Microsurgical revascularization of a symptomatic proximal vertebral artery: pilot experiences from a single center.

Background: Vertebral artery stenosis and occlusion (VASO) is a high-risk factor for posterior circulation stroke. Post-stent restenosis and drug tolerance have facilitated the exploration of microsurgical vascular reconstruction. This study aims to evaluate the safety and efficacy of microsurgical reconstruction of the proximal VA. Methods: Twenty-nine patients (25 men, aged 63.2 years) who had symptoms of posterior circulation ischemia underwent microsurgical revascularization for proximal VASO were retrospectively included in this study. Procedural complications and clinical and angiographic outcomes were reviewed. Results: Twelve, three, and five patients underwent VA endarterectomy, artery transposition, or both, respectively; seven patients underwent vertebral endarterectomy plus stent implantation; and two patients failed surgery because of the difficult exposure of the VA and the occurrence of vascular dissection. The perioperative period-related complications included seven cases of Horner's syndrome, five cases of hoarseness, and one case of chylothorax. No cases of perioperative stroke or death were reported. The mean follow-up period was 28.4 (8-62 months). Most patients improved clinically; however, the vertebrobasilar ischemia symptoms did not decrease significantly in two patients during the follow-up. Moreover, follow-up imaging was performed in all the patients, and no signs of anastomotic stenosis were reported. Conclusion: Microsurgical reconstruction is an alternative option that can effectively treat refractory proximal VASO disease and in-stent stenosis, with a high rate of postoperative vascular recirculation. Prospective cohort studies with larger sample sizes must be conducted to validate the above conclusions.

Reconstructive endovascular treatment for basilar artery trunk aneurysms: complications and clinical and angiography outcomes.

BACKGROUND: Basilar artery trunk aneurysms (BTAs) are rare intracranial aneurysms. We aim to investigate the procedural complications and clinical and angiographic outcomes of BTAs treated with reconstructive endovascular treatment (EVT). METHODS: We retrospectively reviewed the data of 111 patients with BTAs who underwent reconstructive EVT during 2013-2022. The factors associated with procedural complications and clinical and angiographic outcomes were analyzed. RESULTS: The study included 81 men and 30 women (median age 60 years). Overall, 26 (23.4%) cases presented with subarachnoid hemorrhage and 85 (76.6%) presented with unruptured aneurysms. Periprocedural ischemic and hemorrhagic complications occurred in 29 (26.1%) and 4 (3.6%) cases, respectively. The rate of favorable clinical outcomes was 83.8% (92/111) and the mortality rate was 14.4% (16/111). Angiographic follow-up data were available for 77/95 (81.1%) survivors; 57 (74.0%) and 20 (26%) aneurysms exhibited complete and incomplete obliteration, respectively. Old age, high Hunt and Hess grades (IV-V), hemorrhagic complications, and increased aneurysm size were independent risk factors for unfavorable clinical outcomes (p<0.05). Increased aneurysm size and incomplete aneurysm occlusion on immediate angiography were independent risk factors for incomplete occlusion during follow-up (p<0.05). CONCLUSION: Reconstructive EVTs are a feasible and effective treatment for BTAs but are associated with a high risk of ischemic and hemorrhagic complications and a high mortality rate. Larger aneurysms may predict unfavorable clinical outcomes and aneurysm recurrence during follow-up. Hemorrhagic complications may predict unfavorable clinical outcomes, whereas immediate complete aneurysm occlusion may predict total occlusion during follow-up.

A nomogram to predict the risk of postoperative intracranial rebleeding in patients with spontaneous intracranial hematoma.

The 30-day mortality rate of spontaneous cerebral hemorrhage (ICH) is approximately 30-50%. Surgery may improve the prognosis of patients with severe ICH. However, ICH survivors after surgery still face the risks of postoperative intracranial rebleeding (PIB), and clinical tools that accurately predict the risk of PIB occurrence are not available. Therefore, a retrospective study was performed. The population was divided into two groups according to the occurrence of PIB. Univariate and multivariate logistic regression analyses were performed to screen risk factors for PIB. Next, an early PIB risk nomogram prediction model was constructed. In addition, the impact of PIB on the prognosis of ICH was evaluated. In total, 150 ICH patients were continuously enrolled in this study; 21 patients suffered from PIB, and the overall incidence of PIB was 14.0% (21/150). Coronary heart disease history, a lower GCS score, and subarachnoid hemorrhage absence were screened as risk factors for early PIB. The early PIB risk nomogram showed good calibration and discrimination with a concordance index of 0.807 (95% confidence interval (CI), 0.715-0.899), which was confirmed to be 0.788 through bootstrapping validation. In addition, a significant difference in discharged GOS scores (P = 0.043) was observed between the PIB group and the n-PIB group. These results showed that a history of coronary heart disease, a lower GCS score, and absence of subarachnoid hemorrhage were risk factors for early PIB. In addition, the early PIB risk nomogram prediction model exhibits good discrimination and calibration. The occurrence of PIB could reduce the prognosis of ICH patients.

The Effect of Preoperative Antiplatelet Therapy on Early Postoperative Rehemorrhage and Outcomes in Patients With Spontaneous Intracranial Hematoma.

BACKGROUND AND PURPOSE: The effect of antiplatelet therapy (APT) on early postoperative rehemorrhage and outcomes of patients with spontaneous intracerebral hemorrhage (ICH) is still unclear. This study is to evaluate the effect of preoperative APT on early postoperative rehemorrhage and outcomes in ICH patients. METHODS: This was a multicenter cohort study. ICH patients undergoing surgery were divided into APT group and no antiplatelet therapy (nAPT) group according to whether patients received APT or not. Chi-square test, t-test, and Mann-Whitney U test were used to compare the differences in variables, postoperative rehematoma, and outcomes between groups. Multivariate logistics regression analysis was used to correct for confounding variables, which were different in group comparison. RESULTS: One hundred fifty ICH patients undergoing surgical treatment were consecutively included in this study. Thirty five (23.33%) people were included in the APT group, while 115 (76.67%) people were included in the nAPT group. The incidence of early postoperative rehemorrhage in the APT group was significantly higher than that in the nAPT group (25.7% VS 10.4%, p = 0.047 < 0.05). After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT had no significant effect on early postoperative rehemorrhage (p = 0.067). There was no statistical difference between the two groups in early poorer outcomes (p = 0.222) at 14 days after surgery. After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT also had no significant effect on early poorer modified Rankin Scale (mRS) (p = 0.072). CONCLUSION: In conclusion, preoperative APT appears to be safe and have no significant effect on early postoperative rehematoma and outcomes in ICH patients.

Surgical treatment for antiplatelet intracerebral hemorrhage (SAP-ICH): protocol for a prospective cohort study of emergency surgery for severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet treatment.

BACKGROUND: Despite the capability of emergency surgery to reduce the mortality of severe spontaneous intracranial hemorrhage (SSICH) patients, the effect and safety of surgical treatment for severe spontaneous intracranial hemorrhage (SSICH) patients receiving long-term oral antiplatelet treatment (LOAPT) remains unclear. In consideration of this, the cohort study is aimed at figuring out the effect and safety of emergency surgery for SSICH patients on LOAPT. METHODS: As a multicenter and prospective cohort study, it will be conducted across 7 representative clinical centers. Starting in September 2019, the observation is scheduled to be completed by December 2022, with a total of 450 SSICH patients recruited. The information on clinical, radiological, and laboratory practices will be recorded objectively. All of the patients will be monitored until death or 6 months after the occurrence of primary hemorrhage. RESULTS: In this study, two comparative cohorts and an observational cohort will be set up. The primary outcome is the effect of emergency surgery, which is subject to assessment using the total mortality and comparison in the survival rate of SSICH patients on LOAPT between surgical treatment and conservative treatment. The second outcome is the safety of surgery, with the postoperative hemorrhagic complication which is compared between the operated SSICH patients on and not on LOAPT. Based on the observation of the characteristics and outcome of SSICH patients on LOAPT, the ischemic events after discontinuing LOAPT will be further addressed, and the coagulation function assessment system for operated SSICH patients on LOAPT will be established. CONCLUSIONS: In this study, we will investigate the effect and safety of emergency surgery for SSICH patients on LOAPT, which will provide an evidence for management in the future. ETHICS AND DISSEMINATION: The research protocol and informed consent in this study were approved by the Institutional Review Board of Beijing Tiantan Hospital (KY2019-096-02). The results of this study are expected to be disseminated in peer-reviewed journals in 2023. TRIAL REGISTRATION: Name: Effect and safety of surgical intervention for severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet treatment. ChiCTR1900024406 . Date of registration is July 10, 2019.

Perinidal Angiogenesis Is a Predictor for Neurovascular Uncoupling in the Periphery of Brain Arteriovenous Malformations: A Task-Based and Resting-State fMRI Study.

BACKGROUND: Potential neurovascular uncoupling (NVU) related to perinidal angiogenesis (PA) of brain arteriovenous malformations (AVMs) may cause inappropriate presurgical mapping using functional magnetic resonance imaging (fMRI), resulting in overconfident resection and postoperative morbidity. PURPOSE: To evaluate the potential impact of PA upon fMRI blood oxygen level-dependent signal in the periphery of AVMs. STUDY TYPE: Prospective. POPULATION: Twenty-one patients with AVMs located in the primary sensorimotor cortex (SM1) undergoing task-based fMRI (hand motor), and 19 patients with supratentorial AVMs undergoing resting-state fMRI. FIELD STRENGTH/SEQUENCE: 3.0T, echo-planar, time-of-flight, and magnetization-prepared rapid gradient-echo. ASSESSMENT: The presence of PA was determined by three observers (Y.C., J.W., and X.C.) according to digital subtraction angiography and MR angiography. Interhemispheric asymmetry of fMRI activations contralateral to hand movements was evaluated with the interhemispheric ratio of the average t-value within ipsilesional SM1 to contralesional SM1. Regional homogeneity (ReHo) and fractional amplitude of low-frequency fluctuations (fALFF) were extracted from ring-shaped perinidal regions and contralateral homologous regions, and the corresponding interhemispheric ratios were calculated. The effect of PA on the interhemispheric asymmetry of motor activations, ReHo, and fALFF was estimated. STATISTICAL TESTS: Pearson analysis, paired and independent t-test, multiple linear regression, Friedman test, and factorial analysis of variance were used. RESULTS: Motor activations were significantly reduced in ipsilesional SM1 compared to contralesional SM1 (P < 0.05). The presence of PA was the independent predictor of activation loss in ipsilateral SM1(P < 0.05). Furthermore, perinidal regions exhibited reduced ReHo compared to the homologous regions (P < 0.05). PA was significantly associated with the decline of ReHo and fALFF in perinidal regions (P < 0.05, for both). DATA CONCLUSION: The presence of PA can predict perinidal NVU that may confound the interpretation of both task-based and resting-state fMRI, highlighting the importance of alternative approaches of brain functional localization in improving treatment of AVMs. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY STAGE: 2.

Emergency surgery is an effective way to improve the outcome of severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet therapy.

The necessity of emergency surgery for severe spontaneous intracerebral hemorrhage (SSICH) patients on long-term oral antiplatelet therapy (LOAPT) remains unclear. The aim of this study was to investigate the effect and safety of emergency surgery for SSICH patients on LOAPT (SSICH-LOAPT patients). In this study, a retrospective review of patients admitted to our institution for SSICH from January 2012 to December 2018 was conducted. The collected data included demographic, clinical, and surgical information. The outcome was recorded at 3 months after primary hemorrhage. The outcome of SSICH-LOAPT patients receiving emergency surgery and conservative treatment were compared. The risk of postoperative intracranial bleeding (PIB) in operated SSICH-LOAPT patients was further investigated. A total of 522 SSICH patients were retrospectively reviewed, including 181 SSICH-LOAPT patients and 269 operated patients. The total mortality and in-hospital mortality were 40.6% and 19.3%, respectively. As compared with SSICH-LOAPT patients receiving conservative treatment, the operated SSICH-LOAPT patients showed a lower total (p = 0.043) and in-hospital mortality (p = 0.024). When compared with operated patients not on LOAPT, the operated patients on LOAPT exhibited a higher rate of PIB (OR, 2.34; 95% CI 1.14-4.79; p = 0.018). As demonstrated by the multivariate logistic analysis, dual antiplatelet therapy were independent risk factors associated with PIB in operated SSICH-LOAPT patients (OR, 3.42; CI, 1.01-11.51; p = 0.047). Despite of increasing risk of PIB, emergency surgery could improve the outcome of SSICH-LOAPT patients as it could be effective in reducing mortality. Dual antiplatelet therapy was the independent risk factor related to the PIB in operated SSICH-LOAPT patients.

Evaluating the safety of early surgery for ruptured intracranial aneurysms in patients with long-term aspirin use: a propensity score matching study.

BACKGROUND: Early microsurgical clipping is recommended for ruptured intracranial aneurysms to prevent rebleeding. However, dilemma frequently occurs when managing patients with current acetylsalicylic acid (aspirin) use. This study aimed to examine whether aspirin use was associated with worse outcomes after early surgery for aneurysmal subarachnoid hemorrhage (aSAH). METHODS: We retrieved a consecutive series of 215 patients undergoing early microsurgical clipping within 72 h after aneurysmal rupture from 2012 to 2018 in the neurosurgery department of Beijing Tiantan Hospital. The medical records of each case were reviewed. Twenty-one patients had a history of long-term aspirin use before the onset of aSAH, and 194 patients did not. To reduce confounding bias, propensity score matching (PSM) was performed to balance some characteristics of the two groups. The intraoperative blood loss, postoperative hemorrhagic events, postoperative hospital stay, and functional outcome at discharge were compared between aspirin and non-aspirin group. RESULTS: We matched all the 21 patients in aspirin group with 42 patients in non-aspirin group (1:2). Potential confounding factors were corrected between the two groups by PSM. No hospital mortality occurred after surgery. No significant differences were found in intraoperative blood loss (P = 0.540), postoperative hemorrhagic events (P > 0.999), postoperative hospital stay (P = 0.715), as well as functional outcome at discharge (P = 0.332) between the two groups. CONCLUSIONS: Our preliminary results showed that long-term low-dose aspirin use was not associated with worse outcomes. Early surgery can be safe for ruptured intracranial aneurysms in patients with long-term aspirin use.

Altered Brain Structural Networks in Patients with Brain Arteriovenous Malformations Located in Broca's Area.

Focal brain lesions, such as stroke and tumors, can lead to remote structural alterations across the whole-brain networks. Brain arteriovenous malformations (AVMs), usually presumed to be congenital, often result in tissue degeneration and functional displacement of the perifocal areas, but it remains unclear whether AVMs may produce long-range effects upon the whole-brain white matter organization. In this study, we used diffusion tensor imaging and graph theory methods to investigate the alterations of brain structural networks in 14 patients with AVMs in the presumed Broca's area, compared to 27 normal controls. Weighted brain structural networks were constructed based on deterministic tractography. We compared the topological properties and network connectivity between patients and normal controls. Functional magnetic resonance imaging revealed contralateral reorganization of Broca's area in five (35.7%) patients. Compared to normal controls, the patients exhibited preserved small-worldness of brain structural networks. However, AVM patients exhibited significantly decreased global efficiency (p = 0.004) and clustering coefficient (p = 0.014), along with decreased corresponding nodal properties in some remote brain regions (p < 0.05, family-wise error corrected). Furthermore, structural connectivity was reduced in the right perisylvian regions but enhanced in the perifocal areas (p < 0.05). The vulnerability of the left supramarginal gyrus was significantly increased (p = 0.039, corrected), and the bilateral putamina were added as hubs in the AVM patients. These alterations provide evidence for the long-range effects of AVMs on brain white matter networks. Our preliminary findings contribute extra insights into the understanding of brain plasticity and pathological state in patients with AVMs.

Microsurgical outcome of unruptured giant intracranial aneurysms: A single-center experience.

Microsurgical treatment of unruptured giant intracranial aneurysms (GIAs) is challenging. Although previous studies regarded clipping as the first option to repair GIAs, quite a number of GIAs are not clippable. We conducted this study to evaluate the postoperative complications and long-term outcome of patients with unruptured GIAs treated by different microsurgical modalities. We retrospectively reviewed 505 consecutive patients with unruptured intracranial aneurysms (UIAs) who were surgically treated in our department from 2012 to 2015. Patients with UIAs of which diameter ≥2.5 cm were studied. We reported the characteristics of patients and GIAs. Postoperative major complications were observed, and patient functional status were assessed with the modified Rankin Scale (mRS) at discharge and at the last follow-up. Twenty-one patients with unruptured GIAs were analysed, of whom 12 patients were treated by clipping, whereas 9 patients with unclippable aneurysms were treated by trapping or parent vessel occlusion. Fourteen aneurysms were saccular, and 7 were fusiform or serpentine. The mean aneurysm size was 3.7 ±â€¯1.5 cm. After surgery, major complications were observed in 13 of the 21 (61.9%) patients. One (4.8%) patient died during hospital. After a mean 5.2-year follow-up, 9 (75.0%) patients treated by clipping and 7 (77.8%) treated by non-clipping experienced a good outcome (mRS ≤2). We found no significant difference in both postoperative complications and long-term outcome between clipping and non-clipping group. Favorable prognosis can be obtained in most patients with unruptured GIAs treated by appropriate microsurgical modality.

A Tractography-Based Grading Scale of Brain Arteriovenous Malformations Close to the Corticospinal Tract to Predict Motor Outcome After Surgery.

Background: Surgical decision-making for brain arteriovenous malformations (AVMs) close to the corticospinal tract (CST) is always challenging. The purpose of this study was to develop a tractography-based grading scale to improve preoperative risk prediction and patient selection. Methods: We analyzed a consecutive, surgically treated series of 90 patients with AVMs within a 10-mm range from the CST demonstrated by preoperative diffusion tensor tractography. Poor motor outcome was defined as persistent postoperative limb weakness. We examined the predictive ability of nidus-to-CST distance (NCD), the closest CST level (CCL), deep perforating artery supply, as well as variables of the supplemented Spetzler-Martin grading system. Three logistic models were derived from different multivariable logistic regression analyses, of which the most predictive model was selected to construct a prediction grading scale. Receiver operating characteristic analysis was conducted to test the predictive accuracy of the grading scale. Results: Twenty-one (23.3%) patients experienced persistent postoperative limb weakness after a mean 2.7-year follow-up. The most predictive logistic model showed NCD (P = 0.001), CCL (P = 0.017), patient age (P = 0.004), and AVM diffuseness (P = 0.021) were independent predictors for poor motor outcome. We constructed the CLAD grading scale incorporating these predictors. The predictive accuracy of the CLAD grade was better compared with the supplemented Spetzler-Martin grade (area under curve = 0.84 vs. 0.68, P = 0.023). Conclusions: Both NCD and CCL predict motor outcome after resection of AVMs close to the CST. We propose the CLAD grading scale as an effective risk-prediction tool in surgical decision-making. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT01758211 and NCT02868008.

Intracranial aneurysm rupture score may correlate to the risk of rebleeding before treatment of ruptured intracranial aneurysms.

BACKGROUND AND OBJECTIVE: Aneurysm rebleeding after rupture can result in a catastrophic outcome with high mortality and morbidity. In this study, we evaluated the correlation of IARS (intracranial aneurysm rupture score) and aneurysm rebleeding. The aim of this study was to explore the clinical utility of IARS for better clinical decision-making. METHOD: The patients with ruptured intracranial aneurysms between January 2017 and September 2018 were reviewed. Propensity scoring match was performed to construct a cohort. The morphological and hemodynamic parameters were obtained. The difference between stable aneurysms and rebleeding aneurysms was compared. Subsequently, the correlation of IARS and aneurysm rebleeding was studied. RESULTS: The matching process constructed a cohort, including 5 rebleeding aneurysms and 15 stable aneurysms. By comparing the difference between stable aneurysms and rebleeding aneurysms, the statistical significance was found in diameter of neck (p = 0.036), aspect ratio (p = 0.004) and size ratio (p = 0.029), normalized wall shear stress average (p = 0.026), low shear area ratio (p = 0.028), oscillatory shear index (OSI) (p = 0.031), and deviated angle (p = 0.025). The IARS here had a strong correlation with the aneurysm rebleeding, and the interval from the first bleeding to the rebleeding tended to shorten with the increase of IARS (R = 0.715, p = 0.027). IARS had a good predicting value for the aneurysm rebleeding (area under the curve = 0.756, p < 0.001). CONCLUSION: Based on this preliminary study, intracranial aneurysm rupture score may correlate to the rebleeding in ruptured aneurysms. For ruptured aneurysms with high IARS scores, surgery should be given priority, and medical treatment is not recommended.

Symptomatic and silent cerebral infarction following surgical clipping of unruptured intracranial aneurysms: incidence, risk factors, and clinical outcome.

Cerebral infarction (CI) associated with clipping of unruptured intracranial aneurysms (UIAs) has not been completely studied. The role of individual and operative characteristics is not known, and the risk of silent CI has not been well described. To determine the incidence, risk factors, and clinical outcome of postoperative CI, we retrospectively analyzed 388 consecutive patients undergoing clipping of UIAs between January 2012 and December 2015. We reviewed the pre- and postoperative computed tomography (CT) images of each patient. Postoperative CI was defined as a new parenchymal hypodensity in the vascular territory of treated artery. Patient-specific, aneurysm-specific, and operative variables were analyzed as potential risk factors. Functional outcome at discharge was assessed with the modified Rankin Scale (mRS). Postoperative CI was found in 49 (12.6%) patients, 29 of whom manifested neurological deficits. The incidences of symptomatic stroke and silent CI were 7.5 and 5.2%, respectively. Multivariate analysis showed that larger aneurysm size and history of hypertension were significantly associated with CI. Disability (mRS > 2) rate was 42.9% among patients with CI, which was substantially higher than that among patients without (0.9%). In conclusion, the incidence of CI following clipping of UIAs was not low. Larger aneurysm size and history of hypertension were independent risk factors. Postoperative symptomatic stroke correlated with an extremely high risk of disability. Silent CI was seemingly nondisabling, but the possible cognitive consequence is pending.

Relationship of A1 Segment Hypoplasia with the Radiologic and Clinical Outcomes of Surgical Clipping of Anterior Communicating Artery Aneurysms.

OBJECTIVE: This study aims to assess whether the A1 segment hypoplasia is a risk factor for unfavorable radiologic and clinical outcomes of surgical clipping anterior communicating artery (ACoA) aneurysm. METHODS: We retrospectively reviewed 251 patients with ACoA aneurysm who underwent surgical clipping in Beijing Tiantan Hospital between September 2011 and September 2016. Their clinical and radiologic features, as well as clinical outcomes, were reviewed. In addition, univariate and multivariate logistic regression analysis was performed to identify independent risk factors for the postoperative infarction and unfavorable clinical outcomes of surgical clipping ACoA aneurysm. RESULTS: The incidence of A1 segment hypoplasia was 49.8% (125 of 251 patients). Univariate analysis showed that multiple aneurysm (P = 0.025), diameter of aneurysm (P = 0.040), and A1 segment hypoplasia (P = 0.010) were associated with anterior cerebral artery (ACA) territories infarction, and A1 segment hypoplasia (P = 0.002) is significantly correlated with unfavorable clinical outcomes of surgical clipping ACoA aneurysm. Moreover, multivariate analysis showed that multiple aneurysm (P = 0.038; odds ratio [OR], 2.571), diameter of aneurysm (P = 0.034; OR, 1.097), and A1 segment hypoplasia (P = 0.007; OR, 3.619) were strongly independent risk factors for ACA territories infarction. In addition, Hunt and Hess scores (P = 0.036; OR, 2.326) and A1 segment hypoplasia (P = 0.002; OR, 2.873) are significant independent risk factors for unfavorable clinical outcomes of surgical clipping ACoA aneurysm. CONCLUSIONS: A1 segment hypoplasia is a significant independent risk factor for unfavorable clinical outcomes of surgical clipping ACoA aneurysm and ACA infarction after surgery.