Associations Between Vitamin D Deficiency/Insufficiency and Depression Expose Health Disparities in Older Rural West Texans: A Project FRONTIER Study.

OBJECTIVE: To determine associations between Vitamin D (VD) levels and clinical depression through the Geriatric Depression Scale (GDS) and its questions and subdomains, stratified by demographics and Hispanic/Latino ethnicity (HLE). DESIGN, SETTING, AND PARTICIPANTS: A cohort of 299 Project FRONTIER participants aged 62.6 ± 11.7 years old, 70.9% female, and 40.5% HLE were used. Standard correlation and regression analyses were employed. MEASUREMENTS: The main outcome measures were VD (serum 25(OH)-VD) level, GDS-30 (30-item questionnaire), GDS-30 subfactors and questions, and HLE status. VD categories were defined as VD deficiency (VDD; ≤20 ng/mL), VD insufficiency (VDI; 21-29 ng/mL), VD sufficiency (30-38 ng/mL) and high VD sufficiency (>38 ng/mL). RESULTS: The majority (61.5%) of samples fell into VDD/VDI categories. A significant negative association was found between VD level and GDS-30 total score. VD level was negatively correlated with Dysphoria and Meaninglessness GDS-30 subfactors. Although GDS subfactors were similar between HLE and non-HLE groups, VD levels were significantly lower in HLE samples. Finally, HLE/non-HLE groups were differentially stratified across VD categories. Only 4% of HLEs fell into the high VD sufficient category, suggesting low VD supplementation. CONCLUSION: A significant negative association between VD level and depressive symptoms was revealed in our aging Project FRONTIER participants. HLE individuals were overrepresented in VDD/VDI samples, and VDD/VDI was associated primarily with the Dysphoria GDS subdomain. Regression analysis predicted high VD sufficiency (95.5 ng/mL) to be associated with no depressive symptoms (GDS=0). Our results underscore troubling disparities in VD-related depressive symptoms between HLE and non-HLE populations.

Flow Diversion as a Definitive Treatment for Recurrently Ruptured A1-A2 Anterior Cerebral Artery Aneurysm Following Clipping and Coiling.

Even after clipping of intracranial aneurysms, patients may experience incomplete occlusion or the future recurrence of their treated aneurysm. This paper presents a distinctive case of a recurrent A1-A2 anterior cerebral artery aneurysm that underwent four interventions over 16 years. The aneurysm was treated with two clippings, subsequent coiling, and flow diversion for definitive treatment. The challenges encountered in managing bifurcation aneurysms are discussed, emphasizing the importance of considering hemodynamic factors, vessel geometry, and recurrence risk factors in treatment decisions. The case highlights the need for closer follow-up of ruptured bifurcation aneurysms due to the higher likelihood of recurrence. The role of flow diverters in reinforcing vessel anatomy and preventing recurrence is also highlighted.

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 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.

Endothelial Progenitor Cells: A Review of Molecular Mechanisms in the Pathogenesis and Endovascular Treatment of Intracranial Aneurysms.

This comprehensive review explores the multifaceted role of endothelial progenitor cells (EPCs) in vascular diseases, focusing on their involvement in the pathogenesis and their contributions to enhancing the efficacy of endovascular treatments for intracranial aneurysms (IAs). Initially discovered as CD34+ bone marrow-derived cells implicated in angiogenesis, EPCs have been linked to vascular repair, vasculogenesis, and angiogenic microenvironments. The origin and differentiation of EPCs have been subject to debate, challenging the conventional notion of bone marrow origin. Quantification methods, including CD34+ , CD133+ , and various assays, reveal the influence of factors, like age, gender, and comorbidities on EPC levels. Cellular mechanisms highlight the interplay between bone marrow and angiogenic microenvironments, involving growth factors, matrix metalloproteinases, and signaling pathways, such as phosphatidylinositol-3-kinase (PI3K) and mitogen-activated protein kinase (MAPK). In the context of the pathogenesis of IAs, EPCs play a role in maintaining vascular integrity by replacing injured and dysfunctional endothelial cells. Recent research has also suggested the therapeutic potential of EPCs after coil embolization and flow diversion, and this has led the development of device surface modifications aimed to enhance endothelialization. The comprehensive insights underscore the importance of further research on EPCs as both therapeutic targets and biomarkers in IAs.

Ventriculo-atrial shunt with occlusion of the internal jugular vein: operative experience and surgical technique.

BACKGROUND: Ventricular shunts are one of the most frequent techniques used for the management of hydrocephalus. The ventriculoperitoneal shunt (VPS) is the most commonly performed procedure, and the ventriculoatrial shunt (VAS) is the second option in most medical centers. The main objective of this study is to introduce and describe a surgical approach for VAS outlining our experience and comparing it with traditional shunting techniques. METHODS: In this retrospective cohort comparison study, we included patients with hydrocephalus treated with a surgical procedure between January 2010 and February 2021 at a single academic institution. We categorized the procedures into two groups: patients with VPS and conventional VAS grouped together into the conventional technique (CT) group, and the second group was patients with whom we performed VAS with complete internal jugular vein occlusion (IJVOT). We compared the surgical time, postoperative complications, and occurrence of shunt failure among the groups by performing univariate analysis using the Fisher exact test. RESULTS: Out of the 106 patients included in the analysis, IJVOT was performed in 66 patients, and CT in 40 patients. The median surgical time was 60 min (IQR 60-90) for IJVOT versus 100 min (IQR 60-120) for CT (p < 0.01). In the follow-up a month after the procedure, 83.3% of patients with IJVOT and 62.5% of patients with CT did not require shunt removal or shunt revision (p < 0.01). Shunt revision rates were 12.5% and 1.5% for CT while 1.5% and 2.5% for IJVOT at 1 and 6 months after the procedure. CONCLUSION: Our findings demonstrate that VAS with IJVOT is a safe method that exhibited shorter surgical times and outcomes comparable to CT. However, since the present study represents the first cohort evaluating IJVOT, it is imperative to conduct larger prospective studies, along with clinical trials, to fully explore and establish efficacy, long-term outcomes, and an in-depth comparison among shunting techniques.

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 Postoperative Seizures Between Burr-Hole Evacuation and Craniotomy in Patients With Nonacute Subdural Hematomas: A Bi-Institutional Propensity Score-Matched Analysis.

BACKGROUND AND OBJECTIVES: Postoperative seizures are a common complication after surgical drainage of nonacute chronic subdural hematomas (SDHs). The literature increasingly supports the use of prophylactic antiepileptic drugs for craniotomy, a procedure that is often associated with larger collections and worse clinical status at admission. This study aimed to compare the incidence of postoperative seizures in patients treated with burr-hole drainage and those treated with craniotomy through propensity score matching (PSM). METHODS: A retrospective cohort analysis was conducted on patients with surgical drainage of nonacute SDHs (burr-holes and craniotomies) between January 2017 to December 2021 at 2 academic institutions in the United States. PSM was performed by controlling for age, subdural thickness, subacute component, and preoperative Glasgow Coma Scale. Seizure rates and accompanying abnormalities on electroencephalographic tracing were evaluated postmatching. RESULTS: A total of 467 patients with 510 nonacute SDHs underwent 474 procedures, with 242 burr-hole evacuations (51.0%) and 232 craniotomies (49.0%). PSM resulted in 62 matched pairs. After matching, univariate analysis revealed that burr-hole evacuations exhibited lower rates of seizures (1.6% vs 11.3%; P = .03) and abnormal electroencephalographic findings (0.0% vs 4.8%; P = .03) compared with craniotomies. No significant differences were observed in postoperative Glasgow Coma Scale (P = .77) and length of hospital stay (P = .61). CONCLUSION: Burr-hole evacuation demonstrated significantly lower seizure rates than craniotomy using a propensity score-matched analysis controlling for significant variables.

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.

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 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 (interquartile range = 6-17), with a 3-day interval between procedures (interquartile range = 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 (odds ratio [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. CONCLUSIONS: 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 1 anesthetic may decrease the burden on patients and shorten their hospitalizations.

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.

Spontaneous Middle Meningeal Artery Aneurysms: A Case Report and Review of the Literature.

Most reported aneurysms concerning the middle meningeal artery (MMA) are pseudoaneurysms; however, there have been rare reports of non-traumatic MMA aneurysms in the literature. In this paper, we present the case of a 70-year-old female with a true 5-mm aneurysm in the anterior division of the left MMA that was causing erosion through the left temporal bone and was successfully treated with coil embolization. We also present a comprehensive literature review of non-traumatic MMA aneurysms reported since 1930. These aneurysms are associated with conditions such as hypertension, Paget's disease, and intracranial meningiomas and result from flow dynamics disturbances. Treatment involves both endovascular treatment and open surgery, while rupture, especially in the elderly, results in high disability, underscoring the importance of timely intervention upon identification.

Minimally Invasive Surgery for Managing Grade IV and V Spondylolisthesis.

Surgical treatment of high-grade spondylolisthesis is controversial and aims at restoring the spinopelvic sagittal balance through complete or partial reduction of the listhesis. Nerve decompression and interbody fusion are necessary for patients presenting with neurological deficit, severe pain, lower limb asymmetry, or deformities. We present the case and the results of a patient with high-grade spondylolisthesis, in whom minimally invasive management was performed. A narrative review in this topic is also provided. We performed a literature review of high-grade spondylolisthesis to compare our technique to current surgical alternatives. We included articles from PubMed, Embase, Scopus, Ovid, and Science Direct published between 1963 and 2022 that were written in English, German, and Spanish. The terms used were the following: "high grade spondylolisthesis," "spondyloptosis," "surgical management," "interbody fusion," and "arthrodesis." In all, 485 articles were displayed, from which we filtered 112 by title and abstract. At the end, 75 references were selected for the review. Different interbody fusion techniques can be used to correct the lumbosacral kyphosis and restore the spinopelvic parameters. A complete reduction of the listhesis is not always required. The surgical procedure carried out in our patient corresponds to the first known case of minimally invasive circumferential arthrodesis with iliac screws and sacral fixation in a high-grade dysplastic spondylolisthesis. This approach guarantees the correction of the lumbosacral kyphosis and a complete reduction of the listhesis. Further studies are required to determine whether the results of this case can be extrapolated to other patients with high-grade spondylolisthesis.

Muscular Function as an Alternative to Identify Cognitive Impairment: A Secondary Analysis From SABE Colombia.

BACKGROUND: Identification of cognitive impairment is based traditionally on the neuropsychological tests and biomarkers that are not available widely. This study aimed to establish the association between motor function (gait speed and handgrip strength) and cognitive performance in the Mini-Mental State Examination, globally and by domains. A secondary goal was calculating a cut-off point for gait speed and handgrip strength to classify older adults as cognitively impaired. METHODS: This is a secondary analysis of SABE Colombia (Salud, Bienestar & Envejecimiento), a survey that was conducted in 2015 on health, wellbeing, and aging in Colombia. This study used linear regression models to search for an association between motor function and cognitive performance. The accuracy of motor function measurements in identifying cognitive impairment was assessed with receiver operating characteristic (ROC) curves. This study also analyzed other clinical and sociodemographical variables. RESULTS: Gait speed was associated with orientation (r 2 = 0.16), language (r 2 = 0.15), recall memory (r 2 = 0.14), and counting (r 2 = 0.08). Similarly, handgrip strength was associated with orientation (r 2 = 0.175), language (r 2 = 0.164), recall memory (r 2 = 0.137), and counting (r 2 = 0.08). To differentiate older adults with and without cognitive impairment, a gait speed cut-off point of 0.59 m/s had an area under the curve (AUC) of 0.629 (0.613-0.646), and a weak handgrip (strength below 17.5 kg) had an AUC of 0.653 (0.645-0.661). The cut-off points for handgrip strength and gait speed were significantly higher in male participants. CONCLUSIONS: Gait speed and handgrip strength are similarly associated with the cognitive performance, exhibiting the most extensive association with orientation and language domains of the Mini-Mental State Examination. Gait speed and handgrip strength can easily be measured by any clinician, and they prove to be useful screening tools to detect cognitive impairment.

Revisión de los criterios diagnósticos para el síndrome de ovario poliquístico / Review of diagnostic criteria for polycystic ovary syndrome

Resumen El síndrome de ovario poliquístico, es la alteración endocrina metabólica más frecuente en mujeres en edad fértil, teniendo implicaciones a nivel reproductivo, metabólico, cardiovascular y psicosocial. Actualmente, su sobrediagnóstico corresponde a una problemática común derivada de la heterogeneidad en la aplicación de los criterios actualmente avalados para su hallazgo, lo que ha contribuido en el incremento de tratamientos innecesarios, así como los efectos negativos en la calidad de vida y el bienestar de las pacientes falsamente calificadas con este trastorno. Se realizó una búsqueda en PubMed-MENDELEY y Ovid entre los meses de Febrero a Abril del 2020, obteniendo 43 artículos relacionados con el tema, publicados en los últimos 10 años. El conocimiento por parte del personal médico capacitado sobre los consensos actuales para la correcta evaluación del síndrome y el estudio individualizado de cada caso, corresponden las medidas más apropiadas para la reducción del sobrediagnóstico. MÉD.UIS.2020;33(3):21-28

Abstract Polycystic ovary syndrome is the most frequent metabolic endocrine disorder in women of childbearing age, having implications at both the reproductive, metabolic, cardiovascular and psychosocial levels. Currently, its overdiagnosis corresponds to a common problem derived from the heterogeneity in the application of the criteria currently endorsed for its discovery, which has contributed to the increase in unnecessary treatments, as well as the negative effects on the quality of life and well-being of falsely rated patients with this disorder. A search was made in PubMed-MENDELEY and Ovid between the months of February to April of 2020, obtaining 43 articles related to the topic, published in the last 10 years. The knowledge on the part of the trained medical personnel about the current consensuses for the correct evaluation of the syndrome and the individualized study of each case, correspond to the most appropriate measures for the reduction of this event. MÉD.UIS.2020;33(3):21-28