOS were identified through univariable and multivariable analyses. RESULTS: The median LOS for MMAE after conventional surgery was 9 days (IQR = 6 - 17), with a 3-day interval between procedures (IQR = 2 - 5). Among 107 patients, 58 stayed ≤9 days, while 49 stayed longer. Univariable analysis showed the interval between procedures, type of surgery, MMAE sedation, and the number of complications associated with prolonged LOS. Multivariable analysis confirmed longer intervals between procedures (OR=1.52; p<0.01), ≥ 2 medical complications (OR=13.34; p=0.01), and neurological complications (OR=5.28; p=0.05) were independent factors for lengthier hospitalizations. There was a trending association between general anesthesia during MMAE and prolonged LOS (p=0.07). Subgroup analysis revealed diabetes (OR=5.25; p=0.01) and ≥ 2 medical complications (OR=5.21; p=0.03) correlated with a LOS over 20 days, the 75th percentile in our cohort. CONCLUSION: The interval between procedures and the number of medical and neurological complications were strongly associated with prolonged LOS in patients who had adjunct MMAE after open surgery. Reducing the interval between the procedures and potentially performing both under one anesthetic may decrease the burden on patients and shorten their hospitalizations.

Defining light transmission aggregometry cutoff values for clopidogrel and aspirin resistance in flow diversion treatment of intracranial aneurysms.

OBJECTIVE: Concern about thromboembolic events after flow diversion (FD) warrants dual antiplatelet therapy for 3 to 6 months. Platelet function tests are routinely performed prior to the procedure to detect clopidogrel responsiveness, as resistance is associated with CYP2C19 gene polymorphisms. This study aimed to identify optimal cutoff values in light transmission aggregometry (LTA) for clopidogrel and aspirin as predictive indicators of thromboembolic complications. METHODS: The authors conducted a retrospective analysis of aneurysms treated with FD between 2013 and 2023 at a single academic institution. Patients with LTA data for adenosine diphosphate (ADP) and arachidonic acid (ARA) were included, excluding those with aborted procedures. Receiver operating characteristic curves were plotted for ADP and ARA assays to determine optimal cutoff values. RESULTS: A total of 442 patients harboring 552 aneurysms treated in 485 procedures were selected for this analysis. Complete and near-complete aneurysm occlusion on the last radiological follow-up was achieved in 81.8% of aneurysms in a median last imaging follow-up of 13.9 months. A good functional outcome (modified Rankin Scale score ≤ 2) was achieved in 96.3% of patients on the last follow-up. Thromboembolic complications occurred in 4.9% of procedures, and intracranial hemorrhagic complications in 1.9%. For the ADP assay, a value ≥ 40% reached a sensitivity of 82.1% and a specificity of 42.9% with a positive likelihood ratio (LR) of 1.50. For the ARA assay, a value ≥ 13.5% reached a sensitivity of 82.1% and a specificity of 45.6% with a positive LR of 1.51. CONCLUSIONS: This study analyzed the largest FD-treated cohort in which optimal LTA platelet function thresholds for clopidogrel were evaluated and is the first to assess LTA values for aspirin. The authors found that values ≥ 40% for clopidogrel and ≥ 13.5% for aspirin were optimal for predicting thromboembolic complications after FD in treating aneurysms.

Thromboembolic Events in the Posterior Circulation After Flow Diversion-A Closer Look at Coverage of the Posterior Cerebral Artery.

BACKGROUND: Flow diversion for bifurcation aneurysms requires excluding one of the branches from the parent artery, raising concern for ischemic events. We evaluated thromboembolic events and their relationship with covering the origin of the posterior cerebral artery (PCA). METHODS: This retrospective analysis included patients with confirmed basilar and proximal PCA aneurysms treated with flow diversion between 2013 and 2023. Procedures were classified according to the coverage of the origin of the PCA. Thromboembolic events associated with the excluded PCA were evaluated. RESULTS: Of the total 28 aneurysms included, 7 were at the basilar tip, 16 in the basilar trunk, and 5 in the first segment of the PCA; 15 were treated by excluding one of the PCAs. Dual antiplatelet therapy included aspirin and ticagrelor (57.1%), aspirin and clopidogrel (35.7%), or aspirin and prasugrel (3.57%). Complete and near-complete aneurysm occlusion was achieved in 80.8% of the aneurysms treated at a median follow-up of 12.31 months. Thromboembolic complications occurred in 3 patients (2 with basilar perforator stroke and 1 with basilar in-stent thrombosis). However, the difference in these events was not statistically significant between patients with PCA coverage and those without (P = 0.46). Diminished flow and a lack of flow was seen in 8 and 7 of the covered vessels, respectively. A modified Rankin scale score of ≤2 was reported for 89.3% of patients at a median clinical follow-up of 5.5 months. CONCLUSIONS: The incidence of thromboembolic events is high in distal basilar and proximal PCA aneurysms; however, PCA coverage was not associated with their occurrence. There was no difference in postprocedural disability between patients whose aneurysms were treated by excluding one of the PCAs and those who were not.

Thromboembolic Events After the Coverage of Anterior Cerebral Artery with Flow Diversion: A Single Institution Series and Systematic Review.

BACKGROUND: Advances in the use of flow diversion (FD) now extend to bifurcation aneurysms; herein, we compare thromboembolic events in patients with internal carotid artery (ICA) aneurysms treated with and without exclusion of the anterior cerebral artery (ACA). METHODS: Retrospective analysis of aneurysms in the terminal ICA treated with FD from 2013 to 2023 at a single-center study. Procedures were classified according to the coverage at the origin of the ACA and compared through bivariate-analysis. A review was also carried on PubMed, Web of Science, and EMBASE until April 2024, adhering to the PRISMA reporting guidelines. RESULTS: Ninety-five patients harboring 113 aneurysms treated in 102 procedures were evaluated. Fifty-eight were treated covering the ACA origin. Dual antiplatelet regimens included aspirin-clopidogrel (50%), aspirin-ticagrelor (44.1%), and aspirin-prasugrel (4.9%). Thromboembolic events occurred in 6 patients (5.9%), all of which presented with large vessel occlusion of the ICA, but without reaching statistical difference in the 2 treated cohorts (P = 0.46). At a median clinical follow-up of 5.95 months, there were no differences in the functional outcomes in the 2 groups (P = 0.22). Contralateral angiographic runs post-treatment after covering the ACA origin demonstrated increase in the A1 (median: 0.45 mm; IQR = 0.4-1.2) and ICA diameter (median: 0.55 mm; IQR = 0.1-1.2). After pooling data from literature and our cohort, complete side branch occlusion after the coverage of ACA was seen in 25% of branches (95%CI = 0.16-0.36), and thromboembolic events were observed after 3% (95%CI = 0.01-0.04) of procedures. CONCLUSIONS: Thromboembolic events can occur in distal ICA aneurysms treated with FD, but no significant association was seen with covering the ACA origin.

Long-Term Outcomes After Stereotactic Radiosurgery for Pediatric Brain Arteriovenous Malformations: A Systematic Review.

BACKGROUND: The long-term outcomes after stereotactic radiosurgery (SRS) for pediatric brain arteriovenous malformations (AVMs) remain poorly understood given the paucity of longitudinal studies. A systematic review was conducted to pool cumulative incidences for all outcomes. METHODS: PubMed, Embase, and Web of Science were queried to systematically extract potential references. The articles relating to AVMs treated via SRS were required to be written in English, involve pediatric patients (<18 years of age), and include a mean follow-up period of >5 years. Individual patient data were obtained to construct a pooled Kaplan-Meier plot on obliteration rates over time. RESULTS: Among the 6 studies involving 1315 pediatric patients averaging a follow-up period of 86.6 months (range, 6-276), AVM obliteration was observed in 66.1% with cumulative probabilities of 48.28% (95% confidence interval [CI], 41.89-54.68), 76.11% (95% CI, 67.50-84.72), 77.48% (95% CI, 66.37-88.59) over 3, 5, and 10 years, respectively. The cumulative incidence of post-SRS hemorrhage, tumors, cysts, and de novo seizures was 7.2%, 0.3%, 1.6%, and 1.5%, respectively. The cumulative incidence of radiation-induced necrosis, edema, radiologic radiation-induced changes (RICs), symptomatic RICs, and permanent RICs were 8.0%, 1.4%, 28.0%, 8.7%, and 4.9%, respectively. CONCLUSIONS: Studies assessing long-term outcomes after SRS are moderate in quality and retrospective. Thus, interpretation with caution is advised given the variable degree of loss to follow-up, which suggests that complication rates may be higher than the values stated in the literature. Future prospective studies are needed to validate these findings.

Comparison of Thromboembolic Events Between Pipeline Embolization Device (PED) Shield and PED/PED Flex: A Propensity Score-Matched Analysis.

BACKGROUND AND OBJECTIVES: The pipeline embolization device (PED) Flex with Shield technology is a third-generation flow diverter used for intracranial aneurysm treatment designed to decrease thrombogenicity through a phosphorylcholine coating. Herein, we aim to compare the rate of thromboembolic events in PED with Shield technology and PED without it through propensity score matching. METHODS: We conducted a retrospective analysis of aneurysms treated with PED first-generation/PED Flex and PED with Shield between 2013 and 2023 at a single academic institution. Patients were matched through propensity score by controlling for confounding factors including age, smoking history, diabetes, previous subarachnoid hemorrhage, modified Rankin Scale pretreatment, location, aneurysm size, previous treatment, and clopidogrel or aspirin resistance. After matching, we evaluated for periprocedural and postoperative thromboembolic events. Data analysis was performed using Stata 14. RESULTS: A total of 543 patients with 707 aneurysms treated in 605 procedures were included in the analysis. From these, 156 aneurysms were treated with PED with Shield (22.07%) and 551 (77.93%) without Shield technology. Propensity score matching resulted in 84 matched pairs. The rate of thromboembolic events was 3.57% for PED Shield and 10.71% for PED first-generation/PED Flex (P = .07), while retreatment rates were 2.38% for PED Shield and 8.32% for PED Flex (P = .09). Complete occlusion at first (P = .41) and last imaging follow-up (P = .71), in-stent stenosis (P = .95), hemorrhagic complications (P = .31), and functional outcomes (P = .66) were comparable for both groups. CONCLUSION: This is the first study in the literature performing a propensity scored-matched analysis comparing PED with PED with Shield technology. Our study suggests a trend toward lower thromboembolic events for PED Shield, even after controlling for aspirin and clopidogrel resistance, and a trend toward lower aneurysm retreatment rates with PED Shield, without reaching statistical significance.

Evaluation of PHASES Score for Predicting Rupture of Intracranial Aneurysms: Significance of Aneurysm Size.

BACKGROUND: Recent data have identified that certain risk factors for rupture differ between small and larger intracranial aneurysms (IAs). Such differing risk factors make up 5 out of the 6 predictor variables used in the PHASES score, which raises the question on whether IA size has a significant effect on the score's performance. METHODS: Patients who were diagnosed with an IA incidentally or due to a subarachnoid hemorrhage between 2015 and 2023 were selected for potential inclusion. The median IA size of the cohort was chosen as the cutoff point to categorize small and large (6 mm). The PHASES score was calculated for all patients, and a receiver operating characteristic curve analysis was performed to evaluate the classification accuracy of PHASES in predicting rupture for small and large IAs. RESULTS: A total of 677 IAs were included. Among the IAs, 400 (58.9%) presented as UIAs and 279 (41.0%) as subarachnoid hemorrhage. The average PHASES score was 2.9 and 6.5 for small (n = 322) and large (n = 355) IAs, respectively. The PHASES score performed significantly lower for predicting rupture in smaller IAs (area under the curve: 0.634) compared with the larger (area under the curve: 0.741) (P = 0.00083). CONCLUSIONS: PHASES was shown to underperform on small IAs. The decision to treat small unruptured IAs remains highly controversial, and the development of a new score to estimate the annual rupture rate while accounting for IA morphology is of great need. Our findings can help encourage future researchers to develop such a score.

Predictors for a Collar Sign and its Association with Outcomes in Aneurysms after Pipeline Embolization.

BACKGROUND: The collar sign has been previously described as an angiographic indicator of incomplete occlusion after deployment of a pipeline embolization device (PED) for intracranial aneurysms. In the present study, we explore the predictors for a collar sign in aneurysms treated with the PED. METHODS: Aneurysms with a collar sign at the initial follow-up angiogram were identified in a retrospective review of single-center data. The predictors of a collar sign were analyzed through univariate and multivariate analyses. RESULTS: A total of 492 cases of cerebral aneurysm treated with the PED were identified. Among them, 53 were found to have a collar sign on the initial follow-up angiogram. Univariate analysis showed that previous treatment of the same aneurysm (odds ratio [OR], 2.46; P = 0.01), a branch vessel from the aneurysm neck or dome (OR, 6.2; P < 0.001), and a smaller aneurysm neck size (OR, 0.75; P = 0.01) were all predictors for the presence of a collar sign. A larger diameter (OR, 0.92; P = 0.06), increased dome/neck ratio (OR, 1.38; P = 0.1), increased aspect ratio (OR, 1.14; 0 P =.17), and previous treatment showed a trend toward an association with a collar sign. However, after multivariate analysis, a branch from the aneurysm neck or dome (OR, 6.23; P < 0.001), aneurysm diameter (OR, 0.75; P = 0.032), an increased dome/neck ratio (OR, 4.62; P = 0.006), and previous treatment were the strongest predictors for a collar sign. CONCLUSIONS: The presence of a branch vessel arising from the aneurysm neck or dome, an increased dome/neck ratio, aneurysm diameter, and previous treatment are the strongest predictive factors for a collar sign in the angiographic follow-up of PED-treated aneurysms.

Effect of Statin on Radiographic and Clinical Outcomes of Intracranial Aneurysms Treated With Pipeline Embolization: A Propensity Score-Matched Analysis.

BACKGROUND AND OBJECTIVES: Studies have shown that use of statin can improve radiographic and clinical outcomes in patients receiving treatment for coronary artery or peripheral vascular stenosis. Statins are thought to be effective by reducing arterial wall inflammation. The same mechanism may have an influence on the efficacy of pipeline embolization device (PED) for intracranial aneurysm treatment. Although this question has been of interest, there is a lack of well-controlled data in the literature. The objective of this study is to analyze the effect of statins on outcomes of aneurysms treated with pipeline embolization through propensity score matching. METHODS: Patients who underwent PED for unruptured intracranial aneurysms at our institution between 2013 and 2020 were identified. Patients on statin treatment vs those who were not were matched through propensity score by controlling for confounding factors including age, sex, current smoking status, diabetes, aneurysm morphology, volume, neck size, location of aneurysm, history of treatment for the same aneurysm, type of antiplatelet therapy, and elapsed time at last follow-up. Occlusion status at first follow up and last follow-up, and incidence of in-stent stenosis and ischemic complications during the follow-up period were extracted for comparison. RESULTS: In total, 492 patients with PED were identified, of whom 146 were on statin therapy and 346 were not. After one-to-one nearest neighbor matching, 49 cases in each group were compared. At last follow-up, 79.6%, 10.2%, and 10.2% of cases in the statin therapy group and 67.4%, 16.3%, and 16.3% in the nonstatin group were noted to have Raymond-Roy 1, 2, and 3 occlusions, respectively ( P = .45). No significant difference was observed in immediate procedural thrombosis ( P > .99), long-term in-stent stenosis ( P > .99), ischemic stroke ( P = .62), or retreatment ( P = .49). CONCLUSION: Statin use does not affect occlusion rate or clinical outcomes in patients treated with PED treatment for unruptured intracranial aneurysms.