Direct Versus Indirect Revascularization for Moyamoya: a Large Multicenter Study.

BACKGROUND: Moyamoya is a chronic occlusive cerebrovascular disease of unknown etiology causing neovascularization of the lenticulostriate collaterals at the base of the brain. Although revascularization surgery is the most effective treatment for moyamoya, there is still no consensus on the best surgical treatment modality as different studies provide different outcomes. OBJECTIVE: In this large case series, we compare the outcomes of direct (DR) and indirect revascularisation (IR) and compare our results to the literature in order to reflect on the best revascularization modality for moyamoya. METHODS: We conducted a multicenter retrospective study in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines of moyamoya affected hemispheres treated with DR and IR surgeries across 13 academic institutions predominantly in North America. All patients who underwent surgical revascularization of their moyamoya-affected hemispheres were included in the study. The primary outcome of the study was the rate of symptomatic strokes. RESULTS: The rates of symptomatic strokes across 515 disease-affected hemispheres were comparable between the two cohorts (11.6% in the DR cohort vs 9.6% in the IR cohort, OR 1.238 (95% CI 0.651 to 2.354), p=0.514). The rate of total perioperative strokes was slightly higher in the DR cohort (6.1% for DR vs 2.0% for IR, OR 3.129 (95% CI 0.991 to 9.875), p=0.052). The rate of total follow-up strokes was slightly higher in the IR cohort (8.1% vs 6.6%, OR 0.799 (95% CI 0.374 to 1.709) p=0.563). CONCLUSION: Since both modalities showed comparable rates of overall total strokes, both modalities of revascularization can be performed depending on the patient's risk assessment.

Middle meningeal artery patency after surgical evacuation for chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) often requires surgical evacuation, but recurrence rates remain high. Middle meningeal artery (MMA) embolization (MMAE) has been proposed as an alternative or adjunct treatment. There is concern that prior surgery might limit patency, access, penetration, and efficacy of MMAE, such that some recent trials excluded patients with prior craniotomy. However, the impact of prior open surgery on MMA patency has not been studied. METHODS: A retrospective analysis was conducted on patients who underwent MMAE for cSDH (2019-2022), after prior surgical evacuation or not. MMA patency was assessed using a six-point grading scale. RESULTS: Of the 109 MMAEs (84 patients, median age 72 years, 20.2% females), 58.7% were upfront MMAEs, while 41.3% were after prior surgery (20 craniotomies, 25 burr holes). Median hematoma thickness was 14 mm and midline shift 3 mm. Hematoma thickness reduction, surgical rescue, and functional outcome did not differ between MMAE subgroups and were not affected by MMA patency or total area of craniotomy or burr-holes. MMA patency was reduced in the craniotomy group only, specifically in the distal portion of the anterior division (p = 0.005), and correlated with craniotomy area (p < 0.001). CONCLUSION: MMA remains relatively patent after burr-hole evacuation of cSDH, while craniotomy typically only affects the frontal-distal division. However, MMA patency, evacuation method, and total area do not affect outcomes. These findings support the use of MMAE regardless of prior surgery and may influence future trial inclusion/exclusion criteria. Further studies are needed to optimize the timing and techniques for MMAE in cSDH management.

The impact of hypertension on clinical outcomes in moyamoya disease: a multicenter, propensity score-matched analysis.

BACKGROUND: Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by progressive steno-occlusive changes in the internal carotid arteries, leading to an abnormal vascular network. Hypertension is prevalent among MMD patients, raising concerns about its impact on disease outcomes. This study aims to compare the clinical characteristics and outcomes of MMD patients with and without hypertension. METHODS: We conducted a multicenter, retrospective study involving 598 MMD patients who underwent surgical revascularization across 13 academic institutions in North America. Patients were categorized into hypertensive (n=292) and non-hypertensive (n=306) cohorts. Propensity score matching (PSM) was performed to adjust for baseline differences. RESULTS: The mean age was higher in the hypertension group (46 years vs. 36.8 years, p < 0.001). Hypertensive patients had higher rates of diabetes mellitus (45.2% vs. 10.7%, p < 0.001) and smoking (48.8% vs. 27.1%, p < 0.001). Symptomatic stroke rates were higher in the hypertension group (16% vs. 7.1%; OR: 2.48; 95% CI: 1.39-4.40, p = 0.002) before matching. After PSM, there were no significant differences in symptomatic stroke rates (11.1% vs. 7.7%; OR: 1.5; CI: 0.64-3.47, p = 0.34), perioperative strokes (6.2% vs. 2.1%; OR 3.13; 95% CI: 0.83-11.82, p = 0.09), or good functional outcomes at discharge (93% vs. 92.3%; OR 1.1; 95% CI: 0.45-2.69, p = 0.82). CONCLUSION: No significant differences in symptomatic stroke rates, perioperative strokes, or functional outcomes were observed between hypertensive and non-hypertensive Moyamoya patients. Appropriate management can lead to similar outcomes in both groups. Further prospective studies are required to validate these findings.

Postoperative de novo epilepsy after resection of brain arteriovenous malformations: A national database study of 536 patients.

OBJECTIVE: We aimed to assess the incidence and risk factors for de novo epilepsy after arteriovenous malformation (AVM) resection and compare them with a nonresection cohort after propensity score matching, utilizing a national database. METHODS: Utilizing the TriNetX Research Network, we queried cases from January 1, 2004 to March 1, 2022. We included patients of all ages who underwent supratentorial AVM resection, presenting without seizures on or before surgery and without being on antiseizure medications at least 1 day before surgery. The primary outcome was seizures manifesting at least 6 weeks after surgery. Patient characteristics and outcomes were compared between the cohorts with and without postoperative epilepsy. Further cohorts were created to compare cohorts with and without embolization or rupture. After propensity score matching, we compared an additional cohort of patients with an AVM diagnosis who did not undergo resection. RESULTS: Of the 536 patients (mean age = 38.9 ± 19.6, 52% females) presenting without seizure who underwent AVM resection, 99 (18.5%) developed de novo epilepsy, with a 1-year cumulative incidence of 13.8%. Patients with epilepsy had higher rates of intracerebral hemorrhage, and intracerebral hemorrhage was less common in the embolization cohort. Patients in the ruptured cohort were older and more often males. After propensity score matching with 18 588 patients with AVM diagnosis but no resection, each group consisted of 529 patients, and de novo epilepsy at 1 year was significantly higher in the AVM resection cohort compared to the nonresection cohort (11.5% vs. 3.4%, p < .001). SIGNIFICANCE: This analysis of 536 patients provides evidence that de novo epilepsy after brain AVM resection occurs at a 1-year cumulative incidence of 13.8%, with a total of 19.4% developing de novo epilepsy. Intracerebral hemorrhage was inconsistently associated with postoperative de novo epilepsy. De novo epilepsy was significantly less frequent after AVM diagnosis without resection.

Safety and efficacy of the p48 MW and p64 flow modulation devices: a systematic review and meta-analysis.

OBJECTIVE: Flow diverters (FDs) have demonstrated increasing safety and efficacy in treating various types of intracranial aneurysms. Although the underlying mechanism of action of all FDs is similar, differences are noted in their intrinsic characteristics, materials, and deployment techniques. The p64 flow modulation device (p64) and the newer p48 movable wire flow modulation device (p48 MW) are not yet available in the US but have been increasingly used mainly in Europe, demonstrating optimistic results. The authors performed a systematic review and meta-analysis of the literature to evaluate the safety and efficacy of the p64 and p48 MW FDs. METHODS: A literature review (between January 1960 and November 2022) of the PubMed, Scopus, Embase, Web of Science, and Cochrane Central Register of Controlled Trials databases was conducted. The primary efficacy outcome was the proportion of complete angiographic occlusion at last follow-up. Complete occlusion was defined as Raymond-Roy class 1 and O'Kelly-Marotta grade D. The primary safety outcomes were the composite safety rate of ischemic and hemorrhagic events (intra- and postprocedure) and the all-cause mortality rate. Data were analyzed using a random-effects proportions meta-analysis, and statistical heterogeneity was assessed. RESULTS: Twenty studies with 1781 patients harboring 1957 aneurysms were included in the analysis. Seventeen studies were conducted in Europe. Sixteen studies evaluated the performance of the p64 (MW). Patient ages ranged between 20 and 89 years, and most were female (78.7%). Aneurysm size ranged between 1 and 50 mm. Most aneurysms were unruptured (92.8%) and in the anterior circulation (93.1%). Single antiplatelet therapy pre- and postprocedure was used in 2 studies. Follow-up ranged from 2 to 14.5 months. For the p64 and p48 MW, complete angiographic occlusion rates were 77% (95% CI 68%-85%) and 67% (95% CI 49%-81%), adjunctive coil usage rates were 7% (95% CI 4%-12%) and 4% (95% CI 0%-24%), primary safety composite rates were 2% (95% CI 1%-4%) and 3% (95% CI 1%-11%), and mortality rates were 0.49% (95% CI 0%-1%) and 2% (95% CI 1%-6%), respectively. CONCLUSIONS: The p64 and p48 MW have primarily been used in Europe thus far. This analysis found that both devices have an acceptable efficacy and favorable safety profile. However, further studies are needed to evaluate the efficacy and safety of prescribing a single antiplatelet regimen after implantation of the newer-generation FDs with antithrombotic coating surface modification.

Patient sentiment regarding stroke: Analysis of 2,992 social media posts.

INTRODUCTION: Social media reflects personalized sentiment toward disease and increasingly impacts perceptions of treatment options. This study aims to assess patients experience with and perception of stroke through an analysis of social media posts. METHODS: A variety of terms ("stroke", "stroke survivor", "stroke rehab", "stroke recovery") were used to search for possible qualified posts on Twitter and Instagram. Twitter posts containing "#stroke" and "@stroke" were identified, yielding 2,506 Twitter posts relating to the patient's own experience. Four hundred sixty-eight public Instagram posts marked under "#stroke" and "@stroke," including direct references to the patient's own experience, were analyzed. First vs. recurrent stroke was identified when possible. The posts were coded for themes relating to patient experience with the disease. RESULTS: The most common Twitter theme was raising stroke awareness (23.4 %), while spreading positivity was the most common Instagram theme (66.7 %). Most Twitter posts (93.9 %) were from patients experiencing their first stroke, with only 6.1 % of the posts being about recurrent strokes. Women created the majority of Instagram (75.7 %) and Twitter (77.3 %) posts. Men were more likely to discuss mobility/functional outcomes (p = 0.001) and survival/death (p = 0.014), while women were more likely to recount symptoms (p = 0.014), depression (p = 0.002), fear (p<0.001), and mental health (p = 0.006). CONCLUSION: Stroke patients most often describe their quality of life and discuss raising awareness via social media. Men and women differ in the most commonly shared aspects of their stroke experience. Gauging social media sentiment may guide physicians toward better counseling and psychosocial management of stroke patients.

Robot-assisted carotid artery stenting: outcomes, safety, and operational learning curve.

OBJECTIVE: Over the past 2 decades, robots have been increasingly used in surgeries to help overcome human limitations and perform precise and accurate tasks. Endovascular robots were pioneered in interventional cardiology, however, the CorPath GRX was recently approved by the FDA for peripheral vascular and extracranial interventions. The authors aimed to evaluate the operational learning curve for robot-assisted carotid artery stenting over a period of 19 months at a single institution. METHODS: A retrospective analysis of a prospectively maintained database was conducted, and 14 consecutive patients who underwent robot-assisted carotid artery stenting from December 2019 to June 2021 were identified. The metrics for proficiency were the total fluoroscopy and procedure times, contrast volume used, and radiation dose. To evaluate operator progress, the patients were divided into 3 groups of 5, 4, and 5 patients based on the study period. RESULTS: A total of 14 patients were included. All patients received balloon angioplasty and stent placement. The median degree of stenosis was 95%. Ten patients (71%) were treated via the transradial approach and 4 patients (29%) via the transfemoral approach, with no procedural complications. The median contrast volume used was 80 mL, and the median radiation dose was 38,978.5 mGy/cm2. The overall median fluoroscopy and procedure times were 24.6 minutes and 70.5 minutes, respectively. Subgroup analysis showed a significant decrease in these times, from 32 minutes and 86 minutes, respectively, in group 1 to 21.9 minutes and 62 minutes, respectively, in group 3 (p = 0.002 and p = 0.008, respectively). CONCLUSIONS: Robot-assisted carotid artery stenting was found to be safe and effective, and the learning curve for robotic procedures was overcome within a short period of time at a high-volume cerebrovascular center.

Exploring arteriovenous malformations patient sentiments through 1401 social media posts.

INTRODUCTION: Social media has allowed patients with rare diseases to connect and discuss their experiences with others online. This study analyzed various social media platforms to better understand the patient's perception of arteriovenous malformation. METHODS: Twitter, Instagram, and TikTok were searched to find posts about patients' experiences with arteriovenous malformations (AVM). Posts unrelated to the patient's experience were excluded. Posts were coded for the relevant themes related to their experience with the disease, as well as engagement, and gender. RESULTS: The most common theme was raising awareness about the condition (87.0%). Recounting symptoms (50.2%), spreading positivity (17.5%), and survival (8.3%) were other common themes. Other prevalent themes were pain (5.2%) and fear of a rare disease (3.5%). Approximately half of AVM-related Instagram (47.93%) and TikTok (52.94%) posts raised awareness about the condition. Most Instagram (67.75%) and TikTok (89.71%) posts focused on recovery and rehabilitation. Most TikTok posts discussed "survival" or "death" (57.35%), while the majority focused on spreading positivity (79.41%). Most posts were made by women (69.6%). Females were more likely than males to post about the scientific explanation of AVMs (p = 0.003). CONCLUSION: Social media allows patients across the country and the globe to discuss their experiences with uncommon diseases and connect with others. It also allows AVM patients to share their experiences with other patients and the public.

Intraoperative Ionizing Radiation Exposure Awareness and Associated Morbidity in Neurosurgery: A Nationwide Survey.

BACKGROUND: Neurosurgeons often use radiation to visualize blood vessels and implants intraoperatively. However, high exposure to radiation increases one's cancer risk. This study aims to investigate intraoperative ionizing radiation exposure awareness and associated morbidity among neurosurgeons. METHODS: An anonymized 30-question survey about their intraoperative radiation exposure, protective measures, radiation knowledge, and any conditions that can arise from protracted radiation exposure was disseminated to 3344 American Association of Neurological Surgeons members. RESULTS: A total of 227 (6.8%) neurosurgeons completed the survey. Most neurosurgeons (61, 27%) performed 2-4 surgeries per week necessitating radiation (61, 27%), did not use a dosimeter (134, 59%), and wore a lead apron (89%) and a thyroid shield (75%). Only 7 (3%) of respondents could correctly identify the safety limit for occupational radiation. One hundred and thirty-four (59%) respondents correctly identified the relationship between distance and radiation dose reduction. Two hundred and thirteen (94%) neurosurgeons reported concern about occupational radiation exposure. No significant association was found between occupational radiation exposure and the rate of cataracts, combined cancer, and skin cancer. Multivariate logistic regression adjusting for age and cancer history found that the likelihood of developing leukemia (P = 0.02) and nonmalignant thyroid nodular disease (P = 0.01) is positively associated with increased total occupational radiation exposure. CONCLUSIONS: There is a need for improved radiation safety awareness among neurosurgeons, especially in the context of rising usage of minimally invasive surgery. This can allow for a greater understanding of radiation-associated risks among neurosurgeons and guide the implementation of safer practices.

Transcirculation Approaches to Endovascular Flow Diversion of Intracranial Aneurysms: A Systematic Review With Technical Considerations.

BACKGROUND AND OBJECTIVES: Flow diversion (FD) of intracranial aneurysms (IAs) is an increasingly used and efficacious treatment modality. Transcirculation approaches, or approaches that cross the contralateral or anteroposterior arterial supply before reaching a target vessel, have been used to treat cerebrovascular pathologies when traditional approaches are unsuitable or require intraoperative complication management. This study sought to review IAs treated with FD using a transcirculation approach to determine the technique's safety and efficacy. METHODS: A systematic review of the PubMed, Scopus, Web of Science, and Embase databases was completed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they described transcirculation approaches in adult patients with IAs undergoing FD. Outcomes of interest included intraoperative complications and aneurysm occlusion rates. RESULTS: Twelve studies with 19 patients (N = 19, mean age = 54.1 y, 89.5% female) were identified. Wide-necked (N = 5, 26.3%) and saccular (N = 5, 26.3%) aneurysms were most represented, while 57.9% (N = 11) of aneurysms were unruptured and 15.8% (N = 3) of aneurysms were ruptured. The mean aneurysm sac and neck size were 16.9 mm and 11.9 mm, respectively. The most commonly deployed flow diverter was the Pipeline Embolization Device (N = 14, 73.9%). Successful FD (complete occlusion and/or good wall apposition) was recorded in 84.6% of qualifying patients with follow-up data, while 2 patients (15.4%) developed an intraoperative carotid-cavernous fistula. CONCLUSION: Transcirculation approaches to FD offer neurointerventionalists a safe and efficacious method for device deployment, rescue scenarios, and challenging anatomy. Prospective studies may determine the most appropriate indications for transcirculation approaches to FD, while novel, lower profile devices may improve its technical feasibility and safety.

Robotic spinal angiography: A single-center experience.

BACKGROUND AND OBJECTIVES: Robotic neurointervention enhances procedural precision, reduces radiation risk, and improves care access. Originally for interventional cardiology, the CorPath GRX platform has been used in neurointerventions. Recent studies highlight robotic cerebral angiography benefits, but information on spinal angiography is limited. While a new generation of robotic solutions is on the horizon, this series evaluates our experience with the CorPath GRX in spinal angiographic procedures, addressing a key gap in neurointerventional research. METHODS: In this single-center retrospective case series, we analyzed 11 patients who underwent robotic-assisted diagnostic procedures with the CorPath GRX system from February 2022 to March 2023 at our institution. A descriptive synthesis was performed on the demographic, baseline, surgical, and postoperative data collected. RESULTS: The average age of the 11 patients was 54 ± 20.34 years, with six (54.55%) female. The mean body mass index was 29.58 ± 7.86, and 7 (63.64%) were non-smokers. Of the 11 procedures using the CorPath GRX system, four (36.36%) were partially converted to manual technique. General anesthesia was used in nine cases (81.82%), and right-side femoral access in ten (90.91%) patients. Mean fluoroscopy time was 24.81 ± 10.19 min, contrast dose 174.09 ± 57.31 mL, dose area product 472.23 ± 437.57 Gy·cm², and air kerma 2438.84 ± 2107.06 mGy. No robot-related complications and minimal procedure-related complications were reported. CONCLUSION: The CorPath GRX system, a robotic-assisted platform, has proven reliable and safe in spinal angiography, evidenced by its enhanced procedural accuracy and reduced radiation exposure for operators.

Endovascular biopsy in neurointerventional surgery: A systematic review.

INTRODUCTION: Endothelial cells (ECs) continuously line the cerebrovasculature. Molecular aberrations in the ECs are hallmarks and contributory factors to the development of cerebrovascular diseases, including intracranial aneurysms and arteriovenous malformations (AVMs). Endovascular biopsy has been introduced as a method to harvest ECs and obtain relevant biologic information. We aimed to summarize the literature on endovascular biopsy in neurointerventional surgery. METHODS: We conducted a comprehensive literature search in multiple databases, identifying eligible studies focusing on neurosurgical applications of endovascular biopsy. The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The relevant information was collected, including study characteristics, biopsy techniques, and key findings. RESULTS: Nine studies met the inclusion criteria and were included. The studies involved the collection of ECs using various endovascular devices including coils, guide wires, different stents, and forceps. Endothelial-enrichment techniques, such fluorescence-activated cell sorting (FACS), collected ECs and facilitated downstream applications of bulk or single-cell RNA sequencing (scRNAseq). The studies provided insights into gene expression profiles and identified potential biomarkers associated with intracranial aneurysms. However, challenges were observed in obtaining an adequate number of ECs and identifying consistent biomarkers. CONCLUSION: Endovascular biopsy of endothelial cells (ECs) in cerebrovascular pathologies shows promise for gene expression profiling. However, many studies have been limited in sample size and underpowered to identify "signature genes" for aneurysm growth or rupture. Advancements in minimally invasive biopsy methods have potential to facilitate applications of precision medicine in the treatment of cerebrovascular disorders.

Advancing endovascular neurosurgery training with extended reality: opportunities and obstacles for the next decade.

Background: Extended reality (XR) includes augmented reality (AR), virtual reality (VR), and mixed reality (MR). Endovascular neurosurgery is uniquely positioned to benefit from XR due to the complexity of cerebrovascular imaging. Given the different XR modalities available, as well as unclear clinical utility and technical capabilities, we clarify opportunities and obstacles for XR in training vascular neurosurgeons. Methods: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted. Studies were critically appraised using ROBINS-I. Results: 19 studies were identified. 13 studies used VR, while 3 studies used MR, and 3 studies used AR. Regarding specific educational applications, VR was used for simulation in 10 studies and anatomical modeling in 3 studies. AR was only used for live intra-operative guidance (n = 3 studies). MR was only used for modeling and intra-operative teaching. Considering disease-specific uses, XR enhanced trainee understanding of intracranial aneurysms (n = 12 studies) and stroke (n = 7). XR trained surgeons in diverse neurosurgical procedures, including aneurysm coiling (n = 5 studies), diagnostic angiography (n = 5), and thrombectomy (n = 5). Conclusions: Anatomical modeling with VR and MR enhances neurovascular anatomy education with patient-specific, 3-D models from imaging data. AR and MR enable live intra-operative guidance, allowing experienced surgeons to remotely instruct novices, potentially improving patient care and reducing geographic disparities. AR overlays enhance instruction by allowing the surgeon to highlight key procedural aspects during training. Inaccurate tracking of surgical tools is an XR technological barrier for modeling and intra-operative training. Importantly, the most reported application of XR is VR for simulation-using platforms like the Mentice VIST and Angio Mentor. 10 studies examine VR for simulation, showing enhanced procedural performance and reduced fluoroscopy use after short training, although long-term outcomes have not been reported. Early-stage trainees benefited the most. Simulation improved collaboration between neurosurgeons and the rest of the surgical team, a promising role in interprofessional teamwork. Given the strength of VR for simulation, MR for simulation is an important gap in the literature for future studies. In conclusion, XR holds promise for transforming neurosurgical education and practice for simulation, but technological research is needed in modeling and intra-procedural training.

Utilization and reimbursement of diagnostic cerebral angiograms: A Medicare trends analysis from 2013 to 2020.

INTRODUCTION: Increasing life expectancy has caused growing concern about maintaining viable neurointerventional practices due to altered Medicare payment structures. This study analyzes the financial trends of three common diagnostic tests for cerebrovascular disease: cerebral digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). METHODS: Medicare Part B National Summary Data files from 2013 to 2020 were queried by Current Procedural Terminology (CPT) codes for DSA (36221-36228), CTA (70496, 70498), and MRA (70544-70547, 70549). Inflation-adjusted charges and reimbursement were calculated using the U.S. City Average Consumer Price Index for Medical Services. Regression analysis was performed on charges, reimbursement, and volume. RESULTS: A total of 1,519,245 diagnostic procedures were conducted between 2013 and 2020 (782,370 angiograms, 246,603 CTAs, and 490,272 MRAs). A total of $41.005 million was reimbursed by Medicare in 2020 for these diagnostic procedures. The annual percent change in volume for all procedures was -2.90%. From 2013 to 2020, inflation-adjusted: Medicare total physician reimbursement decreased for cerebral angiograms (-4.12%, p = 0.007), CTAs (-2.77%, p = 0.458), and MRAs (-9.06%, p < 0.001). Procedural volume billed to Medicare decreased for cerebral angiograms (-4.63%, p = 0.007) and MRAs (-2.94%, p = 0.0.81) and increased for CTAs (+3.15%, p = 0.004). The greatest increase in Medicare reimbursement (+66.75%) came from CPT code 36224, "place catheter carotid artery", and the greatest decrease in Medicare reimbursement (-8.66%) came from CPT code 36226, "place catheter vertebral artery." CONCLUSIONS: This study provides an analysis of Medicare reimbursement trends for routine cerebrovascular angiogram techniques. The findings highlight a decline in Medicare reimbursements for neurointerventionalists.

Readability of cerebrovascular diseases online educational material from major cerebrovascular organizations.

INTRODUCTION: The internet is an essential resource for patients and their loved ones to understand their medical conditions, and professional medical organizations have taken great strides to develop educational material targeting patients. The average American reads at a seventh to eighth grade reading level, hence it is important to understand the readability of this medical information to ensure patients comprehend what is being presented. METHODS: In January 2023, online patient education material was downloaded from major cerebrovascular healthcare organizations and assessed using eight assessments, including Bormuth Cloze Mean, Bormuth Grade Placement, Coleman-Liau (grade levels), Coleman-Liau (predictive cloze scores), Flesch Reading Ease (FRE), and Fry. RESULTS: A total of 32 files were extracted from six organizations and analyzed across 15 readability measures. None of the organizations met the federal government guidelines for grade-level readability. This held constant across all measured tests. Two organizations had above a postgraduate level. The FRE graphs do not identify any organizations with material below a ninth grade reading level, while the American Association of Neurological Surgeons (AANS) and the Society of Interventional Radiology (SIR) have a postgraduate readability level. The Fry graphs show similar results, with AANS/CNS Cerebrovascular Section, Society of NeuroInterventional Surgery (SNIS), SIR, and AANS having college-level readability. The lowest readability across all measures is only at an early seventh grade reading level. CONCLUSIONS: Current health literacy content for cerebrovascular patients is far above the recommended readability level. We provide straightforward suggestions for how major professional organizations should improve their informational material on cerebrovascular diseases to improve patient understanding.

Multicenter US clinical experience with the Scepter Mini balloon catheter.

INTRODUCTION: Distal navigability and imprecise delivery of embolic agents are two limitations encountered during liquid embolization of cerebrospinal lesions. The dual-lumen Scepter Mini balloon (SMB) microcatheter was introduced to overcome these conventional microcatheters' limitations with few small single-center reports suggesting favorable results. METHODS: A series of consecutive patients undergoing SMB-assisted endovascular embolization were extracted from prospectively maintained registries in seven North-American centers (November 2019 to September 2022). RESULTS: Fifty-four patients undergoing 55 embolization procedures utilizing SMB were included (median age 58.5; 48.1% females). Cranial dural arteriovenous fistula embolization was the most common indication (54.5%) followed by cranial arteriovenous malformation (27.3%). Staged/pre-operative embolization was done in 36.4% of cases; and 83.6% of procedures using Onyx-18. Most procedures utilized a transarterial approach (89.1%), and SMB-induced arterial-flow arrest concurrently with transvenous embolization was used in 10.9% of procedures. Femoral access/triaxial setups were utilized in the majority of procedures (65.5% and 60%, respectively). The median vessel diameter where the balloon was inflated of 1.8 mm, with a median of 1.5 cc of injected embolic material per procedure. Technical failures occurred in 5.5% of cases requiring aborting/replacement with other devices without clinical sequelae in any of the patients, with SMB-related procedural complications of 3.6% without clinical sequelae. Radiographic imaging follow-up was available in 76.9% of the patients (median follow-up 3.8 months), with complete occlusion (100%) or >50% occlusion in 92.5% of the cases, and unplanned retreatments in 1.8%. CONCLUSION: The SMB microcatheter is a useful new adjunctive device for balloon-assisted embolization of cerebrospinal lesions with a high technical success rate, favorable outcomes, and a reasonable safety profile.

The Era of Radial-Specific Catheters: A Multicenter Comparison of the Armadillo and RIST Catheters in Transradial Procedures.

BACKGROUND AND OBJECTIVES: As the radial approach is gaining popularity in neurointervention, new radial-specific catheters are being manufactured while taking into consideration the smaller size of the radial artery, different trajectories of angles into the great vessels from the arm, and subsequent force vectors. We compared outcomes of transradial procedures performed using the Armadillo catheter (Q'Apel Medical Inc.) and the RIST radial guide catheter (Medtronic). METHODS: This is a retrospective multicenter study comparing outcomes of transradial neuroendovascular procedures using the Armadillo and RIST catheters at 2 institutions between 2021 and 2024. RESULTS: The study comprised 206 patients, 96 of whom underwent procedures using the Armadillo and 110 using the RIST. Age and sex were comparable across cohorts. In most procedures, 1 target vessel was catheterized (Armadillo: 94.8% vs 89.1%, P = .29) with no significant difference between cohorts. The use of an intermediate catheter was minimal in both cohorts (Armadillo 5.2% vs RIST: 2.7%, P = .36), and the median number of major vessel catheterization did not significantly differ between cohorts (Armadillo: 1 [1-4] vs RIST: 1 [0-6], P = .21). Failure to catheterize the target vessel was encountered in 1 case in each cohort (Armadillo: 1.0% vs RIST: 0.9%, P = .18), and the rate did not significantly differ between cohorts. Similarly, the rate of conversion to femoral access was comparable between cohorts (Armadillo: 2.1% vs RIST: 1.8%, P = .55). There was no significant difference in access site complications (Armadillo: 1% vs RIST: 2.8%, P = .55) or neurological complications (Armadillo: 3.1% vs RIST: 5.5%, P = .42) between cohorts. CONCLUSION: No significant difference in successful catheterization of target vessels, procedure duration, triaxial system use, complication rates, or the need for transfemoral cross-over was observed between both catheters. Both devices offer high and comparable rates of technical success and low morbidity rates.

Tenecteplase versus alteplase before stroke thrombectomy: outcomes after system-wide transitions in Pennsylvania.

INTRODUCTION: United States stroke systems are increasingly transitioning from alteplase (TPA) to tenecteplase (TNK). Real-world data on the safety and effectiveness of replacing TPA with TNK before large vessel occlusion (LVO) stroke endovascular treatment (EVT) are lacking. METHODS: Four Pennsylvania stroke systems transitioned from TPA to TNK during the study period 01/2020-06/2023. LVO stroke patients who received intravenous thrombolysis with TPA or TNK before EVT were reviewed. Multivariate logistic analysis was conducted adjusting for age, sex, National Institute of Health Stroke Scale (NIHSS), occlusion site, last-known-well-to-intravenous thrombolysis time, interhospital-transfer and stroke system. RESULTS: Of 635 patients, 309 (48.7%) received TNK and 326 (51.3%) TPA prior to EVT. The site of occlusion was the M1 middle cerebral artery (MCA) (47.7%), M2 MCA (25.4%), internal carotid artery (14.0%), tandem carotid with M1 or M2 MCA (9.8%) and basilar artery (3.1%). A favorable functional outcome (90-day mRS ≤ 2) was observed in 47.6% of TNK and 49.7% of TPA patients (p = 0.132). TNK versus TPA groups had similar rates of early recanalization (11.9% vs. 8.4%, p = 0.259), successful endovascular reperfusion (93.5% vs. 89.3%, p = 0.627), symptomatic intracranial hemorrhage (3.2% vs. 3.4%, p = 0.218) and 90-day all-cause mortality (23.1% vs. 21.5%, p = 0.491). CONCLUSIONS: This U.S. multicenter real-world clinical experience demonstrated that switching from TPA to TNK before EVT for LVO stroke resulted in similar endovascular reperfusion, safety, and functional outcomes.

Predictors of occlusion, long-term outcomes, and safety in a cohort of 674 aneurysms treated with the Pipeline embolization device.

OBJECTIVE: By providing a more physiological approach to the treatment of intracranial aneurysms, the Pipeline embolization device (PED) has revolutionized the endovascular treatment of aneurysms. Although there are many flow diverters on the market, the authors report their experience with the PED, the first flow diverter to be approved by the Food and Drug Administration. They aimed to assess the efficacy and safety of PED flow diversion for the treatment of a wide range of aneurysms, as well as to look at factors affecting occlusion. METHODS: This is a retrospective study of a prospectively maintained database of patients treated with the PED between January 2011 and December 2019. Charts were reviewed for patient, aneurysm, and procedure characteristics. The primary outcomes of interest were complication rates, occlusion outcomes (O'Kelly-Marotta grading scale), and functional outcomes (modified Rankin Scale [mRS]). Secondary outcomes included predictors of incomplete occlusion at 6 and 24 months of follow-up. RESULTS: The study cohort included 581 patients with 674 aneurysms. Most aneurysms (90.5%) were in the anterior circulation and had a saccular morphology (85.6%). Additionally, 638 aneurysms (94.7%) were unruptured, whereas 36 (5.3%) were acutely ruptured. The largest mean aneurysm diameter was 8.3 ± 6.1 mm. Complications occurred at a rate of 5.5% (n = 32). The complete occlusion rate was 89.3% at 24 months' follow-up, and 94.8% of patients had a favorable neurological outcome (mRS score 0-2) at the last follow-up. On multivariate analysis, predictors of incomplete aneurysm occlusion at 6 months were hypertension (OR 1.7, p = 0.03), previous aneurysm treatment (OR 2.4, p = 0.001), and increasing aneurysm neck diameter (OR 1.2, p = 0.02), whereas a saccular morphology was protective (OR 0.5, p = 0.05). Predictors of incomplete occlusion at 24 months were increasing aneurysm neck diameter (OR 1.2, p = 0.01) and previous aneurysm treatment (OR 2.3, p = 0.01). CONCLUSIONS: The study findings are corroborated by those of previous studies and trials. The complete occlusion rate was 89.3% at 24 months' follow-up, with 94.8% of patients having favorable functional outcomes (mRS score 0-2). Aneurysm treatment before PED deployment and an increasing aneurysm neck diameter increase the risk of incomplete occlusion at 6 and 24 months.

Femoral versus radial access for middle meningeal artery embolization for chronic subdural hematomas: multicenter propensity score matched study.

BACKGROUND: With transradial access (TRA) being more progressively used in neuroendovascular procedures, we compared TRA with transfemoral access (TFA) in middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH). METHODS: Consecutive patients undergoing MMAE for cSDH at 14 North American centers (2018-23) were included. TRA and TFA groups were compared using propensity score matching (PSM) controlling for: age, sex, concurrent surgery, previous surgery, hematoma thickness and side, midline shift, and pretreatment antithrombotics. The primary outcome was access site and overall complications, and procedure duration; secondary endpoints were surgical rescue, radiographic improvement, and technical success and length of stay. RESULTS: 872 patients (median age 73 years, 72.9% men) underwent 1070 MMAE procedures (54% TFA vs 46% TRA). Access site hematoma occurred in three TFA cases (0.5%; none required operative intervention) versus 0% in TRA (P=0.23), and radial-to-femoral conversion occurred in 1% of TRA cases. TRA was more used in right sided cSDH (58.4% vs 44.8%; P<0.001). Particle embolics were significantly higher in TFA while Onyx was higher in TRA (P<0.001). Following PSM, 150 matched pairs were generated. Particles were more utilized in the TFA group (53% vs 29.7%) and Onyx was more utilized in the TRA group (56.1% vs 31.5%) (P=0.001). Procedural duration was longer in the TRA group (median 68.5 min (IQR 43.1-95) vs 59 (42-84); P=0.038), and radiographic success was higher in the TFA group (87.3% vs 77.4%; P=0.036). No differences were noted in surgical rescue (8.4% vs 10.1%, P=0.35) or technical failures (2.4% vs 2%; P=0.67) between TFA and TRA. Sensitivity analysis in the standalone MMAE retained all associations but differences in procedural duration. CONCLUSIONS: In this study, TRA offered comparable outcomes to TFA in MMAE for cSDH in terms of access related and overall complications, technical feasibility, and functional outcomes. Procedural duration was slightly longer in the TRA group, and radiographic success was higher in the TFA group, with no differences in surgical rescue rates.