Modulating poststroke inflammatory mechanisms: Novel aspects of mesenchymal stem cells, extracellular vesicles and microglia.

Inflammation plays an important role in the pathological process of ischemic stroke, and systemic inflammation affects patient prognosis. As resident immune cells in the brain, microglia are significantly involved in immune defense and tissue repair under various pathological conditions, including cerebral ischemia. Although the differentiation of M1 and M2 microglia is certainly oversimplified, changing the activation state of microglia appears to be an intriguing therapeutic strategy for cerebral ischemia. Recent evidence indicates that both mesenchymal stem cells (MSCs) and MSC-derived extracellular vesicles (EVs) regulate inflammation and modify tissue repair under preclinical stroke conditions. However, the precise mechanisms of these signaling pathways, especially in the context of the mutual interaction between MSCs or MSC-derived EVs and resident microglia, have not been sufficiently unveiled. Hence, this review summarizes the state-of-the-art knowledge on MSC- and MSC-EV-mediated regulation of microglial activity under ischemic stroke conditions with respect to various signaling pathways, including cytokines, neurotrophic factors, transcription factors, and microRNAs.

Association of CDKN2A/CDKN2B Gene Polymorphisms with Increased Susceptibility to Intracranial Aneurysm in a Chinese Han Population.

OBJECTIVE: Several studies have reported that single-nucleotide polymorphisms (SNPs) of the CDKN2A/CDKN2B gene on chromosome 9p21.3 are associated with increased risk of intracranial aneurysm (IA). However, the association between IAs and SNPs of CDKN2A/CDKN2B in Chinese Han people is yet to be evaluated. This study examined the association of the SNPs rs10811661 and rs4977574 with IA in the Chinese Han population. METHODS: A total of 595 IA patients and 600 sex- and age-matched controls were enrolled in the study. Peripheral blood was collected and stored at -80°C until use. CDKN2A/CDKN2B was identified using polymerase chain reaction-ligase detection reaction. SNP genotyping was performed for rs10811661 and rs4977574 using a MassArray system. Associations between these two SNPs and IAs was tested with χ2 or Fisher's exact tests and multivariate logistic regression. RESULTS: rs10811661 and rs4977574 were significantly associated with IA. The frequency of rs10811661-T in IA was higher than in controls (OR 1.26, 95% CI 1.07-1.49; P<0.01). There was no significant difference in frequency of haplotype between control subjects and IA patients. CONCLUSION: rs10811661 and rs4977574 on 9p21.3 were strongly associated with genetic susceptibility to IA in the Chinese Han population, which emphasizes a need for further investigation.

Application of hybrid operating rooms for treating spinal dural arteriovenous fistula.

BACKGROUND: A hybrid operating room (hybrid-OR) is a surgical space that combines a conventional operating room with advanced medical imaging devices. AIM: To explore and summarize the technical features and effectiveness of the application of a hybrid-OR in dealing with spinal dural arteriovenous fistulas (SDAVFs). METHODS: Eleven patients with SDAVFs were treated with the use of a hybrid-OR at the Department of Neurosurgery of our hospital between January 2015 and December 2018. The dual-marker localization technique was used in the hybrid-OR to locate the SDAVFs and skin incision, and the interoperative digital subtraction angiography (DSA) technique was used before and after microsurgical ligation of the fistulae in the hybrid-OR to verify the accuracy of obliteration. The patients were followed for an average of 2 years after the operation, and the preoperative American Spinal Cord Injury Association (ASIA) score and postoperative ASIA score at 6 mo after the operation were compared. RESULTS: The location and skin incision of the SDAVFs were accurately obtained by using the dual-marker localization technique in the hybrid-OR in all patients, and there were no cases that required expansion of the range of the bone window in order to expose the lesions. Intraoperative error obliteration occurred and was identified in two patients by using the intraoperative DSA technique; therefore, the findings provided by the intraoperative DSA system significantly changed the surgical procedure in these two patients. With the assistance of the hybrid-OR, the feeding artery was correctly ligated in all cases, and the intraoperative error obliteration rate decreased from 18.2% (2/11) to 0%. All 11 patients were followed for an average of 2 years. The ASIA score at 6 mo after the operation was significantly improved compared with the preoperative ASIA score, and there were no patients with late recurrence during the follow-up. CONCLUSION: Compared with intra-arterial embolization for the treatment of SDAVFs, hybrid-ORs can solve the problem of a higher incidence of initial failure and late recurrence. Compared with direct occlusion of SDAVFs in microsurgery, hybrid-ORs can take advantage of the intraoperative DSA system for locating the shunt and verifying the obliteration of fistulae in order to reduce the error obliteration rate. At this point, our experience suggests that the safety and ease of use make hybrid-ORs combined with microsurgery and intraoperative DSA systems an attractive modality for dealing with SDAVFs.

Application of hybrid operating rooms for clipping large or giant intracranial carotid-ophthalmic aneurysms.

BACKGROUND: A hybrid operating room (Hybrid-OR) is a surgical theatre that combines a conventional operating room with advanced medical imaging devices. There are still plenty of limitations when endovascular treatment or microsurgical treatment is used individually to treat large or giant carotid-ophthalmic aneurysms. AIM: To explore and summarize the technical features and effectiveness of the application of a Hybrid-OR in managing major intracranial carotid-ophthalmic aneurysms. METHODS: The Department of Neurosurgery treated 12 cases of large or giant intracranial carotid-ophthalmic aneurysms between March 2013 and December 2019 in a Hybrid-OR. All cases were treated with clipping and parent vessel reconstruction. RESULTS: With the assistance of the Hybrid-OR, the rate of incomplete intraoperative aneurysm clipping decreased from 25% (3/12) to 0%, while the rate of vessel stenosis decreased from 16.7% (2/12) to 8.35% (1/12). In terms of thromboembolic events, ischemic infarction complication occurred in only one patient, and none of the patients experienced embolic infarction complications. All 12 patients were followed for an average of 3 years, and no aneurysms recurred. The postoperative recovery was evaluated with the modified Rankin Scale (mRS): 11 patients showed no symptoms (mRS = 0), 1 patient showed slight disability (mRS 1-2), and none of the patients had severe disability (mRS = 5) or died (mRS = 6). CONCLUSION: The Hybrid-OR provides new ideas for the surgical clipping of large or giant intracranial carotid-ophthalmic aneurysms and decreases the rate of intraoperative vessel stenosis and unsuccessful clipping.

Carotid endarterectomy should be performed early or delayed in patients with symptomatic carotid stenosis?

BACKGROUND: To date, the literature directly comparing early carotid endarterectomy (CEA) and delayed CEA in patients with symptomatic carotid stenosis (CS) is limited. We aimed to evaluate the efficacy and safety of early CEA and delayed CEA in patients with symptomatic CS by performing a meta-analysis. MATERIAL AND METHOD: The PubMed, Cochrane Library (last searched in May 2020) and relevant websites such as Web of Science and EMBASE (1990 to May 2020) were searched. All meta-analyses of eligible results were conducted using the STATA version 12.0 (Stata Corporation, College Station, Texas, USA). RESULTS: A total of 7 articles were included in the study hailing from the New Scotland, Chicago, Sweden, UK, Italy, and France. In this study, the early CEA meant that the procedure was performed within the first 14 days or first 30 days. And the delayed CEA meant the procedure was performed more than 14 days or 30 days after the symptom occurrence. Referring to the latter early CEA group and delayed CEA group, there were three publications. The results illustrated that the early CEA group was not associated with a higher incidence of stroke (OR = 0.77, 95 % CI: 0.273-2.170; P = 0.620). And no statistic difference was found on the incidence of postoperative 30-day mortality and stroke or mortality. Meanwhile, referring to the former early CEA group and delayed CEA group, there were six articles. The results demonstrated that the early CEA group was associated with a higher rate of postoperative 30-day mortality (RD = 0.010, 95 % CI: 0.002 to 0.019; P = 0.022). CONCLUSION: The meta-analysis of these related studies suggests that, compared to the delayed CEA group, the early CEA performed in patients with the acute post stroke phase resulted in a higher risk of postoperative mortality. Therefore, the delayed CEA was safer than early CEA for patients with symptomatic CS.

Meta-Analysis of Pterional Versus Supraorbital Keyhole Approach for Clipping Intracranial Aneurysms: Direct Comparison of Approach-Related Complications.

BACKGROUND: The supraorbital keyhole approach (SKA) and pterional approach (PA) have been recommended for clipping intracranial aneurysms (IAs). We conducted a meta-analysis to systematically and comprehensively compare the clinical outcomes between the 2 approaches. METHODS: We retrieved potential academic studies that had compared the clinical outcomes of SKA and PA for clipping IAs from the Cochrane Library, Medline, PubMed, and EMBASE databases. The references of the identified studies were carefully reviewed to ensure that all available documents had been included in the present study. The meta-analysis was conducted in accordance with the acknowledged PRISMA (prioritized reported items for systematic review and meta-analysis) guidelines. RESULTS: A total of 8 studies with 1016 participants were included in our study. Of these 1016 patients with IAs, 518 were assigned to the SKA group and 498 to the PA group. Our results showed that the SKA is preferable for clipping IAs compared with the PA because of its shorter operative time (weighted mean difference, -3.163; 95% confidence interval [CI], -5.577 to -0.749; P = 0.01) and length of stay, especially for the patients with unruptured IAs (weighted mean difference, -52.107; 95% CI, -81.597 to -22.618). However, a lower risk of postoperative infection was found in the SKA group (4.6% vs. 8.5%; odds ratio, 0.398; 95% CI, 0.186-0.850; P = 0.017), which seemed to derive from the ruptured IAs (OR, 0.330; 95% CI, 0.136-0.800; P = 0.014). However, no significant difference was found in the incidence of frontal sinus opening, completed occlusion, procedural complications, intraoperative rupture, postoperative hematoma, or cerebral vessel spasm. CONCLUSIONS: The SKA was associated with a shorter length of stay and operation time and a lower risk of postoperative infection. Hence, the SKA seems to be equally effective and safe for clipping IAs compared with PA and should be recommended for surgeons who have acquired sufficient experience with this technique owing to its advantages compared with the PA.

Patient with Epilepsy Caused by the Spontaneous Rupture of an Intracerebral Dermoid Cyst.

BACKGROUND: This is a rare case of a patient presenting with epileptic seizures and headaches who was diagnosed with spontaneous intracerebral dermoid cyst rupture via radiographic imagery, and rupture was confirmed via a pathology report. CASE DESCRIPTION: We report the case of a woman aged 26 years who presented with a history of chronic headache for 9 years without other symptoms, and progressive worsening of her headache had occurred for 1 month prior to admission. Radiologic examination showed a large mass located in the left temporal fossa and a large amount of homogeneous matter in the subarachnoid space of the ipsilateral cerebral hemisphere, then the tumor was completely excised. A left pterional craniotomy was conducted under general anesthesia for removal of the tumor, and pathological examination showed a dermoid cyst. CONCLUSIONS: We discuss the clinical and radiologic features, as well as the treatment of this patient.

Majocchi's granuloma caused by Trichophyton rubrum after facial injection with hyaluronic acid: A case report.

BACKGROUND: Facial cosmetic procedures become popular for people with a desire to have a younger appearance, and cosmetic technology has developed rapidly over the past several decades. However, increasing complications related to cosmetic injections have been reported, and infection is one of the most serious problems and can cause anxiety and facial injury. We here report a case of Majocchi's granuloma (MG) caused by Trichophyton rubrum after facial injection of hyaluronic acid. CASE SUMMARY: A 37-year-old woman presented to our hospital with a history of red papules, nodules, and abscesses on her left zygomatic arch for 2 mo. She had received a cosmetic injection of hyaluronic acid on the left side of her face prior to the appearance of the lesions. MG caused by Trichophyton rubrum after facial injection of hyaluronic acid was diagnosed based on morphology and molecular biological identification. In vitro antifungal susceptibility testing was conducted according to the Clinical and Laboratory Standards Institute M38-A2 method. Minimal inhibitory concentrations were used to evaluate the antifungal susceptibility. The antifungal agents and their minimal inhibitory concentrations for the strain were terbinafine (< 0.5 µg/mL), itraconazole (0.06 µg/mL), amphotericin B (0.25 µg/mL), fluconazole (32 µg/mL), voriconazole (0.125 µg/mL), posaconazole (0.125 µg/mL), and isavuconazole (0.06 µg/mL). We initially administered 250 mg/d oral terbinafine for 2 mo, but the patient still had painful papules, nodules and abscesses on her face. Then, we adjusted the treatment to itraconazole 400 mg/d for 8 wk based on the in vitro antifungal susceptibility testing results. The skin lesions improved significantly, and there was no recurrence during follow-up. CONCLUSION: This case revealed that facial injection of hyaluronic acid may cause serious MG. Antifungal susceptibility testing should be considered in the treatment of MG caused by Trichophyton rubrum.

Using a New Landmark of the Most External Point in the Embolization of Distal Anterior Choroidal Aneurysms: A Report of Two Cases.

There are landmarks on the course of the anterior choroidal artery (AChoA), such as the original point (OP) and the plexal point (PP), as documented in previous articles. In these previous articles, the AChoA was the terminal branch of the internal carotid artery (ICA), which had two segments throughout its course. The first cisternal segment began from the origin and ended at the point where the artery reached the choroidal fissure (the PP). The second segment consisted of one or more branches, which passed through the choroidal fissure and entered the choroid plexus. However, we found another angiographic landmark, named the most external point (MEP), along the course of the AChoA in the anteroposterior (AP) view. There was a sharp turn at the outermost limit of the course of the AChoA, and then the AChoA progressed inward and upward. We defined the outermost limit as the MEP of the AChoA. This study describes two rare cases of distal AChoA aneurysms associated with arteriovenous malformation (AVM) and Moyamoya disease that developed intraventricular hemorrhage, and we used the parent artery occlusion (PAO) technique to embolize the distal AChoA lesions at the MEP. The patients recovered well without any neurological complications.

Risk factors involved in the formation of multiple intracranial aneurysms.

BACKGROUND: Although several risk factors of the multiple intracranial aneurysms (MIAs) formation has been reported, the results are controversial. We aimed to find out the risk factors of MIAs formation by analyzing our clinic data combined with a meta-analysis. MATERIAL AND METHODS: A retrospective review work of medical records for the patients with aneurysms was undertaken. Univariate analysis was used to examine all mentioned variables. Binary logistic regression analysis was used to identify the risk factors of MIAs formation. RESULTS: In the retrospective review work, a total of 565 patients with aneurysm were included in this study. Of these 565 participants, 449 patients suffered SIAs and 116 patients suffered MIAs. Univariate analysis showed a significant difference in terms of female, cigarette smoking, family history of hypertension, and primary hypertension between the SIAs and MIAs group. The binary logistic regression analysis showed that the female (OR = 1.624), primary hypertension (OR = 1.563), and family history of hypertension (OR = 2.496) were independent risk factors of the formation of MIAs (for each P < 0.05). With regard to the meta-analysis results, it revealed that there was significant difference in the rates of female (P < 0.001), cigarette smoking (P < 0.001), primary hypertension (P = 0.001), and higher age (P = 0.011) among the MIAs patients. CONCLUSIONS: A higher rate of the formation of MIAs is closely associated with the elder and female. Patients with hypertension history, cigarette smoking, and family primary hypertension history also affected the formation of MIAs, these risk factors should be a guard against.

Meta-Analysis of Clipping versus Coiling for the Treatment of Unruptured Middle Cerebral Artery Aneurysms: Direct Comparison of Procedure-Related Complications.

BACKGROUND: Endovascular coiling and surgical clipping are routinely used to treat unruptured middle cerebral artery aneurysms (MCAAs). However, the optimal treatment for unruptured MCAAs is controversial. We aimed to systematically and comprehensively compare the clinical outcomes between endovascular coiling and surgical clipping for the treatment of MCAAs. METHOD: This meta-analysis retrieved academic articles comparing the clinical outcomes between endovascular coiling and surgical clipping for unruptured MCAAs from the Cochrane Library, Medline, PubMed, and EMBASE databases. The reference articles of the identified studies were carefully reviewed to ensure that all available articles were represented in the study. The meta-analysis was conducted in accordance with the acknowledged the prioritized reported items for systematic review and meta-analysis (PRISMA) guidelines. RESULTS: A total of 6 studies, which enrolled a total of 789 participants, were included in our analysis. Of these 789 patients with MCAAs, 144 were assigned to an endovascular coiling group, and 645 were assigned to a surgical clipping group. Our results demonstrated that endovascular coiling was associated with a higher rate of retreatment (OR = 104.926; 95% CI: 12.931 to 851.379; P<0.001) and postoperative complications (OR = 3.157; 95% CI: 1.239 to 8.048; P= 0.016) than surgical clipping, especially for postoperative thrombus without infarction (OR = 4.905, 95% CI: 1.097 to 21.933; P = 0.037). Furthermore, surgical clipping was related to a higher rate of complete occlusion (OR = 0.349, 95% CI: 0.140 to 0.872; P = 0.024) and Glasgow Outcome Scale (GOS) ≥4 (OR = 0.250; 95% CI: 0.072 to 0.867; P= 0.029) than endovascular coiling after the operation. However, there was no significant difference in the rate of death, the proportion of patients with modified Rankin Scale (mRS)>2, infarction, or bleeding. CONCLUSION: Although this study has inherent limitations, surgical clipping of unruptured MCAAs resulted in significantly higher complete aneurysm occlusion and GOS≥4 rates and was associated with a lower incidence of retreatment and complication, especially for postoperative thrombus without infarction. Therefore, the effect induced by surgical clipping of unruptured MCAAs remains superior to that induced by endovascular coiling; surgical clipping should be regarded as the first choice of treatment for unruptured MCAAs.

Comparison between porous tantalum metal implants and autograft in anterior cervical discectomy and fusion: a meta-analysis.

Aim: The objective of this study was to systematically compare the safety and efficacy of porous tantalum metal (TM) implants and autograft in single-level anterior cervical discectomy and fusion. Methods: Potential academic articles were acquired from the Cochrane Library, Medline, PubMed, Embase, Science Direct and other databases. The time range used was from the inception of the electronic databases to March 2018. Gray studies were identified from the references of included literature reports. STATA version 11.0 (Stata Corporation, TX, USA) was used to analyze the pooled data. Results: Four randomized, controlled trials (RCTs) were identified according to the retrieval process. There were significant differences in operation time (mean difference [MD]: -28.846, 95% confidence interval [CI: -47.087, -10.604], p = 0.002) and satisfaction rate (odds ratio [OR]: 2.196, 95% CI: [1.061-4. 546]; p = 0.034). However, no significant difference was detected in blood loss (MD: -73.606, 95% CI: [-217.720, 70.509], p = 0.317), hospital stay (MD: -0.512, 95% CI [-1.082, 0.058]; p = 0.079), fusion rate (OR: 0.497, 95% CI [0.079, 3.115]; p = 0.455), visual analog scale (MD: -0.310, 95% CI [-0.433, -0.186]; p < 0.001) or complication rate (risk difference [RD]: -0.140, 95% CI: [-0.378, 0.099]; p = 0.251). Conclusion: Porous TM implants are equally as effective and safe as autograft in anterior cervical discectomy and fusion processes. In addition, porous TM implants could reduce operation time and improve clinical satisfaction significantly.

Intravenous tranexamic acid reduces blood transfusions in revision total hip arthroplasty: a meta-analysis.

Aim: We performed a meta-analysis to systematically assess the efficacy and safety of intravenous tranexamic acid in revision total hip arthroplasty. Method: Potential academic articles were identified from Cochrane Library, Medline, PubMed, EMBASE, ScienceDirect and other databases. The time range we retrieved from was that from the inception of electronic databases to February 2019. Gray studies were identified from the references of included literature reports. STATA version 11.0 was used to analyze the pooled data. Results: A total of eight articles were involved in our study. The overall participants of tranexamic acid (TXA) group were 3533, whereas it was 11,007 in the control group. Our meta-analysis showed that TXA is preferable for revision total hip arthroplasty because of its lower value of hemoglobin reduction (weighted mean difference = -1.277-1.405; 95% CI: -1.996 to -0.559; p < 0.001), the rate of blood transfusion (odds ratio: 0.233; 95% CI: 0.129-0.422; p < 0.001) and the number of red blood cell units transfused (weighted mean difference = -0.978; 95% CI = -1.631 to -0.324; p = 0.003). However, there was no difference in calculated blood loss (p = 0.075), operation duration (p = 0.569) and venous thromboembolism complications (p = 0.338). Conclusion: Based on available evidence, use of intravenous TXA for patients undergoing revision arthroplasty may reduce hemoglobin reduction, number of red blood cell units transfused and blood transfusion rate without increasing the risk of venous thromboembolism and length of operation duration. Given the relevant possible biases in our study, adequately powered and better-designed studies with long-term follow-up are required to reach a firmer conclusion.

A better strategy using barbed sutures for wound closure in total knee arthroplasty.

Aim: The purpose of this study was to conduct a meta-analysis to systematically compare the clinical outcomes between knee barbed sutures (KBS) and knee traditional sutures (KTS) for wound closure in total knee arthroplasty (TKA). Method: This study retrieved potential academic articles comparing the clinical outcomes between KBS and KTS in TKA from the MEDLINE database, the PubMed database, the EMBASE database and the Cochrane Library. The reference articles for the identified studies were carefully reviewed to ensure that all available documents were represented in the study. Results: A total of 14 articles (eight randomized controlled trials [RCTs], six non-RCTs) were involved in our study. The overall participants of barbed Sutures group were 1255, whereas it was 1247 in the traditional sutures. Our meta-analysis showed that KBS is preferable for wound closure of TKA as its shorter lower total cost (weighted mean difference [WMD] = -276.281, 95% CI = -480.281 to -72.280; p = 0.008) and wound closure time (WMD = -4.895,95% CI = -6.105 to -3.685; p < 0.001). However, there was no difference in any complications (p = 0.572), wound complications (p = 0.550), superficial infection (p = 0.918), deep infection (p = 0.654), wound dehiscence (p = 0.649), suture abscess (p = 0.939), arthrofibrosis (p = 0.970), needle sticks (p = 0.158), suture breakage (p = 0.371) and knee society scores (KSS; p = 0.073). Conclusion: The use of KBS in TKA is associated with significantly shortened wound closure times and total closure cost without increased risk of intraoperative needle sticks and suture breakage and postoperative incision complications. Given the relevant possible biases in our study, adequately powered and more RCTs with long-term follow-up are needed to compare the efficacy and safety between KBS and KTS.

Predictable Risk Factors of Spontaneous Venous Thromboembolism in Patients Undergoing Spine Surgery.

OBJECTIVE: The purpose of this study was to conduct a meta-analysis to identify the risk factors for formation of venous thromboembolism (VTE) in patients after spine surgery. METHODS: This study retrieved potential academic articles on the related factors for VTE formation in patients after spine surgery from MEDLINE, PubMed, EMBASE, and the Cochrane Library. The reference articles for the identified studies were carefully reviewed to ensure that all available documents were represented in the study. RESULTS: A total of 21 articles (20 retrospective studies and 1 prospective study) involving 2,870,105 patients were identified in the analysis, including 7829 patients who presented with VTE after spine surgery; the incidence of VTE was 0.273%. Our meta-analysis showed that compared with patients who did not have VTE after spine surgery, there was significantly more blood loss (weighted mean difference [WMD], 93.295; 95% confidence interval [CI], 60.521-126.069; P < 0.001), higher age (WMD, 6.011; 95% CI, 3.647-9.376; P < 0.001), thoracolumbar surgery (odds ratio [OR], 0.233; 95% CI, 0.198-0.274; P < 0.001), and longer duration of surgery (WMD, 45.672; 95% CI, 10.433 to -80.911; P = 0.011) among the patients with VTE. Patients with a history of hypertension (OR, 1.785; 95% CI, 1.516-2.103; P < 0.001), diabetes (OR, 1.535; 95% CI, 1.286-1.832; P < 0.001), and preoperative walking disability (OR, 4.882; 95% CI, 2.044-11.663; P < 0.001) showed a significantly higher rate of VTE after spine surgery. However, no significant differences were found in gender (P = 0.289), fusion surgery (P = 0.979), body mass index (P = 0.157), history of heart disease (P = 0.397), and level of D-dimer (P = 0.220). CONCLUSIONS: A higher rate of postoperative VTE is closely associated with the elderly, longer duration of surgery, thoracolumbar surgery, greater blood loss, and patients with a history of hypertension, preoperative walking disability, or diabetes after spinal surgery; these risk factors should be guarded against.

Comparison of Flow Diversion and Coiling for the Treatment of Unruptured Intracranial Aneurysms.

BACKGROUND: To systematically assess the efficacy and safety between flow diversion and coiling for patients with unruptured intracranial aneurysms. METHODS: Potential academic articles were identified from Cochrane Library, Medline, PubMed, EMBASE, ScienceDirect, and other databases. The time range we retrieved from was the inception of electronic databases to February 2019. Gray studies were identified from the references of included literature reports. STATA version 11.0 was used to analyze the pooled data. RESULTS: A total of 11 articles (10 retrospective studies and 1 prospective study) were involved in our study. The overall participants of the coiling group were 611, whereas 576 were in the flow diversion group. Our meta-analysis showed that flow diversion was preferable for unruptured intracranial aneurysms as its lower value of total cost per case (weighted mean difference, 5705.906; 95% confidence interval [CI], [4938.536, 6473236]; P < 0.001), fluoroscopy time per case (weighted mean difference, 25.786; 95% CI, 17.169-34.377; P < 0.001), and retreatment rates (odds ratio [OR], 7.127; 95% CI, [3.525, 14.410]; P < 0.001), at the same time, a higher rate of immediate completed occlusion (OR, 0.390; 95% CI, [0.224, 0.680]; P = 0.001) and follow-up completed occlusion (OR, 0.173; 95% CI, [0.080, 0.375]; P < 0.001) was demonstrated in the flow diversion group. There was no difference on intraoperative complication rates (P = 0.070), procedure-related mortality (P = 0.609) and rupture rates (P = 0.408), modified Rankin Scale (mRS) 0-2 at discharge (P = 0.077), and mRS 0-2 at follow-up (P = 0.484). CONCLUSIONS: The use of flow diversion for the treatment of unruptured intracranial aneurysms may reduce total cost per case, fluoroscopy time per case, retreatment rates, and increases immediate completed occlusion and follow-up completed occlusion rates without affecting the results of mRS and intraoperative complication.

Systematic and Comprehensive Comparison of Incidence of Restenosis Between Carotid Endarterectomy and Carotid Artery Stenting in Patients with Atherosclerotic Carotid Stenosis.

OBJECTIVE: The purpose of the present study was to conduct a meta-analysis to systematically compare the incidence rates of in-stent restenosis after carotid artery stenting (CAS) and restenosis after carotid endarterectomy (CEA) for patients with atherosclerotic carotid stenosis. METHODS: We retrieved potential academic reports comparing restenosis between CEA and CAS from the MEDLINE, PubMed, and EMBASE databases and the Cochrane Library from the date of the first CEA (January 1951) to July 20, 2018. The references of the identified studies were carefully reviewed to ensure that all available reports were included in the present study. RESULTS: Our meta-analysis included 27 studies (15 randomized controlled trials, 12 nonrandomized controlled trials) and 20,479 participants with atherosclerotic carotid stenosis. A statistically significant difference was found in the cumulative incidence of restenosis >70% between CEA and CAS (risk difference, -0.033, 95% confidence interval [CI] -0.054 to -0.013; P = 0.002). For the restenosis >70% outcomes, although CEA was relevant with a lower rate of restenosis than CAS within 6 months (odds ratio [OR], 0.495; 95% CI, 0.285-0.861; P = 0.013) and 1 year (OR, 0.626; 95% CI, 0.483-0.811; P < 0.001), no statistically significant differences were found at 1.5 years (P = 0.210), 2 years (P = 0.123), 4 years (P = 0.124), 5 years (P = 0.327), or 10 years (P = 0.839). For the restenosis >50% outcomes, a significant difference was found in the rate of restenosis between the CEA and CAS groups within 1 year (OR, 0.317; 95% CI, 0.228-0.441; P < 0.001) but not at 1.5 years (P = 0.301), 2 years (P = 0.686), or 5 years (P = 0.920). No nominally significant effects were demonstrated with respect to the cumulative incidence of occlusion (P = 0.195) or the cumulative incidence of restenosis for symptomatic patients (P = 0.170) between CEA and CAS. CONCLUSIONS: Although CAS was preferred over CEA, regardless of restenosis >50% or >70% after revascularization within 1 year, no significant difference was observed with extension of the follow-up period to >1 year. CAS was not associated with a greater cumulative incidence of occlusion or the cumulative incidence of restenosis for symptomatic patients.