Contralateral approach to giant ruptured and unruptured ophthalmic artery aneurysms: patient series.

BACKGROUND: Giant ophthalmic artery (OphA) aneurysms remain surgically challenging despite the progress in endovascular treatments. This study describes the contralateral interoptic corridor in select patients based on imaging criteria suitable for clipping. The aim of this study was to show that despite the growing use of novel endovascular techniques, such as coil embolization and flow diversion, for the treatment of OphA aneurysms, microsurgical clipping may still be preferred for giant ones under certain conditions. OBSERVATIONS: The authors retrospectively reviewed the records of the microsurgical treatment of unruptured and ruptured giant OphA aneurysms at the University Hospital Center "Mother Teresa," Tirana, from 2007 to 2016. Four patients were selected for microsurgery and the contralateral approach using ophthalmic evaluations and coronal imaging on computed tomography, magnetic resonance imaging, and digital subtraction angiography that demonstrated aneurysms with a small neck and an orientation between 11 and 13 on the coronal clock face. A prefixed chiasm was a contraindication to this approach. LESSONS: Giant OphA aneurysms can be safely clipped through a contralateral interoptic corridor without creating new visual deficits or a residual aneurysm. https://thejns.org/doi/10.3171/CASE2473.

Comparing surgical clipping with endovascular treatment for unruptured middle cerebral artery aneurysms: a systematic review and updated meta-analysis.

OBJECTIVE: Unruptured middle cerebral artery aneurysm (uMCAA) has traditionally been treated with open surgical clipping (SC). Endovascular treatments (EVTs) were designed to reduce surgical risks in these cases. Nevertheless, despite its potential benefits, many surgeons favor SC for uMCAA. This updated meta-analysis aimed to compare the safety, efficacy, and clinical outcomes of SC and EVT for uMCAA. METHODS: The authors searched the Medline, Embase, and Cochrane Library databases according to the Cochrane and PRISMA guidelines. Eligible studies included those with ≥ 4 patients with uMCAA reporting comparative data of SC and EVT. The endpoints were the complete occlusion rate (Raymond class I and II), good clinical outcomes (modified Rankin Scale score ≤ 2 or Glasgow Outcome Scale score ≥ 4), procedure-related complications (further divided into major and minor), and mortality. The authors pooled OR with 95% CI values with a random-effects model. I2 statistics were used to assess heterogeneity, and sensitivity analysis was conducted to address high heterogeneity. Publication bias was assessed with funnel plot analysis and the Egger's test. RESULTS: The analysis included data from 10 studies. Regarding the complete occlusion assessment, the comparative analysis revealed OR 0.17 (95% CI 0.08-0.40, p < 0.01), favoring SC. In terms of achieving good clinical outcomes, OR 0.44 (95% CI 0.20-0.97, p < 0.05) was determined, favoring SC. No differences regarding total procedure-related complications, major complications, or mortality were identified. However, a higher likelihood of minor complications was identified for EVT, with OR 4.68 (95% CI 2.01-10.92, p < 0.01). CONCLUSIONS: This systematic review and meta-analysis identified a lower likelihood of complete occlusion at last follow-up and lower likelihood of good clinical outcomes in patients treated with EVT when compared with SC. Furthermore, a higher likelihood of minor complications was identified in patients who underwent EVT when compared with SC. The findings reinforce that, based on the currently available data, SC should be considered the primary approach for treating uMCAA. However, EVT is an evolving approach, and this study's findings represent a synthesis of observational studies. Randomized trials are warranted to elucidate which approach should be the mainstay for uMCAA and to identify the nuances that determine whether SC or EVT is more or less indicated for addressing uMCAA with consideration of the individuality of each patient and aneurysm.

The evolution and future directions of bypass surgery.

Cerebral bypass surgery is one of the most complex and elegant procedures in neurosurgery. It involves several meticulous steps that test the skills of even the most prepared neurosurgeons. This surgery has transcended its traditional role in arterial stenosis and atherosclerosis, expanding its applications to include flow preservation techniques for complex conditions such as aneurysms, tumors, and vascular malformations. The decreased number of procedures performed across many hospitals reflects the development of newer endovascular therapies but is also due to the results of the extracranial-intracranial bypass study, the Carotid Occlusion Surgery Study, and the Carotid and Middle Cerebral Artery Occlusion Surgery Study, which have raised questions about the efficacy of cerebral bypass surgery for individuals with carotid artery occlusion who are prone to ischemic stroke. Despite this, there is still a potential benefit of bypass surgery for patients with hemodynamic impairment refractory to medical management. Also, revascularization in moyamoya vasculopathy is an effective strategy for preventing ischemic and hemorrhagic events in both children and adults. Additionally, innovations in the technique, such as the flow-regulated bypass and intraoperative flow assessment, aim to minimize perioperative morbidity. Despite bypass surgery being less performed in this current era, the teaching and development of these skills are still encouraged for future neurosurgeons, as a role for bypass will exist for the foreseeable future.

Timing, type, and impact of thromboembolic events caused by flow diversion: a 10-year experience.

OBJECTIVE: Thromboembolic (TE) events are among the most feared complications after flow diversion (FD) and have been reported to occur even with adequate dual antiplatelet therapy. Herein, the authors characterize thrombotic and embolic events that developed after FD, focusing on the morbidity of each of these events and the predisposing factors associated with their development. METHODS: A retrospective analysis of aneurysms treated with FD at a single institution in the US between 2013 and 2023 was performed. The authors documented the emergence of intraprocedural and postoperative TE events. A survival analysis and a Cox regression model was conducted to identify predictors associated with these events. RESULTS: The authors included 651 procedures performed in 591 patients to treat 746 aneurysms. TE events occurred in 38 of the procedures performed (5.8%), causing permanent deficit in 20 patients and death in 4 patients. Eleven cases presented with acute stent thrombosis, 11 with large-vessel occlusion, and 9 with perforator strokes. At a median follow-up of 9.5 months, 73.0% of patients with an ischemic event had a modified Rankin Scale score ≤ 2. Three of the deaths were secondary to occlusion at the basilar trunk and vertebral artery. In patients with TE events in the anterior circulation, 7 of 11 patients with middle cerebral artery occlusion and 9 of 12 patients with internal carotid artery occlusion achieved independence. Time-to-event Cox regression analysis demonstrated that TE events were more frequent in patients exhibiting aspirin resistance (hazard ratio 2.66; 95% CI 1.10-6.70). CONCLUSIONS: TE events after FD result from multiple factors, including age, aneurysm characteristics, aneurysm location, antiplatelet resistance, and procedural factors. In our cohort, we found the highest morbidity for patients with TE events presenting with large-vessel occlusion at the middle cerebral artery, and vertebrobasilar system.

Assessing superficial temporal artery-middle cerebral artery anastomosis patency using FLOW 800 hemodynamics.

OBJECTIVE: The objective of this study was to investigate the use of indocyanine green videoangiography with FLOW 800 hemodynamic parameters intraoperatively during superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery to predict patency prior to anastomosis performance. METHODS: A retrospective and exploratory data analysis was conducted using FLOW 800 software prior to anastomosis to assess four regions of interest (ROIs; proximal and distal recipients and adjacent and remote gyri) for four hemodynamic parameters (speed, delay, rise time, and time to peak). Medical records were used to classify patients into flow and no-flow groups based on immediate or perioperative anastomosis patency. Hemodynamic parameters were compared using univariate and multivariate analyses. Principal component analysis was used to identify high risk of no flow (HRnf) and low risk of no flow (LRnf) groups, correlated with prospective angiographic follow-ups. Machine learning models were fitted to predict patency using FLOW 800 features, and the a posteriori effect of complication risk of those features was computed. RESULTS: A total of 39 cases underwent STA-MCA bypass surgery with complete FLOW 800 data collection. Thirty-five cases demonstrated flow after anastomosis revascularization and were compared with 4 cases with no flow after revascularization. Proximal and distal recipient speeds were significantly different between the no-flow and flow groups (proximal: 238.3 ± 120.8 and 138.5 ± 93.6, respectively [p < 0.001]; distal: 241.0 ± 117.0 and 142.1 ± 103.8, respectively [p < 0.05]). Based on principal component analysis, the HRnf group (n = 10) was characterized by high-flow speed (> 75th percentile) in all ROIs, whereas the LRnf group (n = 10) had contrasting patterns. In prospective long-term follow-up, 6 of 9 cases in the HRnf group, including the original no-flow cases, had no or low flow, whereas 8 of 8 cases in the LRnf group maintained robust flow. Machine learning models predicted patency failure with a mean F1 score of 0.930 and consistently relied on proximal recipient speed as the most important feature. Computation of posterior likelihood showed a 95.29% chance of patients having long-term patency given a lower proximal speed. CONCLUSIONS: These results suggest that a high proximal speed measured in the recipient vessel prior to anastomosis can elevate the risk of perioperative no flow and long-term reduction of flow. With an increased dataset size, continued FLOW 800-based ROI metric analysis could be used to guide intraoperative anastomosis site selection prior to anastomosis and predict patency outcome.

Safety and efficacy of the Contour Neurovascular System for intracranial aneurysm treatment: a retrospective analysis of 76 patients.

OBJECTIVE: The Contour Neurovascular System (CNS) is a novel intrasaccular flow-disrupting device for the treatment of intracranial aneurysms. This study presents the authors' institutional experience and midterm follow-up results with this device. METHODS: Seventy-six consecutive patients (mean ± SD age 58.9 ± 12.4 years) were treated with the CNS for 76 aneurysms (63 unruptured, 10 recurrent, and 3 ruptured). Aneurysm characteristics, procedural details, and clinical/angiographic outcomes were retrospectively evaluated. RESULTS: The most common aneurysm locations were the basilar tip in 25 (32.9%) cases and the anterior communicating artery in 22 (28.9%). There were 18 (23.7%) sidewall aneurysms. The mean ± SD aneurysm width was 5.6 ± 2.5 mm, and 68 (89.5%) aneurysms were wide-necked. The CNS was successfully implanted in 68 (89.5%) aneurysms, with 11 cases of additional coiling and 1 case each of additional stent and balloon. There were 3 (3.9%) thromboembolic events, of which 1 (1.3%) was symptomatic (a major ischemic stroke) and resulted in morbidity. There were no hemorrhagic events or deaths. At last available follow-up (mean 12 months), 32/56 (57.1%) aneurysms were completely occluded, 16/56 (28.6%) had neck remnants, and 8/56 (14.3%) had an aneurysm remnant. Three (5.4%) aneurysms were retreated. CONCLUSIONS: The use of the CNS was safe and feasible but proper aneurysm selection appears to be required, which may be facilitated with increasing operator experience and further study of this device. Similar to other intrasaccular flow disrupters, midterm complete occlusion rates are moderate but may increase with longer follow-up.

Anterior choroidal artery aneurysms: a systematic review and meta-analysis of outcomes and ischemic complications following surgical and endovascular treatment.

OBJECTIVE: Anterior choroidal artery (AChA) aneurysms account for 2%-5% of all intracranial aneurysms. Treatment considerations include microsurgical clipping, flow diversion, or coiling with or without adjunctive devices. AChA aneurysms pose challenges in treatment due to the origination of the aneurysm from the origin or proximal segment of the AChA. The AChA is particularly susceptible to vasospasm and occlusion during treatment with devastating neurological deficits, including hemiparesis, hemianesthesia, lethargy, neglect, and hemianopia. In this study, the authors performed a meta-analysis to quantify the outcomes and complication rates across treatment modalities for AChA aneurysms and to identify risk factors reported in the literature. METHODS: The authors performed a systematic review of AChA aneurysms treated with surgical clipping, endovascular coiling, or flow diversion and reported in the PubMed, Embase, Scopus, and Cochrane search databases. Single-arm meta-analyses of the selected outcomes were performed in RStudio. RESULTS: Literature review yielded 25 studies that met the inclusion criteria. In total, 1627 patients were included in the analysis, with 554 males, 1009 females, and 64 unspecified. The rate of any complication in the full cohort was 11.6%, with a rate of ischemic complications of 5.5% and a favorable recovery rate of 90.3% of all patients treated. In total, 1064 patients underwent surgical clipping, 443 were treated with coiling, and 120 patients with flow diversion. In clipped patients, the rate of total surgical complications was 17.6%, with an ischemic complication rate of 9.4%. The rate of good functional recovery, defined on the basis of a Glasgow Outcome Scale score of 4-5 or modified Rankin Scale score of 0-2, was 88.0%, and complete obliteration was achieved in 84.5% of surgically clipped aneurysms. The complication rate in coiled patients was 10.3%, with an ischemic complication rate of 3.0%. Good functional recovery was achieved in 88.6% of coiled patients and complete aneurysm obliteration in 74.1%. Flow diversion resulted in a complication rate of 1.3%, with 0.7% rate of ischemic complications. Good functional recovery was achieved in 98.4% of patients and complete aneurysm obliteration in 79.0% in the flow diversion group. Aneurysm morphological features that impacted the complication rate were also identified to augment quantitative data and to help guide treatment selection for AChA aneurysms. CONCLUSIONS: Flow diversion showed significantly lower total and ischemic complications and improved outcomes compared to clipping and coiling. There may be differences in outcomes between treatment types, especially when considering the varied patient presentations that guide treatment selection.

Flow capacity of a superficial temporal artery as a donor in a consecutive series of 100 patients with superficial temporal artery-middle cerebral artery bypass.

OBJECTIVE: A superficial temporal artery-middle cerebral artery (STA-MCA) bypass is classically considered a low-flow bypass. It is known that the flow in the flow augmentation STA-MCA bypass is influenced by flow demand of the revascularized territory and can reach significantly higher values. The authors report their intraoperative flow measurement data in a consecutive series of 100 STA-MCA bypasses performed at their institution. Moreover, in a subanalysis, they show the postoperative bypass flow measured with quantitative MR angiography (qMRA) noninvasive optimal vessel analysis (NOVA). METHODS: Between January 2013 and October 2023, 100 patients with acute, subacute, or chronic large-vessel occlusion (LVO) or moyamoya disease underwent a flow augmentation STA-MCA bypass revascularization at the authors' department with intraoperative bypass flow measurement. Patients with atherosclerotic LVO who underwent bypass surgery within a 6-week period following the onset of ischemic stroke symptoms were categorized into the acute bypass group, encompassing both acute and subacute LVO cases. Conversely, those who underwent bypass surgery > 6 weeks after the last occurrence of ischemic stroke were classified as the chronic group. Since May 2019, a consecutive subgroup of 37 patients received a postoperative (before discharge) bypass flow measurement with the qMRA-NOVA imaging tool. RESULTS: The mean ± SD intraoperative bypass flow in this consecutive series of 100 STA-MCA bypasses was 53.5 ± 28.8 ml/min (range 14-145 ml/min). In the subanalysis, there was no difference in the intraoperative flow capacity between the acute and chronic groups and between the moyamoya and acute groups. Patients in the moyamoya group showed a significantly higher flow rate in the STA-MCA bypass compared with the chronic group (63.0 ± 30.2 ml/min vs 48.4 ± 26.5 ml/min, p = 0.03). In a consecutive subanalysis of 37 STA-MCA bypass cases, postoperative flow measurements were also performed using qMRA-NOVA, showing a significant increase in the flow of STA-MCA bypasses after surgery compared with intraoperative flow measurements (mean intraoperative bypass flow rate vs qMRA-NOVA postoperative bypass flow rate: 73.4 ± 29.9 ml/min vs 111.3 ± 51.4 ml/min, p = 0.005). CONCLUSIONS: Using intraoperative and postoperative quantitative flow measurements of the STA, the data confirm that the flow in the flow augmentation STA-MCA bypass is influenced by the flow demand of the revascularized territory and can reach high values if needed. Moreover, the significant flow increase in the postoperative flow measurement using qMRA-NOVA demonstrates that the bypass can increase its flow over time.

Impact of postoperative cerebral hyperperfusion on 2-year cognitive outcomes of patients undergoing carotid endarterectomy.

OBJECTIVE: In 10% of patients undergoing carotid endarterectomy (CEA), the cognitive function declines postoperatively, primarily in association with postoperative cerebral hyperperfusion. In contrast, in the majority of patients undergoing CEA, long-term cognitive outcomes remain unclear. Furthermore, it is not known whether the decline in cognition due to cerebral hyperperfusion recovers on a long-term basis. This study aimed to understand how postoperative cerebral hyperperfusion affects the cognitive outcomes of patients who undergo CEA. METHODS: The participants in this prospective observational study were patients with internal carotid artery stenosis who underwent CEA. Cerebral hyperperfusion syndrome or asymptomatic cerebral hyperperfusion following CEA was determined based on brain perfusion SPECT scans and symptomatology before and after surgery. Neuropsychological testing was performed preoperatively, at 1-2 months postoperatively, and at 2 years postoperatively to investigate cognitive decline. RESULTS: A logistic regression analysis revealed that asymptomatic cerebral hyperperfusion (95% CI 13.0-84.5, p < 0.0001) and cerebral hyperperfusion syndrome (95% CI 449.7-14,237.4, p < 0.0001) were significantly associated with cognitive decline at 1-2 months postoperatively. The incidence of cognitive decline was significantly decreased at 2 years postoperatively (7%) in comparison to 1-2 months postoperatively (11%) (p = 0.0461). A logistic regression analysis also revealed that asymptomatic cerebral hyperperfusion (95% CI 3.7-36.7, p < 0.0001), cerebral hyperperfusion syndrome (95% CI 128.0-6183.6, p < 0.0001), and further strokes during the 2-year follow-up period (95% CI 1.5-78.7, p = 0.0167) were significantly associated with cognitive decline at 2 years postoperatively. The incidence of cognitive decline at 1-2 months postoperatively was significantly higher in patients with cerebral hyperperfusion syndrome (100%) than in those with asymptomatic cerebral hyperperfusion (44%) (p < 0.0001). No significant difference in incidence was observed in the former patients at 2 years postoperatively (88%), but significant reduction was found in patients with asymptomatic cerebral hyperperfusion and cognitive decline between the timepoints of 1-2 months postoperatively (100%) and 2 years postoperatively (39%) (p = 0.0001). CONCLUSIONS: Postoperative cerebral hyperperfusion causes prolonged cognitive decline at 2 years postoperatively in patients undergoing CEA.

Pipeline embolization device placement under local versus general anesthesia: a propensity score-matched study.

OBJECTIVE: Pipeline embolization device (PED) placement for the treatment of intracranial aneurysms is safe and effective under general anesthesia (GA). However, GA is associated with certain risks, longer procedural time, and higher hospital cost. The authors aimed to compare clinical outcomes and hospital cost between GA and local anesthesia (LA) procedures in patients who underwent PED placement for intracranial aneurysm treatment. METHODS: This retrospective study analyzed the charts of 216 patients with 223 intracranial aneurysms treated using the PED from June 2022 to March 2023. Cases were grouped according to type of anesthesia administered (LA or GA). Propensity score matching (PSM) was used to balance the groups to minimize confounding bias. RESULTS: Eighty-four patients with 88 aneurysms were treated under LA, and 132 patients with 135 aneurysms were treated under GA. The complication rate and modified Rankin Scale score at 6 months were similar in both groups. Procedural time was significantly shorter with LA both before (87.47 ± 22.68 minutes vs 118.90 ± 46.80 minutes, p < 0.001) and after (84.75 ± 16.77 minutes vs 110.02 ± 38.56 minutes, p < 0.001) PSM. LA eliminates the need for postanesthesia recovery. Hospital cost was significantly lower in the LA group both before ($30,820.74 ± $3216.93 vs $32,846.62 ± $4731.50, p = 0.001) and after ($30,127.83 ± $2763.12 vs $33,874.41 ± $3163.56, p = 0.002) PSM. CONCLUSIONS: PED placement under LA can achieve satisfactory outcomes similar to those of PED placement under GA; however, the use of LA reduces procedural time and hospital cost.

REACT: a randomized trial to assess the efficacy and safety of clazosentan for preventing clinical deterioration due to delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Ischemic complications account for significant patient morbidity following aneurysmal subarachnoid hemorrhage (aSAH). The Prevention and Treatment of Vasospasm with Clazosentan (REACT) study was designed to assess the safety and efficacy of clazosentan, an endothelin receptor antagonist, in preventing clinical deterioration due to delayed cerebral ischemia (DCI) in patients with aSAH. METHODS: REACT was a prospective, multicenter, randomized, double-blind, phase 3 study. Eligible patients had aSAH secured by surgical clipping or endovascular coiling, and had presented with thick and diffuse clot on admission CT scan. Patients were randomized (1:1 ratio) to 15 mg/hour intravenous clazosentan or placebo within 96 hours of the aSAH for up to 14 days, in addition to standard of care treatment including oral or intravenous nimodipine. The primary efficacy endpoint was the occurrence of clinical deterioration due to DCI up to 14 days after initiation of the study drug. The main secondary endpoint was the occurrence of clinically relevant cerebral infarction at day 16 after study drug initiation. Other secondary endpoints included clinical outcome assessed on the modified Rankin Scale (mRS) and the Glasgow Outcome Scale-Extended (GOSE) at week 12 post-aSAH. Imaging and clinical endpoints were centrally adjudicated. RESULTS: A total of 409 patients were randomized between February 2019 and May 2022 across 74 international sites. Three patients did not start study treatment and were not included in the analysis set. The occurrence of clinical deterioration due to DCI was 15.8% (32/202 patients) in the clazosentan group and 17.2% (35/204 patients) in the placebo group, and the difference was not statistically significant (relative risk reduction [RRR] 7.2%, 95% CI -42.6% to 39.6%, p = 0.734). A nonsignificant RRR of 34.1% (95% CI -21.3% to 64.2%, p = 0.177) was observed in clinically relevant cerebral infarcts treated with clazosentan (7.4%, 15/202) versus placebo (11.3%, 23/204). Rescue therapy was less frequently needed for patients treated with clazosentan compared to placebo (10.4%, 21/202 vs 18.1%, 37/204; RRR 42.6%, 95% CI 5.4%-65.2%). A nonsignificant relative risk increase of 25.4% (95% CI -10.7% to 76.0%, p = 0.198) was reported in the risk of poor GOSE and mRS scores with clazosentan (24.8%, 50/202) versus placebo (20.1%, 41/204) at week 12 post-aSAH. Treatment-emergent adverse events were similar to those reported previously. CONCLUSIONS: Clazosentan administered for up to 14 days at 15 mg/hour had no significant effect on the occurrence of clinical deterioration due to DCI. Clinical trial registration no.: NCT03585270 (ClinicalTrials.gov) EU clinical trial registration no.: 2018-000241-39 (clinicaltrialsregister.eu).

Superficial Temporal Artery Size Changes After Encephaloduroarteriosynangiosis (EDAS) for the Treatment of Moyamoya Disease.

BACKGROUND AND OBJECTIVES: Surgery is the mainstay of stroke prevention in patients with symptomatic Moyamoya disease. We present the results of a single-center retrospective study of indirect revascularization surgery for adult moyamoya disease, emphasizing angiographic outcomes, including dilation of the superficial temporal artery and formation of new collaterals. METHODS: A prospectively maintained database of procedures performed for Moyamoya disease was reviewed. Adult patients treated with indirect revascularization and with long-term angiographic follow-up were included. Pre-operative and postoperative angiographic images and baseline and procedural characteristics were analyzed. A Wilcoxon signed-rank test was used to test the hypothesis that the superficial temporal artery increases in diameter postoperatively. RESULTS: We identified 40 hemispheres in 27 patients, of which 35 had a sufficient angiographic follow-up. Bilateral procedures were performed on 16 patients. Most patients were female (72.5%), with a median age of 43 years-old. The most common clinical presentation was ischemic stroke in 59.3% of cases. All patients underwent an encephaloduroarteriosynangiosis (EDAS) for treatment. A follow-up angiogram was performed at a median of 13.8 months postoperatively, showing STA-derived collaterals in 71.4% and collateral ingrowth via the burr holes in 61.8% of cases. Disease progression was evident in 34.3% of hemispheres. The normalized STA diameter was significantly increased postoperatively (2.4 to 3 mm; p<0.05). A univariate analysis revealed that transdural collaterals and hyperlipidemia may affect collateral ingrowth from the STA, and no other patient or procedure-related factors, including replacement of the bone flap, impacted on this. CONCLUSION: A significant increase in STA diameter on follow-up angiography after EDAS was found, however this was not directly associated with STA collateral development. Rates of postoperative transient ischemic attacks were low, and no patients had a new ischemic or hemorrhagic stroke at last follow up. The presence of transdural collaterals and the absence of hyperlipidemia were associated with STA collateral development on follow-up angiography, but the causality of this finding is unclear.

Indications for cerebral revascularization for moyamoya syndrome in pediatric sickle cell disease determined by Delphi methodology.

OBJECTIVE: Cerebral revascularization surgery (CRS) has been used to prevent stroke in children with sickle cell disease (SCD) and cerebral vasculopathy (e.g., moyamoya syndrome). While results suggest that it may be an effective treatment, surgical indications have not been well defined. This study sought to determine indications for offering revascularization surgery in centers with established sickle cell programs in the US. METHODS: Three sequential surveys utilizing the Delphi methodology were administered to neurosurgeons participating in the Stroke in Sickle Cell Revascularization Surgery study. Respondents were presented with clinical scenarios of patients with SCD and varying degrees of ischemic presentation and vasculopathy, and the group's agreement to offer surgical revascularization was measured. Consensus was defined as ≥ 75% similar responses. RESULTS: The response rate to all 3 surveys was 100%. Seventeen neurosurgeons from 16 different centers participated. The presence of moyamoya collaterals (MMCs) and arterial stenosis matching an ischemic distribution yielded the strongest recommendations to offer surgery. There was consensus to offer revascularization in the presence of MMCs and at least 50% arterial stenosis matching an ischemic distribution. In contrast, there was no consensus to offer revascularization with 50%-70% stenosis not matching an ischemic presentation in the absence of MMCs. The presence of the ivy sign in the distribution of the stenotic artery also contributed to the consensus to offer surgery in certain scenarios. CONCLUSIONS: There were several clinical scenarios that attained consensus to offer surgery; the strongest was moderate to severe arterial stenosis that matched the distribution of ischemic presentation in the presence of MMCs. Radiological findings of decreased cerebral flow or perfusion also facilitated attaining consensus to offer surgery. The findings of this study reflect expert opinion about questions that deserve prospective clinical research. Determination of indications for CRS can guide clinical practice and aid the design of prospective studies.

The impact of the Woven EndoBridge device on the treatment of anterior circulation wide-neck bifurcation aneurysms: a single-center experience.

OBJECTIVE: The paucity of literature comparing Woven EndoBridge (WEB) embolization to microsurgical clipping for anterior circulation wide-neck bifurcation aneurysms (WNBAs) underscores the need for further investigation into the optimal management of this patient subpopulation. The objective of this study was to compare the rate of endovascular and microsurgical treatment of WNBAs before and after the introduction of the WEB device. In addition, the authors performed a comparison of demographics, aneurysm characteristics, and treatment outcomes in patients before and after the introduction of the WEB device. METHODS: This study was a retrospective review of the usage rate of different treatment modalities for WNBAs before and after the WEB device was approved by the US FDA on September 27, 2018. RESULTS: The study cohort comprised 235 patients with anterior circulation WNBAs treated at the authors' institution, including 127 aneurysms treated pre-WEB and 108 treated post-WEB. Generally, the rate of endovascular treatment of anterior circulation WNBAs was significantly higher post-WEB (86.1% vs 46.5%, p < 0.001), while the rate of clipping was significantly lower (13.9% vs 53.5%, p < 0.001). During follow-up, the rate of adequate aneurysm occlusion (Raymond-Roy occlusion classification [RROC] grades 1 and 2) was nonsignificantly higher in the post-WEB cohort (83.9% vs 78.5%, p = 0.34), while the rate of RROC grade 3 was nonsignificantly higher in the pre-WEB cohort (21.5% vs 16.1%, p = 0.34). Additionally, and although nonsignificant, the rates of recurrence (pre-WEB 25.3% vs post-WEB 14.9%, p = 0.12) and retreatment (pre-WEB 22.8% vs post-WEB 14.9%, p = 0.22) were higher in the pre-WEB cohort. Recurrence was assessed before retreatment. CONCLUSIONS: After the introduction of the WEB device, the rate of endovascular treatment of WNBAs increased while the rate of microsurgical clipping decreased. It is essential for neurointerventionalists to become familiar with the indications, advantages, and shortcomings of all these different techniques to be able to match the right patient with the right technique to produce the best outcome.

In vitro evaluation of flow diverter performance using a human fibrinogen-based flow model.

OBJECTIVE: Fibrin deposition represents a key step in aneurysm occlusion, promoting endothelization of implants and connective tissue organization as part of the aneurysm-healing mechanism. In this study, the authors introduce a novel in vitro testing platform for flow diverters based on human fibrinogen. METHODS: A flow diverter was deployed in 4 different glass models. The glass models had the same internal parent artery (4 mm) and aneurysm (8 mm) diameters with varying parent artery angulations (paraophthalmic, sidewall, bifurcation, and slightly curved models). The neck size and area were 4 mm and 25 mm2, respectively. Human fibrinogen (330 mg/dl) was circulated within the glass models at varying flow rates (0, 3, 4, and 5 ml/sec) with or without heparin, calcium chloride, and thrombin for as long as 6 hours or until complete fibrin coverage of the flow diverter's neck was achieved. Aneurysm neck coverage was defined as macroscopic fibrin deposition occluding the flow diverters' pores. Flow characteristics after flow diverter deployment were assessed with computational fluid dynamics analysis. The effects of flow rates, heparin, calcium chloride, and thrombin on fibrin deposition rates were tested using 1-way ANOVA and the Tukey test. RESULTS: A total of 84 replicates were performed. Human fibrin did not accumulate on the flow diverter stents under static conditions. The fibrin deposition rate on the aneurysm neck was significantly greater with the 5 ml/sec flow rate as compared to 3 ml/sec for all models. The paraophthalmic model had the highest inflow velocity of 48.7 cm/sec. The bifurcation model had the highest maximum shear stress (SS) and maximum normalized shear stress values at the device cells at 843.3 dyne/cm2 and 35.1 SS/SSinflow, respectively. The fibrin deposition rates of the paraophthalmic and bifurcation models were significantly higher than those of sidewall and slightly curved models for all additive or flow rate comparisons (p = 0.001 for all comparisons). The incorporation of thrombin significantly increased the fibrin deposition rates across all models (p = 0.001 for all models). CONCLUSIONS: Rates of fibrin deposition varied widely across different configurations and additive conditions in this novel in vitro model system. Fibrin accumulation started at the aneurysm inflow zone where flow velocity and shear stress were the highest. The primary factors influencing fibrin deposition included flow velocities, shear stress, and the addition of thrombin at a physiological concentration. Further research is needed to test the clinical utility of fibrinogen-based models for patient-specific aneurysms.

Advancing Neurosurgical Skills: A Comparative Study of Training Models for Intra-Extracranial Cerebral Bypass.

BACKGROUND: Training in anastomosis is fundamental in neurosurgery due to the precision and dexterity required. Biological models, although realistic, present limitations such as availability, ethical concerns, and the risk of biological contamination. Synthetic models, on the other hand, offer durability and standardized conditions, although they sometimes lack anatomical realism. This study aims to evaluate and compare the efficiency of anastomosis training models in the intra-extracranial cerebral bypass procedure, identifying those characteristics that enhance optimal microsurgical skill development and participant experience. METHODS: A neurosurgery workshop was held from March 2024 to June 2024 with 5 vascular techniques and the participation of 22 surgeons. The models tested were the human placenta, the Wistar rat, the chicken wing artery, the nasogastric feeding tube, and the UpSurgeOn Mycro simulator. The scales used to measure these models were the Main Characteristics Score and the Evaluation Score. These scores allowed us to measure, qualitatively and quantitatively, durability, anatomical similarity, variety of simulation scenarios, risk of biological contamination, ethical considerations and disadvantages with specific infrastructure. RESULTS: The human placenta model, Wistar rat model, and UpSurgeOn model were identified as the most effective for training. The human placenta and Wistar rat models were highly regarded for anatomical realism, while the UpSurgeOn model excelled in durability and advanced simulation scenarios. Ethical and cost implications were also considered. CONCLUSIONS: The study identifies the human placenta and UpSurgeOn models as optimal for training in intra-extracranial bypass procedures, emphasizing the need for diverse and effective training models in neurosurgery.

Mortality in Amputees with Peripheral Artery Disease during the Post-COVID Era: A Three-Year Analysis.

BACKGROUND: Patients with peripheral artery disease (PAD) have 40-70% higher three-year mortality after lower limb amputation compared to non-amputees. In this study, we examined the consequences of delayed treatment for patients with PAD during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This study employed a retrospective single-centre cohort design at a large tertiary care hospital. We compared amputees with PAD during the initial COVID-19 outbreak period in 2020 with a control group of amputees from 2019 after a three-year follow-up. RESULTS: In total, 134 amputees with PAD were included due to unsuccessful revascularization (n = 84 in 2020 vs. n = 50 in 2019). Patients in 2020 were significantly younger than those in 2019 (p = 0.01) and mostly admitted with advanced stages of PAD (p < 0.03). The proportion of major limb amputations increased significantly in 2020 (p = 0.03). Non-COVID-19-related deaths among patients in 2020 were more than twice as many as those in 2019, and long-term mortality in 2020 was 49% compared to 39% in 2019 (p = 0.04). Diabetes and renal insufficiency had a significantly negative impact on the survival of amputees with PAD (p < 0.01). CONCLUSIONS: Delayed treatment in patients with PAD leads to high long-term mortality risk after amputation, especially in PAD patients with diabetes and renal insufficiency. Therefore, in future pandemics, continuously monitoring patients with PAD will be crucial to prevent delayed treatment and severe short-term and long-term consequences.

Decompressive craniectomy in symptomatic intracerebral hemorrhage after ischemic stroke: a multicenter retrospective cohort study.

OBJECTIVE: Symptomatic intracerebral hemorrhage (sICH) after stroke is a devastating neurological complication. Current guidelines support a "possible benefit" of decompressive craniectomy (DC) for large supratentorial sICH with significant mass effect. METHODS: The authors conducted a retrospective study of 8 comprehensive stroke centers. They included all patients who sustained an sICH after acute ischemic stroke (AIS), as defined by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST), from January 2016 to December 2020. They compared patients who underwent DC to those who were treated with standard medical treatment to measure functional outcome at 90 days, primarily as defined by the modified Rankin Scale (mRS) and secondarily by the Glasgow Outcome Scale-Extended (GOS-E). RESULTS: Eighty-five patients were identified, 26 of whom (30.5%) underwent DC. Patients who underwent DC were younger (58 years [DC] vs 76 years [no DC], p < 0.001). No patient with a previous history of cancer underwent DC (n = 14, p = 0.004). Twenty-five patients (96.2%) in the DC group underwent thrombectomy versus 54 (91.5%) in the non-DC group (p = 0.443). Patients who underwent DC had a longer ICU stay (median [IQR] 240 [38-408] hours vs 24 [5-96] hours in non-DC patients, p = 0.002). At 90 days, 3 patients (4.1%) had obtained an mRS score of 0-2 and 10 patients (11.7%) an mRS score of 0-3. Patients who had improved functional outcome were younger (mRS score, OR 1.06, 95% CI 1.01-1.10, p = 0.012). Patients with a history of cancer had worse 90-day mRS scores (OR 8.49, 95% CI 1.54-159, p = 0.046). The rate of in-hospital mortality or discharge to hospice was significantly higher in the non-DC cohort (10 [38.5%] patients in the DC cohort vs 38 [64.4%] in the non-DC cohort, p = 0.026). Ninety days later, patients who underwent DC were more likely to have improved outcome (mRS mean rank 30.0 vs 40.0, p = 0.027). In multivariable analysis, history of cancer (OR 12.2, 95% CI 1.26-118, p = 0.031) and older age (OR 1.07, 95% CI 1.02-1.13, p = 0.011) increased the odds of worse mRS outcomes while DC did not (OR 1.34, 95% CI 0.357-5.03, p = 0.665). CONCLUSIONS: DC after sICH did not improve functional outcome at 90 days according to multivariable analysis, although younger age and absence of previous cancer history were associated with improved outcomes.

A Challenging Case of Reactive Angioendotheliomatosis.

Introduction: Reactive angioendotheliomatosis (RAE) is a rare, benign, angioproliferative disorder with poorly understood aetiopathogenesis. It is characterised by vascular occlusion that occurs in patients with coexistent systemic or autoimmune disease. Case Presentation: A 60-year-old female presented with an 8-week history of a painful, non-healing, and non-traumatic ulcer on the left thigh. Her past medical history included smoking, peripheral vascular disease (PVD) and previously treated rectal squamous cell carcinoma. The diagnosis of pyoderma gangrenosum with superimposed cellulitis was considered and treatment with oral antibiotics was initiated. Following failure to improve, a biopsy was undertaken leading to the diagnosis of RAE. The patient was referred for urgent consideration of surgical correction of PVD, but was deemed unsuitable for surgical treatment due to a poor performance status. The patient was treated with conservative measures, but her condition rapidly deteriorated and she passed away a few weeks later. Conclusion: RAE is notorious for mimicking a wide spectrum of diseases. It is an important differential diagnosis to consider in patients with non-healing ulceration and underlying systemic or autoimmune disorders. Our case raises awareness of this rare condition and the mortality that it carries if left untreated. In an attempt to reverse disease progression and mortality, we urge clinicians to attempt surgical correction of PVD even when faced with multiple comorbidities and poor performance status.

Three-Pillar Expansive Craniotomy in Children with Acute Ruptured Supratentorial Brain Arteriovenous Malformations.

OBJECTIVE: Acute rupture and hemorrhage of pediatric brain arteriovenous malformations (AVMs) may lead to cerebral herniation or intractable intracranial hypertension, necessitating emerging surgical interventions to alleviate intracranial pressure. However, there is still controversy regarding the timing of treatment for ruptured AVMs. This study aimed to assess the feasibility of utilizing three-pillar expansive craniotomy (3PEC) at different times during the treatment of pediatric ruptured supratentorial AVMs. METHODS: A retrospective analysis was conducted on all consecutive cases of acute rupture in supratentorial AVM children who underwent 3PEC at a single institution from 2020 to 2022. General information, clinical characteristics, radiological data, and prognosis were reviewed and analyzed. RESULTS: Thirteen children were included in the analysis. The intracranial pressure of all patients decreased to below 15 mmHg within 10 days. The expansion volume of the cranial cavity of the patients increased by 18.3 cm3 (95% confidence interval, 10.2-26.3; P < 0.001) compared to the hematoma volume. None of the patients required decompressive craniectomy due to intractable intracranial hypertension caused by cerebral swelling. The median waiting period for patients with delayed AVMs treatment was 8 days, during which no rebleeding occurred. CONCLUSIONS: Emergency intervention with 3PEC in children experiencing acutely ruptured supratentorial AVMs appears to be feasible. For children requiring delayed management of the AVMs, 3PEC may diminish the risk of rebleeding during the waiting period and shorten the waiting period.