A Pilot Study of the Effect of Transcutaneous Spinal Cord Stimulation on Micturition-Related Brain Activity and Lower Urinary Tract Symptoms After Stroke.

PURPOSE: Transcutaneous spinal cord stimulation (TSCS) is a novel neuromodulation modality developed to promote functional restoration in patients with neurological injury or disease. Previous pilot data suggest that lower urinary tract dysfunction (LUTD) due to stroke may be partially alleviated by TSCS. In this study, we examine the mechanism of this effect by evaluating bladder-related brain activity in patients before and after TSCS therapy and comparing it to healthy volunteers. MATERIALS AND METHODS: Patients who developed storage LUTD after a stroke and healthy volunteers without LUTD were recruited. Patients and healthy volunteers underwent simultaneous urodynamics and functional MRI. Patients then completed 24 biweekly sessions of TSCS and underwent another simultaneous urodynamics-functional MRI study. Clinical outcomes were assessed using validated questionnaires and voiding diary. RESULTS: Fifteen patients and 16 healthy volunteers completed the study. Following TSCS, patients exhibited increased blood-oxygen-level-dependent activity in areas including periaqueductal grey, the insula, the lateral prefrontal cortex, and motor cortex. Prior to TSCS therapy, healthy controls exhibited higher blood-oxygen-level-dependent activity in 17 regions, including multiple regions in the prefrontal cortex and basal ganglia. These differences were attenuated after TSCS with no frontal brain differences remaining between healthy volunteers and stroke participants who completed therapy. Neuroimaging changes were complemented by clinically significant improvements in questionnaire scores and voiding diary parameters. CONCLUSIONS: TSCS therapy modulated bladder-related brain activity, reducing differences between healthy volunteers and stroke patients with LUTD. These changes, alongside improved clinical outcomes, suggest TSCS as a promising approach for LUTD management.

Content, face, and construct validity of the Irritable Bowel Syndrome Quality of Life (IBS-QOL) as a measure of bowel-related quality of life in spinal cord injury.

INTRODUCTION: Neurogenic bowel dysfunction is commonly encountered after a spinal cord injury (SCI), leading to a tremendous impact on quality of life (QOL). The neurogenic bowel dysfunction score (NBDS) is commonly used to measure the severity of bowel dysfunction and predict QOL. However, there is no comprehensive instrument to assess bowel-specific QOL for SCI patients. Instead, the Irritable Bowel Syndrome-Quality of Life (IBS-QOL) questionnaire evaluates the impact of bowel dysfunction on several aspects of QOL, although this questionnaire has not been validated for the SCI population. Motivated by the compelling need of instruments to accurately evaluate the QOL in patients who develope NBD after SCI, we aimed to assess the construct, content, and face validity of IBS-QOL in this population. METHODS: Adult SCI patients with at least 3 months after their injury were recruited from the outpatient clinic of a national rehabilitation hospital. Patients completed the NBDS and IBS-QOL via telephone interview or paper survey in the clinic. Content and face validity were assessed via interviews with professionals with expertise in providing chronic care for SCI, as well as a subgroup of patients. Construct validity was assessed using the hypotheses testing method. Internal consistency was assessed using Cronbach's ⍺. Factor analysis was performed to assess the dimensionality of the IBS-QOL in the SCI population. RESULTS: A total of 106 patients with a median age of 45.5 years (interquartile range: 21-79) participated in the study. The majority of the sample were men (n = 82, 77%) and had endured thoracolumbar injuries (n = 74, 71.2%). Twelve patients (seven English- and five Spanish speakers) and six professionals took part in content/face validation interviews. The median IBS-QOL total score was 15.91/100 (interquartile range: 4.55-33.14). IBS-QOL differentiated the subgroups of patients with severe bowel symptoms in terms of uneasiness, sweating, or headaches during bowel emptying (p = 0.0003), time spent on bowel emptying (p = 0.0065), flatus incontinence (p = 0.0076), and overall satisfaction with bowel function (p < 0.001), demonstrating its adequate construct validity. Interviews with the patients and professionals supported the comprehensiveness, comprehensibility, and relevance of IBS-QOL for assessment of bowel-related QOL in the SCI population. Item-level analysis of professional responses showed that 97% of questions were relevant to the construct and population of interest. Internal consistency analysis yielded a Cronbach's ⍺ of 0.9684. Exploratory factor analysis yielded six underlying factors which cumulatively accounted for 72.21% of the total variance, reflecting the dimensionality of bowel-related QOL in SCI population. DISCUSSION: IBS-QOL questionnaire is a comprehensive measure of bowel-related QOL which encompasses the concerns of SCI patients. Our findings support the content, face and construct validity of IBS-QOL as a measure of bowel-related QOL in SCI. Further studies are warranted to assess the reliability and responsiveness of IBS-QOL, and to evaluate its performance across different patient populations.

Cilostazol for the management of moyamoya disease: a systematic review of the early evidence, efficacy, safety, and future directions.

Surgical revascularization remains the standard treatment for symptomatic moyamoya disease (MMD). As with any major surgical treatment, revascularization is associated with risks and limitations, denoting the need for noninvasive treatments to improve ischemic symptoms and prevent strokes. Cilostazol is a selective phosphodiesterase III inhibitor with antiplatelet, antithrombotic, and vasodilatory effects commonly used in peripheral vascular disease. Clinical studies assessing the efficacy of cilostazol in the management of stroke and MMD were recently reported, although a comprehensive assessment of the overall evidence is lacking. A systematic scoping review was conducted to assess the early evidence on cilostazol administration in patients with MMD. The inclusion criteria encompassed original human studies primarily focused on cilostazol's safety, efficacy, or utilization in managing MMD patients. A search of the PubMed database was conducted in June 2023, yielding 5 peer-reviewed publications that satisfied the inclusion criteria and were subjected to narrative synthesis. Risk of bias assessment was not applicable due to the scoping nature of this review. East Asian studies demonstrate increasing rates of cilostazol prescriptions for patients with MMD. In a large population-based study, cilostazol was compared to other antiplatelet medications and yielded the largest decrease in mortality among patients with newly diagnosed MMD. Other studies reported significant improvements in cerebral blood flow and cognitive function, which were deemed to be independent of one another. There are limited data on the safety profile of cilostazol in the MMD population, although the evidence derived from various studies performed in the general stroke population can likely provide insights into its potential utility in MMD patients. Cilostazol targets several critical pathways involved in the pathophysiology of MMD. The evidence corroborates the potential benefits of cilostazol for the management of MMD, although these findings should be interpreted with caution due to the small number of studies and lack of randomized trials. Subgroups of patients need to be identified who can safely undergo medical management in lieu of revascularization surgery or to improve surgical outcomes. Additional studies are needed to assess the efficacy and safety of cilostazol therapy, especially in Western populations.

Health Care Economic Burden of Treatment and Rehabilitation for Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review.

PURPOSE: The clinical, social, and economic impacts of neurogenic lower urinary tract dysfunction (NLUTD) on individuals and health care systems are thought to be immense, yet the true costs of care are unknown. The aims of this study are to illuminate the global costs related to the current state of care for NLUTD. MATERIALS AND METHODS: A systematic review of the literature was performed using MEDLINE, the National Health Service Economic Evaluation Database, and the Cochrane Specialized Urology and Incontinence Registers. Studies reporting the health care costs of NLUTD were identified. All steps of the review were performed by 2 independent reviewers. Costs were converted to 2022 U.S. dollars and reported for different categories of services. RESULTS: A total of 13 studies were included in the final review (12 from high-income economy, and 1 from an upper-middle-income economy). Routine maintenance care varied notably across studies in terms of included services. Annual supportive costs ranged from $2,039.69 to $12,219.07 with 1 study estimating lifetime costs of $112,774 when complications were considered. There were limited data on the costs of care from the patient's perspective. However, catheters and absorbent aids were estimated to be among the costliest categories of expenditure during routine care. More invasive and reconstructive treatments were associated with significant costs, ranging between $18,057 and $55,873. CONCLUSIONS: NLUTD incurs a variety of health care expenditures ranging from incontinence supplies to hospitalizations for management of complications and leads to a significant burden for health care systems over the patient's lifetime. Approaches to NLUTD that focus on functional rehabilitation and restoration, rather than on management of complications, may prove to be a less costly and more effective alternative.

An international survey of the structure and process of care for traumatic spinal cord injury in acute and rehabilitation facilities: lessons learned from a pilot study.

BACKGROUND: To describe the key findings and lessons learned from an international pilot study that surveyed spinal cord injury programs in acute and rehabilitation facilities to understand the status of spinal cord injury care. METHODS: An online survey with two questionnaires, a 74-item for acute care and a 51-item for rehabilitation, was used. A subset of survey items relevant to the themes of specialized care, timeliness, patient-centeredness, and evidence-based care were operationalized as structure or process indicators. Percentages of facilities reporting the structure or process to be present, and percentages of indicators met by each facility were calculated and reported separately for facilities from high-income countries (HIC) and from low and middle-income countries (LMIC) to identify "hard to meet" indicators defined as those met by less than two-thirds of facilities and to describe performance level. RESULTS: A total of 26 acute and 26 rehabilitation facilities from 25 countries participated in the study. The comparison of the facilities based on the country income level revealed three general observations: 1) some indicators were met equally well by both HIC and LMIC, such as 24-hour access to CT scanners in acute care and out-patient services at rehabilitation facilities; 2) some indicators were hard to meet for LMIC but not for HIC, such as having a multidisciplinary team for both acute and rehabilitation settings; and 3) some indicators were hard to meet by both HIC and LMIC, including having peer counselling programs. Variability was also observed for the same indicator between acute and rehabilitation facilities, and a wide range in the total number of indicators met among HIC facilities (acute 59-100%; rehabilitation 36-100%) and among LMIC facilities (acute: 41-82%; rehabilitation: 36-93%) was reported. CONCLUSIONS: Results from this international pilot study found that the participating acute and rehabilitation facilities on average adhered to 74% of the selected indicators, suggesting that the structure and processes to provide ideal traumatic spinal cord injury care were broadly available. Recruiting a representative sample of SCI facilities and incorporating regional attributes in future surveys will be helpful to examine factors affecting adherence to indicators.

Coronavirus disease 2019 (COVID-19) imaging reporting and data system (COVID-RADS) and common lexicon: a proposal based on the imaging data of 37 studies.

BACKGROUND: In the vast majority of the laboratory-confirmed coronavirus disease 2019 (COVID-19) patients, computed tomography (CT) examinations yield a typical pattern and the sensitivity of this modality has been reported to be 97% in a large-scale study. Structured reporting systems simplify the interpretation and reporting of imaging examinations, serve as a framework for consistent generation of recommendations, and improve the quality of patient care. PURPOSE: To compose a comprehensive lexicon for description of the imaging findings and propose a grading system and structured reporting format for CT findings in COVID-19. MATERIAL AND METHODS: We updated our published systematic review on imaging findings in COVID-19 to include 37 published studies pertaining to diagnostic features of COVID-19 in chest CT. Using the reported imaging findings of 3647 patients, we summarized the typical chest CT findings, atypical features, and temporal changes of COVID-19 in chest CT. Subsequently, we extracted a list of descriptive terms and mapped it to the terminology that is commonly used in imaging literature. RESULTS: We composed a comprehensive lexicon that can be used for documentation and reporting of typical and atypical CT imaging findings in COVID-19 patients. Using the same data, we propose a grading system with five COVID-RADS categories. Each COVID-RADS grade corresponds to a low, moderate, or high level of suspicion for pulmonary involvement of COVID-19. CONCLUSION: The proposed COVID-RADS and common lexicon would improve the communication of findings to other healthcare providers, thus facilitating the diagnosis and management of COVID-19 patients. KEY POINTS: • Chest CT has high sensitivity in diagnosing the coronavirus disease 2019 (COVID-19). • Structured reporting systems simplify the interpretation and reporting of imaging examinations, serve as a framework for consistent generation of recommendations, and improve the quality of patient care. • The proposed COVID-RADS and common lexicon would improve the communication of findings to other healthcare providers, thus facilitating the diagnosis and management of COVID-19 patients.

Coronavirus Disease 2019 (COVID-19): A Systematic Review of Imaging Findings in 919 Patients.

OBJECTIVE. Available information on CT features of the 2019 novel coronavirus disease (COVID-19) is scattered in different publications, and a cohesive literature review has yet to be compiled. MATERIALS AND METHODS. This article includes a systematic literature search of PubMed, Embase (Elsevier), Google Scholar, and the World Health Organization database. RESULTS. Known features of COVID-19 on initial CT include bilateral multilobar ground-glass opacification (GGO) with a peripheral or posterior distribution, mainly in the lower lobes and less frequently within the right middle lobe. Atypical initial imaging presentation of consolidative opacities superimposed on GGO may be found in a smaller number of cases, mainly in the elderly population. Septal thickening, bronchiectasis, pleural thickening, and subpleural involvement are some of the less common findings, mainly in the later stages of the disease. Pleural effusion, pericardial effusion, lymphadenopathy, cavitation, CT halo sign, and pneumothorax are uncommon but may be seen with disease progression. Follow-up CT in the intermediate stage of disease shows an increase in the number and size of GGOs and progressive transformation of GGO into multifocal consolidative opacities, septal thickening, and development of a crazy paving pattern, with the greatest severity of CT findings visible around day 10 after the symptom onset. Acute respiratory distress syndrome is the most common indication for transferring patients with COVID-19 to the ICU and the major cause of death in this patient population. Imaging patterns corresponding to clinical improvement usually occur after week 2 of the disease and include gradual resolution of consolidative opacities and decrease in the number of lesions and involved lobes. CONCLUSION. This systematic review of current literature on COVID-19 provides insight into the initial and follow-up CT characteristics of the disease.

Estimating global injuries morbidity and mortality: methods and data used in the Global Burden of Disease 2017 study.

BACKGROUND: While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. METHODS: In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. RESULTS: GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. CONCLUSIONS: GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.

Global injury morbidity and mortality from 1990 to 2017: results from the Global Burden of Disease Study 2017.

BACKGROUND: Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries. METHODS: We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs). FINDINGS: In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505). INTERPRETATION: Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.

Kinematic evaluation of thoracic spinal cord sagittal diameter and the space available for cord using weight-bearing kinematic magnetic resonance imaging.

STUDY DESIGN: Retrospective kinematic MRI (kMRI) study. OBJECTIVE: To evaluate the dynamic changes of thoracic anterior and posterior space available for cord (SAC), and thoracic spinal cord in the dural sac in three positions. SETTING: Expert MRI, Bellflower California; and University of Southern California, in Los Angeles, USA. METHODS: A total of 118 patients (66 males and 52 females, mean age ( ± SD) of 45.6 ± 10.6 years) who underwent thoracic spine kMRI were evaluated from T4-5 to T11-12 in flexion, neutral, and extension positions. The anterior SAC, posterior SAC, and mid-sagittal thoracic cord diameter were measured at each level from T4-5 to T11-12. Inter- and intraobserver agreements were analyzed. RESULTS: The anterior SAC was significantly narrower in flexion position compared with other positions at T8-9 to T11-12 levels (p < 0.01). The T8-9 level had significantly wider posterior SAC in flexion and extension positions compared with the neutral position (p < 0.005). However, the posterior SAC at T9-10 was narrower in extension than the neutral position (p = 0.002). Thoracic spinal cord diameter significantly increased in flexion position when compared with the neutral position at T8-9, T9-10, and T11-12 levels (p < 0.005). CONCLUSIONS: Thoracic spinal cord had dynamic changes with positions. In flexion position, the thoracic cord at T8-9 and below tended to move anteriorly, getting closer to the vertebral body and intervertebral disc. The mid-sagittal diameter of the thoracic cord increased in flexion position at the levels below T8-9. In the presence of lesions in anterior epidural space, the risk of spinal cord compression is higher in flexion position, especially at levels below T8-9.

Dual-layer spectral computerized tomography for metal artifact reduction: small versus large orthopedic devices.

INTRODUCTION: Metal artifacts limit the diagnostic utility of computerized tomography (CT) for implant-related complications. Dual-layer spectral detector CT imaging has been suggested for artifact reduction. Our objective was to evaluate the utility of spectral CT in artifact reduction in patients with small and large metal implants. METHODS: In this prospective study, patients with metallic orthopedic implants underwent CT imaging using a prototype spectral detector CT scanner. Conventional images were generated with iterative reconstruction at 120 kVp, and virtual monochromatic images were generated at 20-keV intervals between 40 to 200 keV. Conventional and monochromatic images were compared quantitatively using signal-to-noise ratio (SNR) and artifact improvement. Qualitative analysis was performed independently by two musculoskeletal radiologists and included six image quality indicators. RESULTS: A total of 12 patients were scanned. In monochromatic images, as the energy level increased, the artifact size decreased progressively (p < 0.01). When conventional and monochromatic images were compared, maximum reduction was seen at 200 keV. Using qualitative assessments, 160 and 180 keV levels had the best overall diagnostic image quality. With increased energy level, there was improvement in qualitative ratings of bone-metal interface conspicuity (p = 0.002), degree of streak artifact (p = 0.010) and trabecular bone definition at 1 cm from implant (p = 0.023), and a trend towards significance for bone definition at 5 cm, soft tissue detail and overall diagnostic quality. Subgroup analysis revealed superior artifact reduction in small implants compared to large hardware. DISCUSSION: Our results support the utility of dual-layer spectral CT in metal artifact reduction. Virtual monochromatic images were diagnostically superior, especially for smaller implants. Virtual monoenergetic images at 160-180 keV are ideal for reducing artifacts.

The future of disc surgery and regeneration.

Low back and neck pain are among the top contributors for years lived with disability, causing patients to seek substantial non-operative and operative care. Intervertebral disc herniation is one of the most common spinal pathologies leading to low back pain. Patient comorbidities and other risk factors contribute to the onset and magnitude of disc herniation. Spine fusions have been the treatment of choice for disc herniation, due to the conflicting evidence on conservative treatments. However, re-operation and costs have been among the main challenges. Novel technologies including cage surface modifications, biologics, and 3D printing hold a great promise. Artificial disc replacement has demonstrated reduced rates of adjacent segment degeneration, need for additional surgery, and better outcomes. Non-invasive biological approaches are focused on cell-based therapies, with data primarily from preclinical settings. High-quality comparative studies are needed to evaluate the efficacy and safety of novel technologies and biological therapies.

Demineralized bone matrix in anterior cervical discectomy and fusion: a systematic review.

PURPOSE: Anterior cervical discectomy and fusion (ACDF) is one of the most widely used procedures in cervical spine. Demineralized bone matrix (DBM) is one of the fusion options that has been used in treatment of the bone defects for years. The purpose of this review is to provide an evidence-based analysis on the current evidence for effectiveness of DBM in ACDF. METHODS: A systematic search of the literature was conducted using MEDLINE, Scopus, and CENTRAL. The risk of bias was evaluated with the criteria recommended by the Cochrane Back and Neck group and the Methodological Index for Non-Randomized Studies (MINORS). The patient-reported outcome measures included the visual analog scale (VAS), Odom's criteria, Japanese Orthopaedic Association (JOA), and Neck Disability Index (NDI). Secondary outcome measures were fusion rate, non-union, subsidence, collapse, displacement, spinal alignment, and re-operation. RESULTS: Twelve studies met the eligibility criteria, of which three were randomized and nine were non-randomized. Patient-reported outcomes were non-inferior for DBM compared with the autograft and other bone substitute materials. The DBM had a fusion rate comparable with other graft materials, particularly in long term (88.8-100%, after 18 months follow-up). The majority of studies reported no collapse, subsidence or displacement with DBM. The revision surgery was mainly due to the symptomatic non-union in 4.1-8.3% of the DBM cases. Preservation of the angle of cervical lordosis was acceptable with DBM fusion. CONCLUSIONS: Most of the studies reported non-inferior results for DBM compared with autograft and other graft substitute materials in terms of patient-reported outcomes, fusion rate, and safety. However, the quantity and quality of evidence is very limited.

Three-Vessel Anastomosis for Direct Multiterritory Cerebral Revascularization: Case Series.

BACKGROUND AND OBJECTIVE: Cerebral revascularization of multiple territories traditionally requires multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. A novel 3-vessel anastomosis technique allows for direct, simultaneous multiterritory cerebral revascularization using a single interposition graft. We herein present our experience with this approach. METHODS: Retrospective review of perioperative data and outcomes for patients undergoing multiterritory cerebral revascularization using a 3-vessel anastomosis from 2019 to 2023. RESULTS: Five patients met inclusion criteria (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery aneurysms (1 ruptured) were treated with proximal ligation or partial/complete clip trapping and multiterritory external carotid artery-M2-M2 revascularization using a saphenous vein interposition graft. Two patients with moyamoya disease, prior strokes, and predominately bilateral anterior cerebral artery hypoperfusion were treated with proximal superficial temporal artery-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap graft. No patients experienced significant surgery-related ischemia. Bypass patency was 100%. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for subdural hematoma evacuation and radial artery fascial flow-through free flap debridement, without affecting bypass patency or neurologic outcome. On hospital discharge, median Glasgow Outcome Scale and modified Rankin Scale scores were 4 (range 3-5) and 2 (range 0-5), respectively. On follow-up, 1 patient died from medical complications of their presenting stroke; Glasgow Outcome Scale and modified Rankin Scale scores were otherwise stable or improved. CONCLUSION: The 3-vessel anastomosis technique can be considered for simultaneous revascularization of multiple intracranial territories.

Open Surgical Treatment of Middle Cerebral Artery Aneurysms: A Single-Center Series in the Endovascular Era.

OBJECTIVE: We review the outcomes of open surgical treatment of middle cerebral artery aneurysms (MCAAs) at a single center, focusing on aneurysm obliteration rates and functional outcomes at the most recent follow-up. These findings can be used for future comparisons of surgical outcomes with MCAAs. METHODS: We retrospectively reviewed cases from a prospectively maintained database of patients receiving open surgical treatment for ruptured or unruptured MCAAs between July 2014 and December 2022. We utilized patients' modified Rankin Scale (mRS) score and Glasgow Outcome Scale score as functional outcome measures. Means, standard deviations, medians, and interquartile ranges were calculated, and a student's t test or its nonparametric equivalent was used to compare subgroups. RESULTS: One hundred fifty patients (114 women, 76%; mean age 55.0 ± 14.7 years) with a total of 156 MCAAs comprised 152 cases; 85 (56%) ruptured and 71 (46%) unruptured. Bypass was performed in 34 cases (22.4%); 18 ruptured (51.4%) and 16 unruptured (48.6%). Intraoperative rupture occurred in 5 (5%) ruptured and 1 (2%) unruptured cases. Onwe hundred forty-five patients (95.4%) had aneurysm obliteration with initial surgery, with 98.4% of patients having complete occlusion at 40.2± 65.5 weeks of follow-up. Intrahospital mortality occurred in 7 (6.9%) ruptured versus 1 (2.0%) unruptured case. Fifty-two (51.5%) of the ruptured compared to 43 (86%) unruptured patients were discharged home, with the remaining patients requiring inpatient rehabilitation or long-term hospitalization. The ruptured group had a mean hospital stay of 18.4 ± 10.5 days versus. 5.7 ± 6.0 days for unruptured. Length of stay, discharge mRS/ Glasgow Outcome Scale, and mRS at 4-6 weeks favored unruptured cases (P < 0.0001-0.0336). Mean change in mRS from presentation to last follow-up favored ruptured cases (-0.7 ± 1.2 vs. -0.04 ± 1.2, P = 0.0215). CONCLUSIONS: Open surgery remains a safe and definitive treatment option for MCAAs in the endovascular era.

A compact and cost-effective laser-powered speckle visibility spectroscopy (SVS) device for measuring cerebral blood flow.

In the realm of cerebrovascular monitoring, primary metrics typically include blood pressure, which influences cerebral blood flow (CBF) and is contingent upon vessel radius. Measuring CBF non-invasively poses a persistent challenge, primarily attributed to the difficulty of accessing and obtaining signal from the brain. This study aims to introduce a compact speckle visibility spectroscopy (SVS) device designed for non-invasive CBF measurements, offering cost-effectiveness and scalability while tracking CBF with remarkable sensitivity and temporal resolution. The wearable hardware has a modular design approach consisting solely of a laser diode as the source and a meticulously selected board camera as the detector. They both can be easily placed on a subject's head to measure CBF with no additional optical elements. The SVS device can achieve a sampling rate of 80 Hz with minimal susceptibility to external disturbances. The device also achieves better SNR compared with traditional fiber-based SVS devices, capturing about 70 times more signal and showing superior stability and reproducibility. It is designed to be paired and distributed in multiple configurations around the head, and measure signals that exceed the quality of prior optical CBF measurement techniques. Given its cost-effectiveness, scalability, and simplicity, this laser-centric tool offers significant potential in advancing non-invasive cerebral monitoring technologies.

Compact and cost-effective laser-powered speckle contrast optical spectroscopy fiber-free device for measuring cerebral blood flow.

Significance: In the realm of cerebrovascular monitoring, primary metrics typically include blood pressure, which influences cerebral blood flow (CBF) and is contingent upon vessel radius. Measuring CBF noninvasively poses a persistent challenge, primarily attributed to the difficulty of accessing and obtaining signal from the brain. Aim: Our study aims to introduce a compact speckle contrast optical spectroscopy device for noninvasive CBF measurements at long source-to-detector distances, offering cost-effectiveness, and scalability while tracking blood flow (BF) with remarkable sensitivity and temporal resolution. Approach: The wearable sensor module consists solely of a laser diode and a board camera. It can be easily placed on a subject's head to measure BF at a sampling rate of 80 Hz. Results: Compared to the single-fiber-based version, the proposed device achieved a signal gain of about 70 times, showed superior stability, reproducibility, and signal-to-noise ratio for measuring BF at long source-to-detector distances. The device can be distributed in multiple configurations around the head. Conclusions: Given its cost-effectiveness, scalability, and simplicity, this laser-centric tool offers significant potential in advancing noninvasive cerebral monitoring technologies.

Direct V3 Vertebral Artery Access for Embolization of Partially Thrombosed Fusiform Basilar Trunk Aneurysm: Technical Case Instruction.

BACKGROUND AND IMPORTANCE: Fusiform vertebrobasilar aneurysms carry significant morbidity. Endovascular strategies are preferred; however, unsafe or unfeasible access can call for innovative strategies. CLINICAL PRESENTATION: An octogenarian patient with an enlarging fusiform proximal basilar artery aneurysm causing a sixth nerve palsy was found to have multiple anatomic features that precluded a transradial or transfemoral endovascular approach. She was thus treated with direct microsurgical access of the V3 segment of the vertebral artery for subsequent coil embolization and flow diversion. CONCLUSION: This case introduces a novel combined microsurgical and endovascular strategy for treating a complex partially thrombosed fusiform basilar artery aneurysm. This approach should be reserved only for patients where conventional endovascular access is dangerous or unfeasible.