Shifts in Diagnostic Testing for Headache in the Emergency Department, 2015 to 2021.

Importance: Subarachnoid hemorrhage is typically diagnosed by noncontrast head computed tomography (CT); lumbar puncture is recommended if computed tomography is nondiagnostic, although CT cerebral angiography has been promoted as an alternative to lumbar puncture in this diagnostic pathway. The outcomes of this debate in practice have not been studied. Objective: To determine whether CT cerebral angiography use has increased in lieu of lumbar puncture among emergency department (ED) patients with headache, with an increase in unruptured intracranial aneurysm detection. Design, Setting, and Participants: This retrospective cohort study took place in 21 community EDs of an integrated health care system in Northern California between 2015 and 2021. Participants were adult (aged >17 years) health plan members with a chief concern of headache. Exclusions were prior diagnoses of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral arteriovenous malformation, or cerebrospinal fluid shunt. Data were analyzed from October to November 2023. Exposures: CT cerebral angiography and/or lumbar puncture during the ED encounter. Main Outcomes and Measures: Primary and secondary outcomes were 14-day and 90-day unruptured intracranial aneurysm detection, respectively. Safety outcomes were missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. The annual incidence of unruptured intracranial aneurysm detection was normalized to the incidence of subarachnoid hemorrhage (UIA:SAH ratio). Average annualized percentage changes were quantified using joinpoint regression analysis. Results: Among 198 109 included ED encounters, the mean (SD) age was 47.5 (18.4) years; 140 001 patients (70.7%) were female; 29 035 (14.7%) were Black or African American, 59 896 (30.2%) were Hispanic or Latino, and 75 602 (38.2%) were White. Per year, CT cerebral angiography use increased (18.8%; 95% CI, 17.7% to 20.3%) and lumbar punctures decreased (-11.1%; 95% CI, -12.0% to -10.4%), with a corresponding increase in the 14-day UIA:SAH ratio (3.5%; 95% CI, 0.9% to 7.4%). Overall, computed tomography cerebral angiography use increased 6-fold relative to lumbar puncture, with a 33% increase in the detection of UIA. Results were similar at 90 days and robust to sensitivity analyses. Subarachnoid hemorrhage (1004 cases) and bacterial meningitis (118 cases) were misdiagnosed in 5% and 18% of cases, respectively, with no annual trends (P = .34; z1003 = .95 and P = .74; z117 = -.34, respectively). Conclusions and Relevance: In this cohort study of ED patients with headache, increases in CT cerebral angiography use were associated with fewer lumbar punctures and higher detection of unruptured intracranial aneurysms, with no significant change in missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. While this shift in diagnostic strategy appeared safe in the short-term, the long-term consequences remain unclear.

Safety of local anesthesia in endovascular treatment of Aneurysms: A systematic review and Meta-Analysis.

BACKGROUND: Endovascular treatment of intracranial aneurysms (EVTIAs) is increasingly popular due to its minimally invasive nature and high success rate. While general anesthesia (GA) has been the historical preference for EVTIAs, there's growing interest in local anesthesia (LA). However, concerns persist about LA safety for EVTIAs. Therefore, we conducted a systematic review and meta-analysis to assess LA safety for EVTIAs. METHODS: Following PRISMA guidelines, we searched PubMed, Embase, and Web of Science databases. Pooled analysis with 95 % confidence intervals (CI) assessed effects, I2 statistics gauged heterogeneity, and a random-effects model was adopted. Conversion to GA, neurological or procedure-related complications, intraoperative intracranial hemorrhagic complications (IIHC), and mortality were assessed. Subanalyses for ruptured and unruptured cases were performed. RESULTS: The analysis included eleven studies, 2,133 patients, and 2,369 EVTIAs under LA. Conversion to GA rate was 1 % (95 %CI: 0 to 2 %). Neurological or procedure-related complications rate was 13 % (95 % CI: 8 % to 17 %). IIHC analysis revealed a rate of 1 % (95 % CI: 1 % to 2 %). The mortality rate was 0 % (95 %CI: 0 % to 0 %). Subanalyses revealed similar rates in ruptured and unruptured subgroups, except for a slightly high rate of complications and IIHC in the ruptured subgroup. CONCLUSION: Findings indicate that EVTIA under LA is safe, with low conversion and mortality rates, even for ruptured aneurysms. Complications rates, also in IIHC rates, are comparable to those reported for GA, emphasizing LA's comparable safety profile in EVTIAs. Considering these promising outcomes, the decision to opt for the LA approach emerges as meaningful and well-suited for the endovascular treatment of aneurysms. Beyond its safety, LA introduces inherent supplementary advantages, including shortened hospitalization periods, cost-effectiveness, and an expedited patient recovery process.

miR-30c-5p Protects from Brain Injury After Cerebral Aneurysmal Subarachnoid Hemorrhage Through the ATG5/ATG12 Pathway.

Objective: To assess the role of miR-30c-5p in subarachnoid hemorrhage (SAH) and its possible mechanism. Methods: We established a SAH model by injecting fresh arterial non-heparinized blood into the anterior cistern of the optic chiasm of healthy Sprague-Dawley rats. Next, we treated the rats with a miR-30c-5p inhibitor or miR-30c-5p mimics. We then assessed behavior, serum lactate dehydrogenase levels, albumin expression, neuronal degeneration, neuronal apoptosis, neuronal survival, and the cerebral edema index in the SAH model rats. We identified downstream target genes of miR-30c-5p using the Targetscan database and confirmed them via luciferase reporter assay. Finally, we assessed the effect of these targeted genes on brain injury in SAH rats through a recovery assay. Results: Our results showed that the overexpression of miR-30c-5p in brain tissue 24h after SAH prevented brain injury, reduced inflammation levels and nerve function scores, inhibited neuronal apoptosis, and improved neuronal survival. Meanwhile, inhibiting miR-30c-5p yielded opposite effects. Two genes related to the autophagy pathway, ATG5 and ATG12, were identified as miR-30c-5p downstream target genes. Silencing ATG5 and ATG12 alleviated brain injury induced by knocking down miR-30c-5p. Conclusion: Our findings suggest that miR-30c-5p protects from SAH-induced brain injury by inhibiting the ATG5/ATG12 pathway and it may serve as a new diagnostic maker or target for treatment of SAH patients.

Vitamin D deficiency promotes intracranial aneurysm rupture.

Intracranial aneurysm rupture causes severe disability and high mortality. Epidemiological studies show a strong association between decreased vitamin D levels and an increase in aneurysm rupture. However, the causality and mechanism remain largely unknown. In this study, we tested whether vitamin D deficiency promotes aneurysm rupture and examined the underlying mechanism for the protective role of vitamin D against the development of aneurysm rupture utilizing a mouse model of intracranial aneurysm. Mice consuming a vitamin D-deficient diet had a higher rupture rate than mice with a regular diet. Vitamin D deficiency increased proinflammatory cytokines in the cerebral arteries. Concurrently, vitamin D receptor knockout mice had a higher rupture rate than the corresponding wild-type littermates. The vitamin D receptors on endothelial and vascular smooth muscle cells, but not on hematopoietic cells, mediated the effect of aneurysm rupture. Our results establish that vitamin D protects against the development of aneurysmal rupture through the vitamin D receptors on vascular endothelial and smooth muscle cells. Vitamin D supplementation may be a viable pharmacologic therapy for preventing aneurysm rupture.

Misdiagnosis of a Dissecting Aneurysm as a Cerebral Aneurysm: A Preoperative Case Report.

Background: Intracranial Aneurysm (IA) is characterized by abnormal dilation of intracranial arterial walls, a tumor-like protrusion, often occurring in the anterior communicating artery. Intracranial Dissecting Aneurysm (IDA) refers to hemodynamic changes within intracranial arteries, leading to ruptures between blood vessel walls, disrupting normal arterial blood flow within the arterial lumen. IDA is relatively uncommon in the anterior circulation. To date, there have been no reported cases of dissecting aneurysms misdiagnosed as cerebral aneurysms before surgical intervention. This case report presents a patient's detailed clinical diagnosis, treatment, and imaging data. Case Presentation: A 56-year-old female patient experienced post-work headaches. Cranial Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Digital Subtraction Angiography (DSA) examinations revealed a small hemorrhage following infarction and aneurysms in the initial part of the right A2 segment. Initially, the patient was diagnosed with a ruptured cerebral aneurysm, accompanied by hemorrhage and cerebral vasospasm (cerebral infarction in the right frontal lobe). Subsequently, cerebral aneurysm clipping was performed. During surgery, it was observed that the aneurysm originated from the ipsilateral A2 starting site and displayed dissecting-like changes extending towards the distal end. The final diagnosis confirmed an aneurysm evolving from intracranial artery dissection. Artificial meninges were employed to encase and clip the aneurysm. Post-surgery, the patient was transferred to a superior hospital for A3 bypass. Follow-up assessments indicated a successful recovery. Conclusion: Cerebral aneurysms typically involve larger arteries with rare possibilities of stenosis. Moreover, the cerebral artery is relatively small, making it challenging for Brain Computed Tomography Angiography (CTA) to distinguish true and false lumen within blood vessels. The diagnosis of dissecting aneurysms is difficult and often susceptible to clinical misdiagnosis.

Genetically predicted coffee and tea consumption and risk of intracranial aneurysm.

OBJECTIVES: Observational studies have shown associations between coffee and tea consumption and risk of intracranial aneurysm (IA). However, the results are not consistent. We conducted a Mendelian randomization study to clarify whether genetically predicted coffee and tea consumption has a causal effect on IA and its subtypes. METHODS: Genetic variants associated with coffee and tea consumption (cups/day) were obtained from large genome-wide association studies (GWASs), up to 349,376 subjects. Summary-level data for IA were adopted from a GWAS in 79,429 subjects (23 cohorts, 7495 cases, and 71,934 controls). RESULTS: Genetically predicted coffee consumption was associated with a higher risk of any IA and aneurysmal subarachnoid hemorrhage (SAH), but not with unruptured IA. The ORs per 1 cup/day increase in genetically predicted coffee consumption were 1.42 (95% CI: 1.09-1.86; P = 0.010) for IA, 1.51 (95% CI: 1.13-2.03; P = 0.005) for aneurysmal SAH, and 1.20 (95% CI: 0.74-1.96; P = 0.460) for unruptured IA. Genetically predicted tea consumption was not associated with risk of any IA and its subtypes (P > 0.05). The associations remained consistent in sensitivity analyses, and no evidence of pleiotropy was detected. CONCLUSIONS: Our study provides evidence to support that coffee consumption may increase the risk of IA and associated hemorrhage. Coffee should be limited for those at high risk of IA and associated hemorrhage.

Immediate effects of electroacupuncture in oculomotor nerve palsy following brainstem infarction: A case report.

INTRODUCTION: Research has demonstrated that electroacupuncture (EA) stimulation of paralyzed muscles significantly improves nerve regeneration and functional recovery. DESCRIPTION: An 81-year-old man with no history of diabetes mellitus or hypertension presented with a history of brainstem infarction. Initially, the patient had medial rectus palsy in the left eye and diplopia to the right in both eyes, which almost returned to normal after six sessions of EA. METHODS: The CARE guidelines informed the case study report. The patient was diagnosed with oculomotor nerve palsy (ONP) and photographed to document ONP recovery after treatment. The selected acupuncture points and surgical methods are listed in the table. DISCUSSION: Pharmacological treatment of oculomotor palsy is not ideal, and its long-term use has side effects. Although acupuncture is a promising treatment for ONP, existing treatments involve many acupuncture points and long cycles, resulting in poor patient compliance. We chose an innovative modality, electrical stimulation of paralyzed muscles, which may be an effective and safe complementary alternative therapy for ONP.

The markers and risk stratification model of intracranial aneurysm instability in a large Chinese cohort.

Intracranial aneurysm is the leading cause of nontraumatic subarachnoid hemorrhage. Evaluating the unstable (rupture and growth) risk of aneurysms is helpful to guild decision-making for unruptured intracranial aneurysms (UIA). This study aimed to develop a model for risk stratification of UIA instability. The UIA patients from two prospective, longitudinal multicenter Chinese cohorts recruited from January 2017 to January 2022 were set as the derivation cohort and validation cohort. The primary endpoint was UIA instability, comprising aneurysm rupture, growth, or morphology change, during a 2-year follow-up. Intracranial aneurysm samples and corresponding serums from 20 patients were also collected. Metabolomics and cytokine profiling analysis were performed on the derivation cohort (758 single-UIA patients harboring 676 stable UIAs and 82 unstable UIAs). Oleic acid (OA), arachidonic acid (AA), interleukin 1ß (IL-1ß), and tumor necrosis factor-α (TNF-α) were significantly dysregulated between stable and unstable UIAs. OA and AA exhibited the same dysregulated trends in serums and aneurysm tissues. The feature selection process demonstrated size ratio, irregular shape, OA, AA, IL-1ß, and TNF-α as features of UIA instability. A machine-learning stratification model (instability classifier) was constructed based on radiological features and biomarkers, with high accuracy to evaluate UIA instability risk (area under curve (AUC), 0.94). Within the validation cohort (492 single-UIA patients harboring 414 stable UIAs and 78 unstable UIAs), the instability classifier performed well to evaluate the risk of UIA instability (AUC, 0.89). Supplementation of OA and pharmacological inhibition of IL-1ß and TNF-α could prevent intracranial aneurysms from rupturing in rat models. This study revealed the markers of UIA instability and provided a risk stratification model, which may guide treatment decision-making for UIAs.

Current management of subarachnoid hemorrhage in a northern urban Chinese population: a multi-center surveillance study.

OBJECTIVE: The current management of subarachnoid hemorrhage (SAH) in the urban Chinese population remains unclear and the relevant literature is still lacking. Therefore, this work aimed to investigate the recent clinical practice in the management of spontaneous SAH in an urban population-based setting. PATIENTS AND METHODS: From 2009 to 2011, the China Epidemiology Research In Subarachnoid Hemorrhage (CHERISH) project, which was a two-year prospective, multi-center, population-based, case-control study, was performed in the northern urban Chinese population. SAH cases were described in terms of their features, clinical management, and in-hospital outcomes. RESULTS: Totally of 226 cases were enrolled with a final diagnosis of primary spontaneous SAH (65% of females; mean age, 58.5±13.2 years; range, 20-87 years). Among them, 92% of these patients received nimodipine, while 93% took mannitol. Meanwhile, 40% of them received traditional Chinese medicine (TCM), while 43% took neuroprotective agents. Endovascular coiling was applied in 26% of 98 angiography-confirmed intracranial aneurysms (IA) cases, while neurosurgical clipping was in 5% of them. CONCLUSIONS: Our findings on the management of SAH in the northern metropolitan Chinese population reveal that nimodipine is an effective medical therapy with a high rate of use. There is also a high utilization rate of alternative medical interventions. Endovascular coiling occlusion is more common than neurosurgical clipping. Therefore, regionally traditional therapy may be a key factor for the difference in the treatment of SAH between northern and southern China.

And don't forget your anti in-stent stenosis pill! Commentary on 'Factors associated with in-stent stenosis after cerebral aneurysm embolization using a Pipeline embolization device' by Flores-Milan et al.

In their INR study, Flores-Milan et al. present a retrospective single-centre study that aimed to investigate and determine some of the factors associated with in-stent stenosis (ISS) after intracranial aneurysm (IA) embolization using a commercially available flow diverter stent (FD). The retrospective analyses included ruptured and unruptured intracranial aneurysms treated with standalone flow diverter stent implantation or initial coil obliteration with the FD device placed subsequently two weeks after initial treatment. The article's methodology was carefully tailored to demystify the unknown pathophysiological mechanism behind the entity of interest called in-stent stenosis. Study outcomes also included angiographic evaluation of aneurysm occlusion thrombotic and hemorrhagic events. The authors reported excellent technical and clinical results altogether. The achieved angiographic occlusion rates resonate with the current obliteration results reported in the literature. Mortality and morbidity are congruent with previously published results and were 5.3% and 1.1%, respectively.

Effect of combined fenestration of lamina terminalis and Liliequist membrane during surgical clipping on the incidence of chronic hydrocephalus in patients with anterior circulation ruptured aneurysms.

PURPOSE: To explore the effects of combined fenestration of lamina terminalis and Liliequist membrane during surgical clipping on the occurrence of chronic hydrocephalus in patients with ruptured anterior circulation aneurysm. METHODS: Clinical data of 78 patients with anterior circulation ruptured aneurysms who were treated between June 2018 and January 2021 were retrospectively analyzed. Based on the surgical treatment, patients were divided into 3 groups: clipping group (26 cases); fenestration group (lamina terminalis fenestration combined with clipping, 28 cases); and combination group (lamina terminalis fenestration and Liliequist membrane opening combined with clipping, 24 cases). The incidence of postoperative chronic hydrocephalus, the postoperative hydrocephalus shunt rate, and the Glasgow prognostic score (GOS) were evaluated. RESULTS: The incidence of postoperative chronic hydrocephalus in the combined group (16.6 %, 4/24) was significantly lower than that in the clipping group (46.1 %, 12/26) and the fenestration group (35.7 %, 10/28; P < 0.05). The shunt rate of chronic hydrocephalus in the combined group (4.1 %, 1/24) was significantly lower than that in the clipping group (30.7 %, 8/26) and the fenestration group (17.8 %, 5/28; P < 0.05). The rate of postoperative GOS score of 5 in the combined group (75.0 %, 18/24) was significantly higher than that in the clipping group (23.0 %, 6/26) and the fenestration group (57.1 %, 16/28; P < 0.05). CONCLUSION: Aneurysm clipping combined with lamina terminalis fenestration and Liliequist membrane opening can reduce the occurrence of chronic hydrocephalus and the rate of chronic hydrocephalus shunt surgery, thereby improving the prognosis of patients.

Intracranial aneurysms: The era of endovascular intervention in Australia.

Intracranial aneurysms (ICAs) can be treated by surgical or endovascular techniques. Endovascular procedures have become common in many specialties, including neurosurgery. In this paper we aim to examine the overall numbers and trends in treatment of IA in Australia. This study was a ten-year retrospective analysis of the Medicare Benefits Schedule (MBS) and Australian Institute of Health and Welfare (AIHW) National Hospital Morbidity databases. These databases were searched for codes corresponding to clipping of ICAs and endovascular coiling of ICAs from the financial years 2008-2009 to 2018-2019. The total number of procedures increased from 2.25 to 3.37 per 100,000 from 2008 to 2009 to 2018-2019 financial years in the MBS database and 7.90 to 10.35 per 100,000 people in the AIHW database for the same financial years. The rate of change of MBS was 0.12 (0.08- 0.16, p < 0.0001) and for AIHW 0.23 (0.19- 0.28, p < 0.0001). Endovascular coiling reached parity with surgical clipping in the 2010-2011 financial year. Women were over twice as likely as men to be treated. The frequency of treatment per 100,000 people peaked in the 55-64 year-old age group. Tasmania performed the most number of treatments per capita compared to other Australian states and territories, according to the MBS database. These figures from Australian databases are in line with other countries from studies around the world that examine preferences of intervention and demographics.

Development and assessment of machine learning models for predicting recurrence risk after endovascular treatment in patients with intracranial aneurysms.

Intracranial aneurysms (IAs) remain a major public health concern and endovascular treatment (EVT) has become a major tool for managing IAs. However, the recurrence rate of IAs after EVT is relatively high, which may lead to the risk for aneurysm re-rupture and re-bleed. Thus, we aimed to develop and assess prediction models based on machine learning (ML) algorithms to predict recurrence risk among patients with IAs after EVT in 6 months. Patient population included patients with IAs after EVT between January 2016 and August 2019 in Hunan Provincial People's Hospital, and an adaptive synthetic (ADASYN) sampling approach was applied for the entire imbalanced dataset. We developed five ML models and assessed the models. In addition, we used SHapley Additive exPlanations (SHAP) and local interpretable model-agnostic explanation (LIME) algorithms to determine the importance of the selected features and interpret the ML models. A total of 425 IAs were enrolled into this study, and 66 (15.5%) of which recurred in 6 months. Among the five ML models, gradient boosting decision tree (GBDT) model performed best. The area under curve (AUC) of the GBDT model on the testing set was 0.842 (sensitivity: 81.2%; specificity: 70.4%). Our study firstly demonstrated that ML-based models can serve as a reliable tool for predicting recurrence risk in patients with IAs after EVT in 6 months, and the GBDT model showed the optimal prediction performance.

Cannabis Abuse and Perioperative Complications After Treatment of Intracranial Aneurysms: A Nationwide Analysis.

OBJECTIVE: In the present retrospective cohort analysis, we examined the differences in baseline characteristics and peri- and postoperative outcomes stratified by 3 groups: cannabis abuse or dependence versus none, surgical versus endovascular treatment, and unruptured and ruptured intracranial aneurysms. METHODS: A study population of 26,868 patients was defined using the 2009-2016 National Inpatient Sample database. The baseline characteristics were compared between the cannabis and no-cannabis groups, and the traits that differed significantly were factored into the multivariate analysis using 1:1 propensity score matching. The matched groups were analyzed to compare the cannabis and no-cannabis cohorts for the following endpoints: mortality, length of stay, discharge disposition, total hospital charges, and several peri- and postoperative outcomes. RESULTS: In the surgically and endovascularly treated groups for unruptured intracranial aneurysms, those in the cannabis group were more likely to be male and younger and to smoke tobacco than were those in the no-cannabis group. After matching, no significant endpoint differences were noted. Similarly, in the surgically and endovascularly treated ruptured aneurysm groups, those in the cannabis group were more likely to be male and younger and to smoke tobacco. After matching, the cannabis group within the endovascular treatment group had had a longer length of stay and were more likely to have developed any hydrocephalus, obstructive hydrocephalus, sepsis, and acute kidney injury. Those in the cannabis group who had undergone surgery were more likely to have developed any hydrocephalus, specifically, communicating hydrocephalus. CONCLUSIONS: The cannabis group with ruptured intracranial aneurysms was more likely to experience certain adverse outcomes after surgical or endovascular treatment compared with the no-cannabis group. However, such was not the case for cannabis abusers treated for unruptured aneurysms.

Coenzyme Q10 inhibits intracranial aneurysm formation and progression in a mouse model.

BACKGROUND: The aim of this study was to investigate the effect of coenzyme Q10 (CoQ10), a commonly used nutritional supplement, on intracranial aneurysm (IA) initiation and progression in a mouse model, as well as the mechanism. METHODS: Hydrogen peroxide (H2O2) was used to treat mouse-derived vascular smooth muscle cells (VSMCs) to induce oxidative injury, followed by incubation with CoQ10. In the mouse IA model established by elastase injection, CoQ10 was orally administered at 10 mg/kg every other day for 14 days, during which the incidence of IA, rupture rate, symptom-free survival, and systolic blood pressure were recorded. RESULTS: CoQ10 promoted the expression of nuclear factor erythroid 2-related factor 2 and antioxidant enzymes. In H2O2-treated VSMCs, reactive oxygen species and cell apoptosis were reduced by CoQ10. In IA mice, CoQ10 treatment decreased the rupture rate of IA, improved the symptom-free survival, and reduced systolic blood pressure. Macrophage infiltration and expression of pro-inflammatory cytokines in the cerebral arteries were mitigated by CoQ10 treatment. CONCLUSIONS: CoQ10 is effective in reducing oxidative stress in VSMCs, thereby attenuating IA formation and rupture in mice. CoQ10 also alleviates inflammation and restores normal phenotypes of VSMCs in the cerebral arteries. Our data suggest that CoQ10 is a potentially effective drug for managing IA. IMPACT: To investigate the effect of CoQ10, a commonly used nutritional supplement, on IA initiation and progression in a mouse model, as well as the mechanism. CoQ10 promoted the expression of Nrf2 and antioxidant enzymes. In H2O2-treated VSMCs, ROS and cell apoptosis were reduced by CoQ10. CoQ10 is effective in reducing oxidative stress in VSMCs, thereby attenuating IA formation and rupture in mice.

Adjuvant hyperbaric oxygen treatment of acute brain herniation after microsurgical clipping of a recurring cerebral aneurysm: a case report.

INTRODUCTION: Acute brain herniation is a life-threatening neurological condition that occasionally develops due to severe complications following cerebral aneurysm clipping. Strategies for managing acute brain herniation have not improved substantially during the past decade. Hyperbaric oxygen treatment (HBOT) may alleviate harmful effects of cerebral hypoxia, which is one of the most important pathophysiological features of acute brain herniation and, therefore, may be useful as an adjuvant therapy for acute brain herniation. A case treated with adjuvant HBOT is reported. CASE REPORT: A 60-year-old asymptomatic man presented with a recurring left middle cerebral artery bifurcation aneurysm with previous stent-assisted embolisation. After craniotomy for surgical clipping of the aneurysm, disturbance of consciousness and right hemiplegia occurred. Computed tomography (CT) images suggested simultaneous cerebral ischaemia and intracranial haemorrhage. Pharmacologic treatment resulted in no improvement. A CT scan acquired five days after surgery showed uncal and falcine herniation. HBOT was administered five days after surgery, and the patient's condition dramatically improved. He became conscious, and his hemiplegia improved following seven sessions of HBOT. Simultaneously, CT images showed regression of the acute brain herniation. CONCLUSIONS: The patient had recovered completely at one year post-treatment. HBOT may be effective in the treatment of acute brain herniation following cerebral aneurysm clipping.

YouTube as a source of patient information on brain aneurysms: a content-quality and audience engagement analysis.

INTRODUCTION: The internet allows patients to access a vast amount of health information. We aimed to evaluate the credibility of YouTube videos that members of the public are accessing on brain aneurysms, and to evaluate what characteristics drive audience engagement. MATERIAL AND METHODS: The first 50 videos for each of the following search terms were taken for analysis: 'brain aneurysm', 'cerebral aneurysm' and 'intracranial aneurysm'. The quality of each video was evaluated by two neurosurgeons and two medical students independently using the Journal of the American Medical Association (JAMA) and the DISCERN instruments. Qualitative and quantitative video data was analysed for quality and audience engagement. Inter-rater agreement was ascertained. RESULTS: Out of a total of 150 videos, 70 met the inclusion criteria. The mean total DISCERN score was 36.5 ± 8.4 (out of 75 points), indicating that the videos were of poor quality. The mean JAMA score was 2.7 ± 0.7 (out of 4 points). Inter-rater agreement between the four raters was excellent (intraclass correlation coefficient 0.90 for DISCERN and 0.93 for JAMA). Most videos were uploaded by hospitals (50%) or educational health channels (30%). Videos had a higher number of average daily views when they included animation (P = 0.0093) and diagrams (P = 0.0422). CONCLUSIONS: YouTube is a poor source of patient information on brain aneurysms. Our quality and audience engagement analysis may help content creators (i.e. hospital staff and physicians) to create more holistic, educational and engaging medical videos concerning brain aneurysms. Physicians could usefully refer their patients to the highest quality videos that we have found.

Effect of adjunctive lidocaine-based scalp block and laryngotracheal local anesthesia vs general anesthesia only on plasma and cerebrospinal fluid pro-inflammatory cytokine concentrations in patients with cerebral aneurysm: a randomized controlled trial.

AIM: To compare the effect of adjunctive lidocaine-based scalp block and laryngotracheal local anesthesia vs general anesthesia only on pro-inflammatory cytokine concentrations in patients with non-ruptured brain aneurysms undergoing elective open surgery. METHODS: This parallel, randomized, controlled, open-label trial was conducted at Clinical Hospital Center Zagreb between March 2019 and March 2020. At the beginning of anesthesia, lidocaine group received 40 mg of 2% lidocaine for laryngotracheal topical anesthesia and 4 mg/kg for the scalp block. Control group underwent general anesthesia only. Plasma concentrations of IL-6, TNF-α, and IL-1ß were measured before anesthesia (S0); at the incision (S1); at the end of surgery (S2); 24 hours postoperatively (S3). Cerebrospinal fluid (CSF) cytokine concentrations were measured at the incision (L1) and the end of surgery (L2). RESULTS: Forty patients (each group, 20) were randomized; 37 were left in the final analysis. IL-6 plasma concentrations increased significantly compared with baseline at S3 in lidocaine group, and at S2 and S3 in control group. In both groups, changes in TNF-α and IL-1ß were not significant. CSF cytokine concentrations in lidocaine group did not change significantly; in control group IL-6 and IL-1ß were significantly higher at L2 than at L1. CSF IL-6 in control group significantly increased at L2, but TNF-α and IL-1ß did not. No differences in clinical outcome and complication rates were observed. CONCLUSION: Adjunctive lidocaine-based scalp block and laryngotracheal local anesthesia might attenuate CSF IL-6 concentration increase in patients with brain aneurysm.

Effectiveness comparisons of drug therapies for postoperative aneurysmal subarachnoid hemorrhage patients: network meta­analysis and systematic review.

OBJECTIVE: To compare the effectiveness of various drug interventions in improving the clinical outcome of postoperative patients after aneurysmal subarachnoid hemorrhage (aSAH) and assist in determining the drugs of definite curative effect in improving clinical prognosis. METHODS: Eligible Randomized Controlled Trials (RCTs) were searched in databases of PubMed, EMBASE, and Cochrane Library (inception to Sep 2020). Glasgow Outcome Scale (GOS) score, Extended Glasgow Outcome Scale (GOSE) score or modified Rankin Scale (mRS) score was used as the main outcome measurements to evaluate the efficacy of various drugs in improving the clinical outcomes of postoperative patients with aSAH. The network meta-analysis (NMA) was conducted based on a random-effects model, dichotomous variables were determined by using odds ratio (OR) with 95% confidence interval (CI), and a surface under the cumulative ranking curve (SUCRA) was generated to estimate the ranking probability of comparative effectiveness among different drug therapies. RESULTS: From the 493 of initial citation screening, forty-four RCTs (n = 10,626 participants) were eventually included in our analysis. Our NMA results showed that cilostazol (OR = 3.35,95%CI = 1.50,7.51) was the best intervention to improve the clinical outcome of patients (SUCRA = 87.29%, 95%CrI 0.07-0.46). Compared with the placebo group, only two drug interventions [nimodipine (OR = 1.61, 95%CI 1.01,2.57) and cilostazol (OR = 3.35, 95%CI 1.50, 7.51)] achieved significant statistical significance in improving the clinical outcome of patients. CONCLUSIONS: Both nimodipine and cilostazol have exact curative effect to improve the outcome of postoperative patients with aSAH, and cilostazol may be the best drug to improve the outcome of patients after aSAH operation. Our study provides implications for future studies that, the combination of two or more drugs with relative safety and potential benefits (e.g., nimodipine and cilostazol) may improve the clinical outcome of patients more effectively.