Intrasaccular Treatment of Intracranial Aneurysms: A Comprehensive Review.

Background: The endovascular treatment of complex intracranial aneurysms, such as wide-neck aneurysms (WNAs), remains a challenge. More established endovascular techniques, which include balloon-assisted coiling, stent-assisted coiling, and flow diversion, all have their drawbacks. Intrasaccular flow disruptor devices have emerged as a useful tool for the neurointerventionalist. Methods: Here, we discuss landmark studies and provide a comprehensive, narrative review of the Woven EndoBridge (WEB; Microvention, Alisa Viejo, CA, USA), Artisse (Medtronic, Irvine, CA, USA), Contour (Stryker, Kalamazoo, MI, USA), Saccular Endovascular Aneurysm Lattice Embolization System (SEAL; Galaxy Therapeutics Inc, Milpitas, CA, USA), Medina (Medtronic, Irvine, CA, USA), and Trenza (Stryker, Kalamazoo, MI, USA) devices. Results: Intrasaccular devices have proven to be effective in treating complex aneurysms like WNAs. Conclusions: Intrasaccular flow disruptors have emerged as a new class of effective endovascular therapy, and results of ongoing clinical studies for the newer devices (e.g., SEAL and Trenza) are much anticipated.

The use of balloon guide catheters during venous sinus stenting: A case series.

BACKGROUND: Venous sinus stenting (VSS) is a safe and effective treatment strategy for pulsatile tinnitus (PT) and idiopathic intracranial hypertension (IIH). Although complications are rare, the morbidity associated with the complications is high. Navigating through the venous sinuses poses unique challenges to the interventionalist. There is limited literature regarding device selection to maximize safety and efficiency. We report on the safety and advantages of using a balloon guide catheter (BGC) for venous access in VSS. METHODS: Retrospective analysis of all patients undergoing VSS using a BGC over a three-month period. RESULTS: A total of 22 patients were included in the analysis (median age 35; 21 female). The indication for treatment was PT in 10 patients and IIH in 12 patients. The BGC was navigated into the sigmoid and transverse sinuses, enabling successful delivery of the stent in all cases. The BGC balloon was inflated 23 times for navigating past tortuosity or obstructions, and for anchoring. There were no intraprocedural complications. CONCLUSIONS: The use of BGC in VSS is safe and feasible. BGCs have features that can be utilized to overcome the unique challenges encountered during VSS.

Digital Light Process 3D Printing of Magnetically Aligned Liquid Crystalline Elastomer Free-forms.

Liquid crystalline elastomers (LCEs) are anisotropic soft materials capable of large dimensional changes when subjected to a stimulus. The magnitude and directionality of the stimuli-induced thermomechanical response is associated with the alignment of the LCE. Recent reports detail the preparation of LCEs by additive manufacturing (AM) techniques, predominately using direct ink write printing. Another AM technique, digital light process (DLP) 3D printing, has generated significant interest as it affords LCE free-forms with high fidelity and resolution. However, one challenge of printing LCEs using vat polymerization methods such as DLP is enforcing alignment. Here, we document the preparation of aligned, main-chain LCEs via DLP 3D printing using a 100 mT magnetic field. Systematic examination isolates the contribution of magnetic field strength, alignment time, and build layer thickness on the degree of orientation in 3D printed LCEs. Informed by this fundamental understanding, DLP is used to print complex LCE free-forms with through-thickness variation in both spatial orientations. The hierarchical variation in spatial orientation within LCE free-forms is used to produce objects that exhibit mechanical instabilities upon heating. DLP printing of aligned LCEs opens new opportunities to fabricate stimuli-responsive materials in form factors optimized for functional use in soft robotics and energy absorption.

Internal hematoma architecture predicts subdural hematoma responsiveness to standalone middle meningeal artery embolization.

PURPOSE: Subdural hematoma (SDH) is quickly becoming the most common neurosurgical pathology due to the aging population. Middle meningeal artery embolization (MMAE) has recently emerged as an effective adjunct to surgical SDH evacuation by decreasing recurrence risk. MMAE has also shown promise as a standalone SDH intervention, but clinical and radiographic predictors of successful MMAE remain ill-defined. METHODS: Retrospective chart review from 2020 to 2023 at a single center identified all MMAE cases performed as primary SDH treatment. Cases were classified by hematoma internal architecture as homogeneous, separated, laminar, or trabecular. SDH maximal thickness was assessed on all follow-up imaging and any recurrences or expansions requiring surgery were denoted as treatment failures. RESULTS: 164 standalone MMAE cases were reviewed. Most cases were in male patients (75.0%) with a mean age of 73.2 years. The overall MMAE treatment failure rate was 6.7% with a 4.9% periprocedural complication rate. The cases with trabecular and laminar collections were slightly larger than those with homogeneous and separated collections (16.2 mm vs. 14.2 mm, p = 0.008*), but other baseline characteristics were similar. The MMAE failure rate was significantly lower in the laminar and trabecular subgroup (1.2%) compared to the homogeneous and separated subgroup (12.4%) (p = 0.005*). Homogeneous and separated internal hematoma architecture was the only predictor of MMAE failure in multivariate analysis (OR 10.5, p = 0.027*) and was also associated with delayed SDH resorption (ANOVA: F = 4.8, p = 0.0025*). CONCLUSIONS: Standalone MMAE is an effective, safe, and durable treatment for non-acute SDHs, and is especially effective for SDHs with more membranous internal architecture.

Protocol for a prospective randomized trial of surgical versus conservative management for unstable fractures of the distal radius in patients aged 65 years and older.

Aims: The primary aim of this study is to quantify and compare outcomes following a dorsally displaced fracture of the distal radius in elderly patients (aged ≥ 65 years) who are managed conservatively versus with surgical fixation (open reduction and internal fixation). Secondary aims are to assess and compare upper limb-specific function, health-related quality of life, wrist pain, complications, grip strength, range of motion, radiological parameters, healthcare resource use, and cost-effectiveness between the groups. Methods: A prospectively registered (ISRCTN95922938) randomized parallel group trial will be conducted. Elderly patients meeting the inclusion criteria with a dorsally displaced distal radius facture will be randomized (1:1 ratio) to either conservative management (cast without further manipulation) or surgery. Patients will be assessed at six, 12, 26 weeks, and 52 weeks post intervention. The primary outcome measure and endpoint will be the Patient-Rated Wrist Evaluation (PRWE) at 52 weeks. In addition, the abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH), EuroQol five-dimension questionnaire, pain score (visual analogue scale 1 to 10), complications, grip strength (dynamometer), range of motion (goniometer), and radiological assessments will be undertaken. A cost-utility analysis will be performed to assess the cost-effectiveness of surgery. We aim to recruit 89 subjects per arm (total sample size 178). Discussion: The results of this study will help guide treatment of dorsally displaced distal radial fractures in the elderly and assess whether surgery offers functional benefit to patients. This is an important finding, as the number of elderly distal radial fractures is estimated to increase in the future due to the ageing population. Evidence-based management strategies are therefore required to ensure the best outcome for the patient and to optimize the use of increasingly scarce healthcare resources.

Photochemical Control of Network Topology in PEG Hydrogels.

Hydrogels are often synthesized through photoinitiated step-, chain-, and mixed-mode polymerizations, generating diverse network topologies and resultant material properties that depend on the underlying network connectivity. While many photocrosslinking reactions are available, few afford controllable connectivity of the hydrogel network. Herein, a versatile photochemical strategy is introduced for tuning the structure of poly(ethylene glycol) (PEG) hydrogels using macromolecular monomers functionalized with maleimide and styrene moieties. Hydrogels are prepared along a gradient of topologies by varying the ratio of step-growth (maleimide dimerization) to chain-growth (maleimide-styrene alternating copolymerization) network-forming reactions. The initial PEG content and final network physical properties (e.g., modulus, swelling, diffusivity) are tailored in an independent manner, highlighting configurable gel mechanics and reactivity. These photochemical reactions allow high-fidelity photopatterning and 3D printing and are compatible with 2D and 3D cell culture. Ultimately, this photopolymer chemistry allows facile control over network connectivity to achieve adjustable material properties for broad applications.

Treatment of tumor-induced cerebral venous sinus stenosis: Technical note and review of the literature.

INTRODUCTION: Tumors that invade or compress the venous sinuses have the potential to impair venous drainage. Rarely, this may be so severe as to induce intracranial hypertension. Other studies have previously described venous sinus stenting (VSS) for the treatment of these symptomatic lesions. In this report, we present our series of eight cases of VSS for symptomatic tumor-induced venous sinus stenosis and review the existing literature. CASES: Eight patients with mostly intracranial tumors were found to have symptomatic venous sinus stenosis with the most common presenting symptom being elevated intracranial pressure. Six of the eight (75%) patients presented with papilledema on neuro-ophthalmological exam. The most affected locations were the transverse and sigmoid sinuses in four patients, followed by the superior sagittal sinus in three patients. All eight patients underwent VSS with no adverse events. In total, 6 out of 8 (75%) of patients had complete resolution of their symptoms, while the remaining patients experienced at least partial improvement. CONCLUSION: Tumors that cause symptomatic venous sinus stenosis may be successfully managed with VSS to improve venous drainage. This may facilitate continued conservative management of meningiomas or allow for treatment with noninvasive means, such as stereotactic radiosurgery. Depending on the size of the target stenosis, balloon-mounted coronary stents may be a suitable option to treat these lesions.

Marine Fish Movement: home range sizes for commercially relevant species.

Estimates of home range sizes for marine fishes are essential for designing and assessing the effects of spatial wildlife conservation policies and management interventions. However, in situ studies of marine species movement are challenging and often expensive, resulting in a paucity of data on the home range size of the vast majority of marine fishes. Here, we develop a set of new datasets, which we have collectively named Marine Fish Movement, that synthesises published empirically evaluated home ranges reported for adult marine fishes that interact with fisheries and leverage these data to estimate home range sizes for unstudied species. The empirical data contain estimated home range sizes (km2) for 193 species across 63 family groups from 179 studies published between 1971 and 2022. We use a random forest regression model to estimate home range sizes (km2) for 664 fished marine species currently lacking home range estimates. Marine Fish Movement can inform spatial interventions including the design and management of marine protected areas and dynamic fisheries management to meet sustainability goals.

Cerebrospinal fluid venous fistula causing spontaneous intracranial hypotension resulting in venous sinus thrombosis and coma.

Cerebrospinal fluid (CSF) fistulas have recently been recognized as a cause of spontaneous intracranial hypotension (SIH), predominantly presenting with headaches, especially positional headaches. Atypical presentations like tinnitus and cranial nerve symptoms have also been reported. SIH has been linked to venous sinus thrombosis; however, to our knowledge, no prior cases describe a CSF venous fistula causing SIH that leads to cerebral venous thrombosis and coma. We report a patient who developed progressive venous sinus thrombosis, leading to coma, and was found to have low intracranial pressure indicative of SIH. Invasive monitoring and imaging confirmed the low intracranial pressure, prompting a dynamic myelogram that revealed a T2/3 CSF venous fistula. The patient underwent transvenous embolization of the fistula, which resulted in the resolution of symptoms and almost immediate improvement in both venous thrombosis and intracranial hypotension. CSF venous fistulae as a cause of SIH is a recently recognized entity, with ongoing research into its treatment through transvenous embolization. Most documented cases focus on patients with headaches. This case highlights a novel presentation, emphasizing the importance of thorough diagnostic workup in patients with cerebral venous thrombosis. Early detection and treatment of this condition can lead to significant clinical improvement, including the resolution of coma.

Diagnostic Accuracy of Cone-Beam CT for Acute Intracranial Hemorrhage: A Systematic Review and Meta-Analysis.

OBJECTIVE: Our purpose was to synthesize evidence in the literature to determine the diagnostic accuracy of cone-beam CT (CBCT) for the detection of intracranial hemorrhage (ICH) and hemorrhage types, including intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and intraventricular hemorrhage (IVH). METHODS: We performed a meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Our protocol was registered with International Prospective Register of Systematic Reviews (PROSPERO-CRD42021261915). Systematic searches were last performed on April 30, 2024, in EMBASE, PubMed, Web-of-Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases. Inclusion criteria were (1) studies reporting diagnostic metrics of CBCT for ICH and (2) studies using a reference standard to determine ICH. Exclusion criteria were (1) case reports, abstracts, reviews and (2) studies without patient-level data. Pooled estimates and 95% confidence intervals (CIs) were calculated for diagnostic odds ratios (DORs), sensitivity, and specificity using random-effects and common-effects models. Mixed methods appraisal tool was used to evaluate risk of bias. RESULTS: Seven studies were included in the meta-analysis yielding 466 patients. Mean or median age ranged from 54 to 75 years. Female patients represented 51.4% (222 of 432) in reported studies. Multidetector CT was the reference standard in all studies. DOR, pooled sensitivity, and pooled specificity for ICH were 5.28 (95% CI: 4.11-6.46), 0.88 (95% CI: 0.79-0.97), and 0.99 (95% CI: 0.98-1.0). Pooled sensitivity for IPH, SAH, and IVH was 0.98 (95% CI: 0.95-1.0), 0.82 (95% CI: 0.57-1.0), and 0.78 (95% CI: 0.55-1.0). Pooled specificity for IPH, SAH, and IVH was 0.99 (95% CI: 0.98-1.0), 0.99 (95% CI: 0.97-1.0), and 1.0 (95% CI: 0.98-1.0). DISCUSSION: CBCT had moderate DOR and high pooled specificity for ICH and hemorrhage types. However, pooled sensitivity varied by hemorrhage type, with the highest sensitivity for IPH, followed by SAH and IVH.

Organizing a Regional In-Person Medical Student Symposium in Neuroscience and Neurosurgery Research: A How-To Guide.

BACKGROUND: Medical students are increasingly seeking out research opportunities to build their skills and network with future colleagues. Medical student-led conferences are an excellent endeavor to achieve this goal. METHODS: The American Association of Neurological Surgeons student chapter at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell designed an in-person medical student research symposium alongside the Northwell Health Department of Neurosurgery. Postconference feedback forms were sent out digitally to student attendees to evaluate event planning and execution and responses were given on a scale of 1-5 (5 being the highest score). RESULTS: In December 2023, the Northeast Medical Student Research Symposium was held with over 80 participants and 52 medical student presenters. Keynote speakers delivered lectures geared toward students interested in neurosurgery and neuroscience research, followed by an interactive poster board session and resident/attending networking dinner. After the conference, students affirmed that they learned more about neuroscience research after the event (mean: 4.3), were more inclined to attend other neuroscience research events in the future (mean: 4.7), and would attend this event if held next year (mean: 4.8). The poster sessions (mean: 4.75) and keynote lectures (mean: 5) were the highest rated events, while the resident/attending networking dinner (mean: 3.6) was a potential area for improvement. CONCLUSIONS: Regional in-person conferences are an excellent way to foster interest in neurosurgery and neuroscience research, network with like-minded peers, and prepare students for presentations at national meetings.

Stiffness anisotropy coordinates supracellular contractility driving long-range myotube-ECM alignment.

The ability of cells to organize into tissues with proper structure and function requires the effective coordination of proliferation, migration, polarization, and differentiation across length scales. Skeletal muscle is innately anisotropic; however, few biomaterials can emulate mechanical anisotropy to determine its influence on tissue patterning without introducing confounding topography. Here, we demonstrate that substrate stiffness anisotropy coordinates contractility-driven collective cellular dynamics resulting in C2C12 myotube alignment over millimeter-scale distances. When cultured on mechanically anisotropic liquid crystalline polymer networks (LCNs) lacking topography, C2C12 myoblasts collectively polarize in the stiffest direction. Cellular coordination is amplified through reciprocal cell-ECM dynamics that emerge during fusion, driving global myotube-ECM ordering. Conversely, myotube alignment was restricted to small local domains with no directional preference on mechanically isotropic LCNs of the same chemical formulation. These findings provide valuable insights for designing biomaterials that mimic anisotropic microenvironments and underscore the importance of stiffness anisotropy in orchestrating tissue morphogenesis.

Occipital venous sinus stenting for idiopathic intracranial hypertension and pulsatile tinnitus: A case series.

Venous sinus stenting for dural venous sinus outflow obstruction due to an intrinsic filling obstruction or extrinsic stenosis is an increasingly popular treatment strategy for idiopathic intracranial hypertension (IIH) and isolated pulsatile tinnitus (PT). The most common site of stenosis is the lateral venous sinus at the transverse-sigmoid junction. Approximately 10% of the population has a persistent occipital venous sinus (OVS), a variant that may be the dominant venous drainage pathway in the setting of a hypoplastic or aplastic transverse sinus. OVS stenosis has been rarely associated with IIH and isolated PT with only a handful published cases. We herein report a retrospective series of OVS stenting in five patients, four of whom presented with non-IIH PT and one with IIH.

Engineering a Hydrazone and Triazole Crosslinked Hydrogel for Extrusion-Based Printing and Cell Delivery.

Covalent adaptable crosslinks, such as the alkyl-hydrazone, endow hydrogels with unique viscoelastic properties applicable to cell delivery and bioink systems. However, the alkyl-hydrazone crosslink lacks stability in biologically relevant environments. Furthermore, when formed with biopolymers such as hyaluronic acid (HA), low molecular weight polymers (<60 kDa), or low polymer content (<2 wt%) hydrogels are typically employed as entanglements reduce injectability. Here, a high molecular weight (>60 kDa) HA alkyl-hydrazone crosslinked hydrogel is modified with benzaldehyde-poly(ethylene glycol)3-azide to incorporate azide functional groups. By reacting azide-modified HA with a multi-arm poly(ethylene glycol) (PEG) functionalized with bicyclononyne, stabilizing triazole bonds are formed through strain-promoted azide-alkyne cycloaddition (SPAAC). Increasing the fraction of triazole bonds within the hydrogel network from 0% to 12% SPAAC substantially increases stability. The slow gelation kinetics of the SPAAC reaction in the 12% SPAAC hydrogel enables transient self-healing properties and a similar extrusion force as the 0% SPAAC hydrogel. Methyl-PEG4-hydrazide is then introduced to further slowdown network evolution, which temporarily lowers the extrusion force, improves printability, and increases post-extrusion mesenchymal stem cell viability and function in the 12% SPAAC hydrogel. This work demonstrates improved stability and temporal injectability of high molecular weight HA-PEG hydrogels for extrusion-based printing and cell delivery.

Tunable and Switchable Thermochromism in Cholesteric Liquid Crystalline Elastomers.

Thermochromic materials have found widespread commercial use in packaging as temperature indicators. Often, these products utilize leuco dyes that are mixed into conventional polymeric resins to prepare coatings or films that exhibit temperature-dependent color change. Here, we consider a distinctive approach to thermochromism via the selective reflection of liquid crystalline elastomers that retain the helicoidal structure of the cholesteric phase (CLCEs). Upon heating, the order of the CLCEs reduces and approaches zero, resulting in a change in birefringence as well as material thickness, both of which manifest as changes in the selective reflection to heating. This examination systematically prepares CLCEs capable of reversible thermochromic response as a function of cross-link density and liquid crystalline composition. A particular focus of this examination is the preparation of CLCEs composed of chiral and achiral liquid crystalline monomers that reduce the strength of the mesogen-mesogen interaction and accordingly reduce the nematic-isotropic transition temperature. The low birefringence of some of the CLCE compositions facilitates thermochromic reflection tuning, followed by switching.

Deep learning workflow to support in-flight processing of digital aerial imagery for wildlife population surveys.

Deep learning shows promise for automating detection and classification of wildlife from digital aerial imagery to support cost-efficient remote sensing solutions for wildlife population monitoring. To support in-flight orthorectification and machine learning processing to detect and classify wildlife from imagery in near real-time, we evaluated deep learning methods that address hardware limitations and the need for processing efficiencies to support the envisioned in-flight workflow. We developed an annotated dataset for a suite of marine birds from high-resolution digital aerial imagery collected over open water environments to train the models. The proposed 3-stage workflow for automated, in-flight data processing includes: 1) image filtering based on the probability of any bird occurrence, 2) bird instance detection, and 3) bird instance classification. For image filtering, we compared the performance of a binary classifier with Mask Region-based Convolutional Neural Network (Mask R-CNN) as a means of sub-setting large volumes of imagery based on the probability of at least one bird occurrence in an image. On both the validation and test datasets, the binary classifier achieved higher performance than Mask R-CNN for predicting bird occurrence at the image-level. We recommend the binary classifier over Mask R-CNN for workflow first-stage filtering. For bird instance detection, we leveraged Mask R-CNN as our detection framework and proposed an iterative refinement method to bootstrap our predicted detections from loose ground-truth annotations. We also discuss future work to address the taxonomic classification phase of the envisioned workflow.

The role of surgical disconnection for posterior fossa pial arteriovenous fistulas and dural fistulas with pial supply: an illustrative case series.

BACKGROUND: Pial arteriovenous fistulas (pAVFs) are rare vascular malformations characterized by high-flow arteriovenous shunting involving a cortical arterial supply directly connecting to venous drainage without an intermediate nidus. Dural arteriovenous fistulas (dAVFs) can infrequently involve additional pial feeders which can introduce higher flow shunting and increase the associated treatment risk. In the posterior fossa, arteriovenous fistula (AVF) angioarchitecture tends to be particularly complex, involving either multiple arterial feeders-sometimes from both dural and pial origins-or small caliber vessels that are difficult to catheterize and tend to be intimately involved with functionally critical brainstem or upper cervical cord structures. Given their rarity, published experience on microsurgical or endovascular treatment strategies for posterior fossa pAVFs and dAVFs with pial supply remains limited. METHODS: Retrospective chart review from 2019-2023 at a high-volume center identified six adult patients with posterior fossa pAVFs that were unable to be fully treated endovascularly and required microsurgical disconnection. These cases are individually presented with a technical emphasis and supported by comprehensive angiographic and intraoperative images. RESULTS: One vermian (Case 1), three cerebellopontine angle (Cases 2-4) and two craniovertebral junction (Cases 5-6) posterior fossa pAVFs or dAVFs with pial supply are presented. Three cases involved mixed dural and pial arterial supply (Cases 1, 4, and 6), and one case involved a concomitant microAVM (Case 2). Endovascular embolization was attempted in four cases (Cases 1-4): The small caliber and tortuosity of the main arterial feeder prevented catheterization in two cases (Cases 1 and 3). Partial embolization was achieved in Cases 2 and 4. In Cases 5 and 6, involvement of the lateral spinal artery or anterior spinal artery created a prohibitive risk for endovascular embolization, and surgical clip ligation was pursued as primary management. In all cases, microsurgical disconnection resulted in complete fistula obliteration without evidence of recurrence on follow-up imaging (mean follow-up 27.1 months). Two patients experienced persistent post-treatment sensory deficits without significant functional limitation. CONCLUSIONS: This illustrative case series highlights the technical difficulties and anatomical limitations of endovascular management for posterior fossa pAVFs and dAVFs with pial supply and emphasizes the relative safety and utility of microsurgical disconnection in this context. A combined approach involving partial preoperative embolization-when the angioarchitecture is permissive-can potentially decrease surgical morbidity. Larger studies are warranted to better define the role for multimodal intervention and to assess associated long-term AVF obliteration rates in the setting of pial arterial involvement.