International multicentre validation of the arteriovenous malformation-related intracerebral haemorrhage (AVICH) score.

OBJECTIVE: The recently published arteriovenous malformation-related intracerebral haemorrhage (AVICH) score showed better outcome prediction for patients with arteriovenous malformation (AVM)-related intracerebral haemorrhage (ICH) than other AVM or ICH scores. Here we present the results of a multicentre, external validation of the AVICH score. METHODS: All participating centres (n=11) provided anonymous data on 325 patients to form the Spetzler-Martin (SM) grade, the supplemented SM (sSM) grade, the ICH score and the AVICH score. Modified Rankin score (mRS) at last follow-up (mean 25.6 months) was dichotomized into favourable (mRS 0-2, n=210) and unfavourable (mRS 3-6;n=115). Univariate and AUROC analyses were performed to validate the AVICH score. RESULTS: Except nidus structure and AVM size, all single parameters forming the SM, sSM, ICH and AVICH score and the scores itself were significantly different between both outcome groups in the univariate analysis. The AVICH score was confirmed to be the highest predictive outcome score with an AUROC of 0.765 compared with 0.705 for the ICH score and 0.682 for the sSM grade. CONCLUSION: The multicentre-validated AVICH score predicts clinical outcome superior to pre-existing scores. We suggest the routine use of this score for future clinical outcome prediction and in clinical research. TRIAL REGISTRATION NUMBER: NCT02920645.

Attention-Deficit Hyperactivity Disorder Among American Youth: A Comprehensive 20-Year Analysis of National Center for Health Statistics (NCHS) Data.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition that has a significant impact on the lives of children and adolescents. This study conducts a comprehensive 20-year analysis of data from the National Center for Health Statistics (NCHS) to investigate the prevalence of ADHD among American youth, as well as its demographic patterns and socioeconomic determinants. METHODS: A retrospective analysis of NCHS data spanning from 1997 to 2018 was carried out. The dataset included information on ADHD diagnoses, demographic characteristics (such as age, gender, and race/ethnicity), socioeconomic indicators (including poverty level and health insurance status), and temporal variables. A range of statistical analyses were performed, encompassing temporal trend analysis, demographic assessments, and socioeconomic examinations. RESULTS: It was consistently observed that boys had a higher prevalence of ADHD (12.93% compared to 5.61%), aligning with established trends. Among adolescents aged 10-17, the prevalence was the highest at 11.09%, while for the 5-9 age group, it stood at 6.57%. In terms of racial and ethnic groups, individuals identifying as two or more races exhibited the highest prevalence at 12.36%, followed by white (9.83%), black or African American (10.09%), Hispanic or Latino (5.36%), and non-Hispanic or Latino (10.64%). Socioeconomic disparities were evident, with a prevalence of 11.41% among those living below the poverty line, compared to 10.6% (100%-199% of the poverty line), 8.6% (200%-399%), and 8.39% (400% or more). Medicaid beneficiaries had the highest prevalence at 12.57%, followed by those with private insurance (9.65%), insured (8.11%), and uninsured (5.83%). CONCLUSION: These findings underscore the intricate relationship between ADHD prevalence and demographic and socioeconomic factors. It is imperative to address these disparities to ensure equitable assessment and intervention for ADHD, taking into account cultural influences, determinants of health tied to socioeconomic status, and access to healthcare for all children. This analysis by the NCHS provides essential insights into ADHD among American youth, emphasizing the necessity for tailored interventions, equitable healthcare access, and further research to comprehensively address this complex neurodevelopmental disorder.

Anatomical triangles defining routes to anterior communicating artery aneurysms: the junctional and precommunicating triangles and the role of dome projection.

OBJECTIVE: Anterior communicating artery (ACoA) aneurysms are common intracranial aneurysms. Despite advances in endovascular therapy, microsurgical clipping remains an important treatment for aneurysms with broad necks, large size, intraluminal thrombus, complex branches, or previous coiling. Anatomical triangles identify safe corridors for aneurysm access. The authors introduce the A1-A2 junctional triangle and the A1-A1 precommunicating triangle and examine relationships between dome projection, triangular corridors of access, and surgical outcomes. METHODS: Preoperative catheter and CT angiograms were evaluated to characterize aneurysm dome projection. Aneurysm projection was categorized into quadrants and octants. Preoperative, intraoperative, and postoperative factors were correlated to aneurysm dome projection and patient outcomes using univariate and multivariate analyses. RESULTS: A total of 513 patients with microsurgically treated ACoA aneurysms were identified over a 13-year period, and 400 had adequate imaging and follow-up data for inclusion. Surgical clipping was performed on 271 ruptured and 129 unruptured aneurysms. Good outcomes were observed in 91% of patients with unruptured aneurysms and 86% of those with ruptured aneurysms, with a mortality rate < 1% among patients with unruptured aneurysms. Increasing age (p < 0.01), larger aneurysm size (p = 0.03), and worse preoperative modified Rankin Scale score (p < 0.01) affected outcomes adversely. Aneurysms projecting superiorly and posteriorly required dissection in the junctional triangle, and multivariate analysis demonstrated worse clinical outcomes in these patients (p < 0.01). CONCLUSIONS: Anteriorly and inferiorly projecting aneurysms involve only the precommunicating triangle, are simpler to treat microsurgically, and have more favorable outcomes. Superior and posterior dome projections make ACoA aneurysms more difficult to visualize and require opening the junctional triangle. Added visualization through the junctional triangle is recommended for these aneurysms in order to facilitate dissection of efferent branch arteries, careful clip application, and perforator preservation. Dome projection can be determined preoperatively from images and can help anticipate dissection routes through the junctional triangle.

Radiation exposure prior to traumatic brain injury induces responses that differ as a function of animal age.

PURPOSE: Uncontrolled radiation exposure due to radiological terrorism, industrial accidents or military circumstances is a continuing threat for the civilian population. Age plays a major role in the susceptibility to radiation; younger children are at higher risk of developing cognitive deterioration when compared to adults. Our objective was to determine if an exposure to radiation affected the vulnerability of the juvenile hippocampus to a subsequent moderate traumatic injury. MATERIALS AND METHODS: Three-week-old (juvenile) and eight-week-old young adult C57BL/J6 male mice received whole body cesium-137 ((137)Cs) irradiation with 4 gray (Gy). One month later, unilateral traumatic brain injury was induced using a controlled cortical impact system. Two months post-irradiation, animals were tested for hippocampus-dependent cognitive performance in the Morris water-maze. After cognitive testing, animals were euthanized and their brains frozen for immunohistochemical assessment of activated microglia and neurogenesis in the hippocampal dentate gyrus. RESULTS: All animals were able to learn the water maze task; however, treatment effects were seen when spatial memory retention was assessed. Animals that received irradiation as juveniles followed by a moderate traumatic brain injury one month later did not show spatial memory retention, i.e., were cognitively impaired. In contrast, all groups of animals that were treated as adults showed spatial memory retention in the probe trials. CONCLUSION: Although the mechanisms involved are not clear, our results suggest that irradiation enhanced a young animal's vulnerability to develop cognitive injury following a subsequent traumatic injury.

Current management of middle cerebral artery aneurysms: surgical results with a "clip first" policy.

BACKGROUND: One response to randomized trials like the International Subarachnoid Aneurysm Trial has been to adopt a "coil first" policy, whereby all aneurysms be considered for coiling, reserving surgery for unfavorable aneurysms or failed attempts. Surgical results with middle cerebral artery (MCA) aneurysms have been excellent, raising debate about the respective roles of surgical and endovascular therapy. OBJECTIVE: To review our experience with MCA aneurysms managed with microsurgery as the treatment of first choice. METHODS: Five hundred forty-three patients with 631 MCA aneurysms were managed with a "clip first" policy, with 115 patients (21.2%) referred from the Neurointerventional Radiology service and none referred from the Neurosurgical service for endovascular management. RESULTS: Two hundred eighty-two patients (51.9%) had ruptured aneurysms and 261 (48.1%) had unruptured aneurysms. MCA aneurysms were treated with clipping (88.6%), thrombectomy/clip reconstruction (6.2%), and bypass/aneurysm occlusion (3.3%). Complete aneurysm obliteration was achieved with 620 MCA aneurysms (98.3%); 89.7% of patients were improved or unchanged after therapy, with a mortality rate of 5.3% and a permanent morbidity rate of 4.6%. Good outcomes were observed in 92.0% of patients with unruptured and 70.2% with ruptured aneurysms. Worse outcomes were associated with rupture (P = .04), poor grade (P = .001), giant size (P = .03), and hemicraniectomy (P < .001). CONCLUSION: At present, surgery should remain the treatment of choice for MCA aneurysms. Surgical morbidity was low, and poor outcomes were due to an inclusive policy that aggressively managed poor-grade patients and complex aneurysms. This experience sets a benchmark that endovascular results should match before considering endovascular therapy an alternative for MCA aneurysms.