Vertebral Bone Quality Score as a Predictor of Adjacent Segment Disease After Lumbar Interbody Fusion.

BACKGROUND AND OBJECTIVE: With lumbar spine fusion being one of the most commonly performed spinal surgeries, investigating common complications such as adjacent segment disease (ASD) is a high priority. To the authors' knowledge, there are no previous studies investigating the utility of the preoperative magnetic resonance imaging-based vertebral bone quality (VBQ) score in predicting radiographic and surgical ASD after lumbar spine fusion. We aimed to investigate the predictive factors for radiographic and surgical ASD, focusing on the predictive potential of the VBQ score. METHODS: A single-center retrospective analysis was conducted of all patients who underwent 1-3 level lumbar or lumbosacral interbody fusion for lumbar spine degenerative disease between 2014 and 2021 with a minimum 12 months of clinical and radiographic follow-up. Demographic data were collected, along with patient medical, and surgical data. Preoperative MRI was assessed in the included patients using the VBQ scoring system to identify whether radiographic ASD or surgical ASD could be predicted. RESULTS: A total of 417 patients were identified (mean age, 59.8 ± 12.4 years; women, 54.0%). Eighty-two (19.7%) patients developed radiographic ASD, and 58 (13.9%) developed surgical ASD. A higher VBQ score was a significant predictor of radiographic ASD in univariate analysis (2.4 ± 0.5 vs 3.3 ± 0.4; P < .001) and multivariate analysis (odds ratio, 1.601; 95% CI, 1.453-1.763; P < .001). For surgical ASD, a significantly higher VBQ score was seen in univariate analysis (2.3 ± 0.5 vs 3.3 ± 0.4; P < .001) and served as an independent risk factor in multivariate analysis (odds ratio, 1.509; 95% CI, 1.324-1.720; P < .001). We also identified preoperative disk bulge and preoperative existence of adjacent segment disk degeneration to be significant predictors of both radiographic and surgical ASD. Furthermore, 3-level fusion was also a significant predictor for surgical ASD. CONCLUSION: The VBQ scoring system might be a useful adjunct for predicting radiographic and surgical ASD.

Transvenous embolization of noncavernous dural arteriovenous fistulas (dAVFs): A systematic review and meta-analysis.

BACKGROUND: Intracranial dural arteriovenous fistulas (dAVFs) are abnormal connections between arteries and veins within the dura mater. Various treatment modalities, such as surgical ligation, endovascular intervention, and radiosurgery, aim to close the fistulous connection. Although transvenous embolization (TVE) is the preferred method for carotid-cavernous fistulas, its description and outcomes for noncavernous dAVFs vary. This has prompted a systematic review and meta-analysis to comprehensively assess the effectiveness of TVE in treating noncavernous dAVFs, addressing variations in outcomes and techniques. METHODS: We searched PubMed and Embase, spanning from the earliest records to December 2022, to identify pertinent English-language articles detailing the utilization of TVE. We focused on specific procedural details, outcomes, and complications in patients older than 18 years. The data collected and analyzed comprised the sample size, number of fistulas, publication specifics, presenting symptoms, fistula grades, and pooled rates of embolizations, outcomes, follow-up information, and complications. RESULTS: From a total of 565 screened articles, 15 retrospective articles encompassing 166 patients spanning across seven countries met the inclusion criteria. Their Newcastle-Ottawa scores ranged from 6 to 8. Intraprocedural complication rate was 10% (95% confidence interval [CI] = 5.9-17.1) and in-hospital postprocedural complication rate was 5.4% (95% CI = 2.8-10.6). Prevalence of in-hospital mortality was 5.5% (95% CI = 2.9-10.6). Complication rate during follow-up was 8.6% (95% CI = 4.7-15.7) with fistula rupture occurring in 5.5% (95% CI = 2.6-11.6) of patients. Complete obliteration rate at final angiographic follow-up was 94.9% (95% CI = 90.3-99.9). Symptoms improved in 95% (95% CI = 89.8-100) of patients at final follow-up. CONCLUSION: To our knowledge, we present the first meta-analysis assessing obliteration rates, outcomes, and complications of TVE for dAVFs. Our analysis highlights the higher (>90%) complete obliteration rates. Large prospective multicenter studies are needed to better define the utility of TVE for noncavernous dAVFs.

A propensity score-matched comparative study of balloon guide catheters versus conventional guide catheters for concurrent mechanical thrombectomy with carotid stenting in tandem strokes: comparison of first pass effect, symptomatic intracranial hemorrhage, and 90-day functional outcomes.

BACKGROUND: Extensive clot burden in tandem strokes accounts for poor mechanical thrombectomy (MT) outcomes. Several studies have shown the benefit of balloon guide catheters (BGCs) in MT and carotid artery stenting. OBJECTIVE: In view of this potential benefit, to investigate the safety and effectiveness of proximal flow arrest using a BGC during concurrent MT and carotid revascularization for tandem stroke treatment in a comparative, propensity score-matched (PSM) study. METHODS: Patients with a tandem stroke identified from our endovascular database were dichotomized into groups treated with BGCs versus conventional guide catheters. One-to-one PSM adjustment for baseline demographics and treatment selection bias using nearest-neighbor matching was performed. Patient demographics, presentation characteristics, and procedural details were recorded. Outcomes assessed were final modified Thrombolysis in Cerebral Infarction (mTICI) grade, periprocedural symptomatic intracranial hemorrhage (sICH) rate, in-hospital mortality, and 90-day modified Rankin Scale (mRS) score. Mann-Whitney U test and multivariate logistic regression were performed to compare procedural parameters and clinical outcomes. RESULTS: Concurrent carotid revascularization (stenting with/without angioplasty) and MT was performed in 125 cases (BGC: 85; no BGC: 40). After PSM (40 patients/group), the BGC group had a significantly shorter procedure duration (77.9 vs 61.5 min; OR=0.996; P=0.006), lower discharge National Institutes of Health Stroke Scale score (8.0 vs 11.0; OR=0.987; P=0.042), and higher odds of 90-day mRS 0-2 score (52.3% vs 27.5%; OR=0.34; P=0.040). On multivariate regression, the BGC group had a significantly higher first pass effect rate (mTICI 2b or 3)(OR=1.115, 95% CI 1.015 to 1.432; P=0.013) and lower periprocedural sICH rate (OR=0.615, 95% CI 0.406 to 0.932; P=0.025). No difference in in-hospital mortality was observed (OR=1.591, 95% CI 0.976 to 2.593; P=0.067). CONCLUSION: BGCs used for concurrent MT-carotid revascularization with flow arrest were safe and resulted in superior clinical and angiographic outcomes in patients with a tandem stroke.

Visual Morbidity in Patients With Ophthalmic Segment Aneurysms Treated With Flow Diverters: A Dual-Center Experience.

BACKGROUND AND OBJECTIVE: Flow diverter (FD) treatment for aneurysms of the ophthalmic segment of the internal carotid artery (ICA) may raise concerns about visual morbidity related to coverage of the ophthalmic artery by the device. Our objective was to evaluate clinical and angiographic outcomes associated with FD treatment of these aneurysms, with particular emphasis on visual morbidity. METHODS: We performed a retrospective analysis of the endovascular databases at 2 US centers to identify consecutive patients with aneurysms along the ophthalmic segment of the ICA that were treated with FDs between January 2010 and December 2022. Baseline demographics, aneurysm characteristics, and periprocedural and postprocedural data, including the occurrence of visual complications, were collected. RESULTS: One hundred and thirteen patients with 113 aneurysms were identified for inclusion in this study. The mean age of the patients was 59.5 ± 12.4 years, and 103 (91.2%) were women. The ophthalmic artery origin was involved in 40 (35.4%) aneurysms, consisting of a neck origin in 33 (29.2%) and a dome origin in 7 (6.2%). New transient visual morbidity during the hospital stay included impaired visual acuity or blurriness in 1 (0.9%) patient, diplopia in 1 (0.9%), and floaters in 1 (0.9%). New transient visual morbidity during follow-up included impaired visual acuity or blurriness in 5 patients (4.4%), diplopia in 3 (2.7%), ipsilateral visual field defect in 1 (0.9%), and floaters in 6 (5.3%). Permanent visual morbidity occurred in 1 patient (0.9%). Among the 101 patients who had angiographic follow-up, the Raymond-Roy occlusion classifications were I (complete aneurysm occlusion) in 85 (84.2%), II (residual neck) in 11 (10.9%), and III (residual aneurysm) in 5 (4.9%). CONCLUSION: In our experience, flow diversion for ICA ophthalmic segment aneurysms resulted in low rates of visual morbidity, which was mostly transient in occurrence.

Orbitofrontal and striatal metabolism, volume, thickness and structural connectivity in relation to social anhedonia in depression: A multimodal study.

BACKGROUND: Social anhedonia is common within major depressive disorder (MDD) and associated with worse treatment outcomes. The orbitofrontal cortex (OFC) is implicated in both reward (medial OFC) and punishment (lateral OFC) in social decision making. Therefore, to understand the biology of social anhedonia in MDD, medial/lateral OFC metabolism, volume, and thickness, as well as structural connectivity to the striatum, amygdala, and ventral tegmental area/nucleus accumbens were examined. A positive relationship between social anhedonia and these neurobiological outcomes in the lateral OFC was hypothesized, whereas an inverse relationship was hypothesized for the medial OFC. The association between treatment-induced changes in OFC neurobiology and depression improvement were also examined. METHODS: 85 medication-free participants diagnosed with MDD were assessed with Wisconsin Schizotypy Scales to assess social anhedonia and received pretreatment simultaneous fluorodeoxyglucose positron emission tomography (FDG-PET) and magnetic resonance imaging (MRI), including structural and diffusion. Participants were then treated in an 8-week randomized placebo-controlled double-blind course of escitalopram. PET/MRI were repeated following treatment. Metabolic rate of glucose uptake was quantified from dynamic FDG-PET frames using Patlak graphical analysis. Structure (volume and cortical thickness) was quantified from structural MRI using Freesurfer. To assess structural connectivity, probabilistic tractography was performed on diffusion MRI and average FA was calculated within the derived tracts. Linear mixed models with Bonferroni correction were used to examine the relationships between variables. RESULTS: A significantly negative linear relationship between pretreatment social anhedonia score and structural connectivity between the medial OFC and the amygdala (estimated coefficient: -0.006, 95 % CI: -0.0108 - -0.0012, p-value = 0.0154) was observed. However, this finding would not survive multiple comparisons correction. No strong evidence existed to show a significant linear relationship between pretreatment social anhedonia score and metabolism, volume, thickness, or structural connectivity to any of the regions examined. There was also no strong evidence to suggest significant linear relationships between improvement in depression and percent change in these variables. CONCLUSIONS: Based on these multimodal findings, the OFC likely does not underlie social anhedonia in isolation and therefore should not be the sole target of treatment for social anhedonia. This is consistent with previous reports that other areas of the brain such as the amygdala and the striatum are highly involved in this behavior. Relatedly, amygdala-medial OFC structural connectivity could be a future target. The results of this study are crucial as, to our knowledge, they are the first to relate structure/function of the OFC with social anhedonia severity in MDD. Future work may need to involve a whole brain approach in order to develop therapeutics for social anhedonia.

Residual In-Stent Carotid Stenosis and Cigarette Smoking are Independent Predictors of Carotid Restenosis After Carotid Artery Stenting-Results from 738 Carotid Artery Stenting Procedures at a Single Center.

BACKGROUND AND OBJECTIVES: Carotid artery stenting (CAS) has become a viable alternative to carotid endarterectomy for the management of carotid stenosis. Our aim was to determine the rate of radiographic restenosis after CAS and clinical, radiographic, and procedural predictors of in-stent restenosis. METHODS: Our single-center, prospectively maintained database was retrospectively reviewed for CAS procedures performed in symptomatic and asymptomatic patients over 12 years (2010-2022). Baseline demographic data, procedural characteristics, and preprocedural and postprocedural radiographic and clinical details were noted. Baseline characteristics of patients with and without carotid restenosis were compared using the χ2 test for categorical variables and the Student t-test for continuous variables. Univariate and multivariate analyses were performed to determine risk factors associated with restenosis, defined as >70% on digital subtraction angiography. RESULTS: A total of 1017 consecutive CAS procedures were performed in 905 patients during the 12-year period, with 738 in 632 patients included in our study. Our cohort's overall restenosis rate was 17%, with a 14% restenosis rate at 2 years. On multivariate regression analysis, former or current smoking status (odds ratio [OR] = 2.3, 95% CI 1.2-4.1), plaque irregularity (OR 0.55, 95% CI 0.33-0.91), moderate (50.1%-75%) contralateral stenosis (OR 3.2, 95% CI 1.4-7.2), severe (75.1%-99.9%) contralateral stenosis (OR 2.8, 95% CI 1.3-6.0), and residual (>70%) in-stent stenosis after initial stenting (OR 433, 95% CI 80-2346) were significantly associated with carotid restenosis. Area under the curve for the multivariate regression model analysis was 0.78. Patients with <28.6% initial (residual) in-stent stenosis (45/517 cases) had a 9% restenosis rate, whereas those with >28.6% initial in-stent stenosis (77/221 cases) had a 35% restenosis rate. CONCLUSION: In this large, single-center study of carotid artery stenosis treated with CAS, residual in-stent carotid stenosis of approximately 30% and smoking status were independent predictors for restenosis. Maximizing treatment of initial stenosis and smoking cessation education are important steps in preventing future carotid restenosis.

Cerebral emboli detection and autonomous neuromonitoring using robotic transcranial Doppler with artificial intelligence for transcatheter aortic valve replacement with and without embolic protection devices: a pilot study.

BACKGROUND: Periprocedural ischemic stroke remains a serious complication in patients undergoing transcatheter aortic valve replacement (TAVR). We used a novel robotic transcranial Doppler (TCD) system equipped with artificial intelligence (AI) for real-time continuous intraoperative neuromonitoring during TAVR to establish the safety and potential validity of this tool in detecting cerebral emboli, report the quantity and distribution of high intensity transient signals (HITS) with and without cerebral protection, and correlate HITS occurrence with various procedural steps. METHODS: Consecutive patients undergoing TAVR procedures during which the robotic system was used between October 2021 and May 2022 were prospectively enrolled in this pilot study. The robotic TCD system included autonomous adjustment of the TCD probes and AI-assisted post-processing of HITS and other cerebral flow parameters. Basic demographics and procedural details were recorded. Continuous variables were analyzed by a two-sample Mann-Whitney t-test and categorical variables by a χ2 or Fisher test. RESULTS: Thirty-one patients were prospectively enrolled (mean age 79.9±7.6 years; 16 men (51.6%)). Mean aortic valve stenotic area was 0.7 cm2 and mean aortic-ventricular gradient was 43 mmHg (IQR 31.5-50 mmHg). Cerebral protection was used in 16 cases (51.6%). Significantly fewer emboli were observed in the protection group than in the non-protection group (mean 470.38 vs 693.33; p=0.01). Emboli counts during valve positioning and implantation were significantly different in the protection and non-protection groups (mean 249.92 and 387.5, respectively; p=0.01). One (4%) transient ischemic attack occurred post-procedurally in the non-protection group. CONCLUSION: We describe a novel real-time intraoperative neuromonitoring tool used in patients undergoing TAVR. Significantly fewer HITS were detected with protection. Valve positioning-implantation was the most significant stage for intraprocedural HITS.

Mechanical thrombectomy in low Alberta stroke program early CT score (ASPECTS) in hyperacute stroke-a systematic review and meta-analysis.

OBJECTIVE: Major randomized controlled trials of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) failed to include a substantial number of patients presenting with low baseline Alberta Stroke Program Early CT Score (ASPECTS:0-5). Patients experiencing hyperacute strokes (last known well ≤ 6 h) can potentially benefit most from MT. We conducted a systematic review and meta-analysis to report presentation severity and radiographic and clinical outcomes for hyperacute stroke patients presenting with low-ASPECTS. METHODS: Our comprehensive literature search of PubMed, Embase, and Cochrane databases up to August 31, 2022 included articles reporting patients presenting hyperacutely who underwent MT for anterior circulation large vessel occlusion AIS with an ASPECTS ≤ 5 on baseline imaging. Pooled averages were calculated for age and presenting National Institutes of Health Stroke Scale (NIHSS). Fixed- and random-effects meta-analyses for weighted estimation of overall rates were performed. Forest plots were generated for proportions and estimated overall outcome rates. RESULTS: 18 studies (1958 patients) were included (mean age = 64.1 years; presenting NIHSS = 18.4). Final modified thrombolysis in cerebral infarction 2b-3 grade was achieved in 76.4%, with symptomatic intracranial hemorrhage in 12.1%. Good (modified Rankin Scale [mRS] 0-2) and ambulatory (mRS 0-3) 3-month outcomes were achieved by 27.4 and 46.7%, respectively; 90-day mortality was 26.4%. CONCLUSION: MT in low-ASPECTS hyperacute stroke patients may result in ambulatory clinical outcomes with acceptable hemorrhage risk. Recanalization rates achieved were similar to those in patients presenting with ASPECTS ≥ 6; this did not fully translate to better clinical outcomes. ADVANCES IN KNOWLEDGE: MT should be considered for hyperacute strokes with low presenting ASPECTS.

Analysis of craniectomy bone flaps stored in a neurosurgical cryopreservation freezer: microorganism culture results and reimplantation rates.

BACKGROUND: Cryopreservation of bone flaps after decompressive craniectomies is a common practice. A frequent complication after bone flap reimplantation is postoperative infection, so culturing of frozen craniectomy bone flaps is a crucial practice that can prevent patient morbidity and mortality. Although many studies report on infection rates after cranioplasty, no study reports on the results of bone flaps stored in a cryopreservation freezer, reimplanted or otherwise. We sought to analyze the flaps in our medical center's bone bank freezer, including microorganism culture results and reimplantation rates of cryopreserved bone flaps. METHODS: Patients who underwent craniectomy and had bone flaps cryopreserved between January 1, 2016, and July 1, 2022, were included in this retrospective study. Information about bone flap cultures and reimplantation or discard was obtained from a prospectively maintained cryopreservation database. Information including infection rates and mortality was acquired from a retrospective review of patient records. Culture results were obtained for all flaps immediately before cryopreservation and again at the time of reimplantation at the operator's discretion. RESULTS: There were 148 bone flaps obtained from 145 patients (3 craniectomies were bilateral) stored in our center's freezer. Positive culture results were seen in 79 (53.4%) flaps. The most common microorganism genus was Propionibacterium with 47 positive flaps, 46 (97.9%) of which were P. acnes. Staphylococcus was the second most common with 23 positive flaps, of which 8 (34.8%) tested positive for S. epidermidis. Of the 148 flaps, 25 (16.9%) were reimplanted, 116 (78.4%) were discarded, and 7 (4.7%) are still being stored in the freezer. Postcranioplasty infections were seen in 3 (12%) patients who had flap reimplantation. CONCLUSIONS: Considering the substantial number of positive cultures and limited reimplantation rate, we have reservations about the logistical efficiency of cryopreservation for flap storage. Future multicenter studies analyzing reimplantation predictors could help to reduce unnecessary freezing and culturing.

Mechanical thrombectomy in low Alberta Stroke Program Early Computed Tomographic Score: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Due to their poor natural history and lack in level-I evidence, patients with large vessel occlusion and large core infarcts (Alberta Stroke Program Early Computed Tomographic Score <6) have been excluded from receiving mechanical thrombectomy. This systematic review and meta-analysis seeks to summarize current evidence from published randomized controlled trials to compare the safety and efficacy of mechanical thrombectomy with optimal medical therapy in treating stroke patients with large core infarcts. METHODS: We searched PubMed and EMBASE for randomized controlled trials investigating the safety and efficacy of mechanical thrombectomy vs optimal medical therapy in patients presenting with large vessel occlusion and large infarcts. Basic demographic and comorbidities were assessed, and clinical outcomes were compared, including modified Rankin scale 0-3, and 0-2 at 3 months, symptomatic intracranial hemorrhage, decompressive hemicortectomy, and 90-day mortality. RESULTS: Three randomized controlled trials totaling 1011 patients (501 and 510 in the medical management and mechanical thrombectomy arm, respectively) were included. Patients undergoing mechanical thrombectomy had significantly higher odds of achieving better functional outcomes at 3 months: Modified Rankin scale 0-2 (OR = 3.05, 95% CI = 2.101-4.4021, p < 0.0001) and modified Rankin scale 0-3 (OR = 2.20, 95% CI = 1.67-2.89, p < 0.0001) as compared to those receiving optimal medical management. There were no differences between groups in 90-day mortality (OR = 0.93, 95% CI = 0.70-1.23, p = 0.60), symptomatic intracranial hemorrhage (OR = 1.89, 95% = CI 0.95-3.77, p = 0.07) or decompressive hemicraniectomy (OR = 1.25, 95% CI = 0.69-2.25, p = 0.46). CONCLUSION: Mechanical thrombectomy for patients with large infarcts is associated with improved functional outcomes and a similar safety profile compared to optimal medical management. Ongoing trials will help better refine the target population that benefits the most from treatment.

Early Termination versus Standard Regimen Duration of Dual Antiplatelet Therapy in Intracranial Aneurysm Patients Treated With Pipeline Embolization Device Flex With Shield Technology: Preliminary Experience of 3 U.S. Centers.

BACKGROUND: Pipeline Flex Embolization Device with Shield Technology (PED-Shield) is a third-generation flow diverter with reduced thromboembolic potential. However, safety profile and dual antiplatelet therapy (DAPT) recommendations with PED-Shield is not well -established. We aim to assess the safety and complication profile with early termination of DAPT with use of PED-Shield. METHODS: Databases of 3 high-volume cerebrovascular centers were retrospectively reviewed. We identified patients with unruptured and ruptured intracranial aneurysms treated with PED-Shield. Patient demographics, aneurysm characteristics, complications, and angiographic outcomes were extracted. All patients who had early termination of DAPT, defined as <180 days, as well as standard duration were included. RESULTS: A total of 37 patients, totaling 37 aneurysms, had early termination of DAPT and 24 patients with 24 aneurysms received standard duration (>180 days) of DAPT. There was no difference in pre-procedural DAPT regimens between the groups (P = 0.503). Following DAPT termination, o1ne major thromboembolic complication was observed in the early termination group while no major or minor thromboembolic or hemorrhagic complication was noted in the standard duration group. Time of angiographic follow-up was not statistically different (P = 0.063) between the early termination (343 days, interquartile range [IQR] 114-371 days) and the standard duration (175 days, IQR 111-224.5 days) groups. There were no statistically significant differences in complete aneurysm occlusion (P = 0.857), residual neck (P = 0.582), and aneurysm remnant (P = 0.352) rates between the groups on angiography. CONCLUSIONS: Early termination of DAPT proves safe after PED-Shield treatment of intracranial aneurysms with comparable complete occlusion rates.

The first decade of flow diversion for intracranial aneurysms with the Pipeline embolization device.

OBJECTIVE: Flow diverter devices have revolutionized the treatment of intracranial aneurysms (IAs) since their approval in 2011 and have continued to evolve. The devices have been widely adopted across institutions and centers over the past decade; however, long-term follow-up after treatment with the Pipeline embolization device (PED) is not well described in the literature. The authors' institution was among the first to begin using PEDs, allowing them to report their series of patients treated with flow diverters ≥ 10 years ago. In this study, the authors aimed to evaluate the long-term angiographic and clinical outcomes of these patients and review lessons learned along the way. METHODS: The authors performed a retrospective review of their institution's IA database from January 2007 to July 2012. All patients with IAs treated with a PED prior to July 2012 were included. Clinical and angiographic characteristics were extracted. Available angiographic follow-up at 1, 3, 5, and 10 years was reported. RESULTS: A total of 83 patients with 92 aneurysms treated with a PED ≥ 10 years ago were identified and included in the study. The mean aneurysm dome diameter was 9.2 (SD 5.7) mm, the mean aneurysm height was 10.4 (SD 6.8) mm, and the mean neck width was 4.1 (SD 2.4) mm. Only 1 (1.1%) aneurysm was ruptured at presentation. Eight (8.7%) aneurysms were recurrences of previous treatment modalities. The morphology was saccular in 77 (83.7%) aneurysms, fusiform in 14 (15.2%), and blister-like in 1 (1.1%). Among saccular aneurysms, 60 (77.9%) were wide-necked. Seventy-five (81.5%) aneurysms were in the internal carotid artery, 12 (13.0%) were vertebrobasilar, 3 (3.3%) were in the middle cerebral artery, and 2 (2.2%) were in the posterior cerebral artery. Angiographic follow-up at 1, 3, 5, and 10 years was available for 75, 59, 50, and 15 patients, respectively. The complete occlusion rates at 1, 3, 5, and 10 years were 94.7%, 96.6%, 96.0%, and 100%, respectively. The retreatment rates at 1, 3, 5, and 10 years were 8.0%, 6.8%, 8.0%, and 6.7%, respectively. CONCLUSIONS: The authors provide their single-institution series of IA patients treated with a PED ≥ 10 years ago, with the first report of 10-year follow-up for the available patients.

Coiling Variations for Treatment of Ruptured Intracranial Aneurysms: A Meta-Analytical Comparison of Comaneci-, Stent-, and Balloon-Coiling Assistance Techniques.

BACKGROUND: Wide-necked aneurysms represent a challenge for treatment in the setting of acute subarachnoid hemorrhage. Stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) are well-known techniques for treating wide-necked aneurysms. Comaneci-assisted coiling (CAC) is a newer technique involving temporary stent deployment to assist aneurysm coiling. We aim to present the first meta-analysis comparing these treatments of ruptured aneurysms. METHODS: Following PRISMA guidelines, PubMed and Embase databases were queried from earliest records to July 2022 for literature reporting SAC, BAC, or CAC of ruptured intracranial aneurysms. A meta-analysis of identified articles was performed. RESULTS: Of the 571 articles queried, 64 articles were included. One study reported BAC and SAC, 8 reported BAC, 52 reported SAC, and 3 reported CAC. These studies comprised 3153 patients with 3207 ruptured aneurysms treated with CAC (161 patients and aneurysms), BAC (330 patients and aneurysms), and SAC (2662 patients, 2716 aneurysms). Rates of periprocedural thromboembolic or hemorrhagic complications, overall or procedure-related mortality, immediate complete occlusion, retreatment, and length of angiographic follow-up did not differ significantly between SAC and BAC. Periprocedural thromboembolic (P = 0.03) and hemorrhagic (P = 0.01) complication rates were higher with BAC than CAC. Periprocedural thromboembolic (P = 0.03) and hemorrhagic (P < 0.0001) complication rates were higher with SAC than CAC. Complete aneurysm occlusion rates (P = 0.033) were higher with CAC than BAC. No significant differences were present in CAC versus BAC or SAC retreatment rates. CONCLUSIONS: CAC was associated with lower hemorrhagic and thromboembolic complication rates and demonstrated similar complete occlusion and residual retreatment rates to those for BAC and SAC.

Hyperacute stenting and angioplasty for acute extracranial non-tandem internal carotid artery strokes within the first 48†h: A 20-year experience and a systematic review and meta-analysis.

BACKGROUND: Acute strokes involving complete, isolated occlusion of the extracranial cervical internal carotid artery (EC-ICA) with no intracranial clot burden account for a minority of stroke cases that are managed variably. Here we present our two-decade experience and a systematic review of endovascular management of acute isolated EC-ICA strokes in the hyperacute phase (<48 h) and attempt to evaluate clinical effectiveness and safety. METHODS: Our prospectively maintained database was retrospectively searched for patients who presented between January 1, 2003 and December 31, 2022 with acute cervical ICA stroke confirmed on angiography. Only patients who had an isolated 100% occlusion of the cervical ICA segment and attempted acute stenting with/without angioplasty within the first 48 h of time since last known well were included. Demographics, procedural details, and outcomes were recorded. For the systematic review, a search of PubMed and Embase databases was conducted. RESULTS: Forty-six patients with acute, isolated EC-ICA occlusive stroke were included. Median presenting National Institutes of Health Stroke Scale (NIHSS) score was 8 (interquartile range 3-10) with a perfusion deficit in 78.3% of the 40 cases assessed with computed tomography perfusion imaging. Median time from symptom onset to intra-arterial puncture was 14.4 h. Immediate recanalization was achieved in 82.6% cases. Two cases (4.3%) of symptomatic intracranial hemorrhage (sICH) occurred postprocedure. Outcome measures were stable or improved discharge NIHSS score in 86.9% of cases, functional independence at 90 days (modified Rankin scale score ≤2) in 78.3%, and mortality in 6.5%. The systematic review included 167 patients from four articles. The estimated rate of immediate recanalization was 92.7% (95% confidence interval (CI), 88.77-96.77%), favorable outcome was 62.01% (95% CI, 55.04-69.87%), and sICH was 6.2% (95% CI, 3.41-11.32%). CONCLUSION: Stenting and angioplasty for acute cervical ICA occlusive strokes during the hyperacute phase can be performed successfully with favorable clinical outcomes and an acceptable recanalization rate.

The first endovascular rat glioma model for pre-clinical evaluation of intra-arterial therapeutics.

BACKGROUND: Several translational animal models have been described assessing intra-arterial (IA) treatments for malignant gliomas. We describe the first endovascular animal model that allows testing of IA drug delivery as a first-line treatment, which is difficult to do in actual patients. We report a unique protocol for vascular access and IA delivery in the rat model that, unlike prior reports, does not require direct puncture and opening of proximal cerebrovasculature which carries risk of ischemia in the animal brain post-delivery. METHODS: Wistar rats underwent left femoral artery catherization with a Balt Magic 1.2F catheter or Marathon Flow directed 1.5F Microcatheter with an Asahi Chikai 0.008 micro-guidewire which was navigated to the left internal carotid artery under x-ray. 25% mannitol was administered to test blood brain barrier breakdown (BBBB). Additional rats were implanted with C6 glioma cells in the left frontal lobe. C6 Glioma-Implanted Rats (C6GRs) were monitored for overall survival and tumor growth. Tumor volumes from MRI images were calculated utilizing 3D slicer. Additional rats underwent femoral artery catheterization with Bevacizumab, carboplatin, or irinotecan injected into the left internal carotid artery to test feasibility and safety. RESULTS: A successful endovascular access and BBBB protocol was established. BBBB was confirmed with positive Evans blue staining. 10 rats were successfully implanted with C6 gliomas with confirmed growths on MRI. Overall survival was 19.75 ± 2.21 days. 5 rats were utilized for the development of our femoral catheterization protocol and BBBB testing. With regards to IA chemotherapy dosage testing, control rats tolerated targeted 10 mg/kg of bevascizumab, 2.4 mg/kg of carboplatin, and 15 mg/kg of irinotecan IA ICA injections without any complications. CONCLUSIONS: We present the first endovascular IA rat glioma model that allows selective catheterization of the intracranial vasculature and assessment of IA therapies for gliomas without need for access and sacrifice of proximal cerebrovasculature.

The abscopal effect: inducing immunogenicity in the treatment of brain metastases secondary to lung cancer and melanoma.

PURPOSE: The phenomenon of radiation therapy (RT) causing regression of targeted lesions as well as lesions outside of the radiation field is known as the abscopal effect and is thought to be mediated by immunologic causes. This phenomena has been described following whole brain radiation (WBRT) and stereotactic radiosurgery (SRS) of brain metastasis (BM) in advanced melanoma and non-small-cell lung cancer (NSCLC). We systematically reviewed the available literature to identify which radiation modality and immunotherapy (IT) combination may elicit the abscopal effect, the optimal timing of RT and IT, and potential adverse effects inherent to the combination of RT and IT. METHODS: Using PRISMA guidelines, a search of PubMed, Medline, and Web of Science was conducted to identify studies demonstrating the abscopal effect during treatment of NSCLC or melanoma with BM. RESULTS: 598 cases of irradiated BM of melanoma or NSCLC in 18 studies met inclusion criteria. The most commonly administered ITs included PD-1 or CTLA-4 immune checkpoint inhibitors (ICI), with RT most commonly administered within 3 months of ICI. Synergy between ICI and RT was described in 16 studies including evidence of higher tumor response within and outside of the irradiated field. In the 12 papers (n = 232 patients) that reported objective response rate (ORR) in patients with BM treated with RT and concurrent systemic IT, the non-weighted mean ORR was 49.4%; in the 5 papers (n = 110 patients) that reported ORR for treatment with RT or IT alone, the non-weighted mean ORR was 27.8%. No studies found evidence of significantly increased toxicity in patients receiving RT and ICI. CONCLUSION: The combination of RT and ICIs may enhance ICI efficacy and induce more durable responses via the abscopal effect in patients with brain metastases of melanoma or NSCLC.

Pretreatment and Posttreatment Factors Associated with Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis.

BACKGROUND: Hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to evaluate novel preoperative and postoperative risk factors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis. METHODS: A systematic search was conducted using PubMed and Embase databases for studies pertaining to aSAH and SDHC. Articles were assessed by meta-analysis if the number of risk factors for SDHC was reported by >4 studies and could be extracted separately for patients who did or did not develop SDHC. RESULTS: Thirty-seven studies were included, comprising 12,667 patients with aSAH (SDHC 2214 vs. non-SDHC 10,453). In a primary analysis of 15 novel potential risk factors, 8 were identified to be significantly associated with increased prevalence of SDHC after aSAH, including high World Federation of Neurological Surgeons grades (odds ratio [OR], 2.43), hypertension (OR, 1.33), anterior cerebral artery (OR, 1.36), middle cerebral artery (OR, 0.65), and vertebrobasilar artery (2.21) involvement, decompressive craniectomy (OR, 3.27), delayed cerebral ischemia (OR, 1.65), and intracerebral hematoma (OR, 3.91). CONCLUSIONS: Several new factors associated with increased odds of developing SDHC after aSAH were found to be significant. By providing evidence-based risk factors for shunt dependency, we describe an identifiable list of preoperative and postoperative prognosticators that may influence how surgeons recognize, treat, and manage patients with aSAH at high risk for developing SDHC.

Head and neck angiography in the pediatric population: single-center experience with indications, safety, feasibility, and technical differences among infants, childhood, and adolescents.

OBJECTIVE: Pediatric patients are candidates for head and neck endovascular procedures less frequently than adults. Data on utilization, feasibility, safety, and technical details of head and neck angiography in the pediatric population are scarce. METHODS: The authors performed a retrospective review of their center's endovascular database to identify all patients ≤ 18 years of age who underwent diagnostic or interventional catheter-based angiography of the head and neck. Procedure-related variables for identified patients were compared across infancy (birth to 2 years), childhood (> 2-11 years), and adolescence (> 11-18 years). RESULTS: One hundred twenty-one pediatric patients who underwent 274 angiogram procedures were included in this study. Of these angiograms, 197 were diagnostic and 118 were interventional (including 41 of the diagnostic angiogram procedures that were performed concurrently with the intervention). The most common indications for diagnostic angiograms were suspected vascular malformations in 52 cases (26.4%) and aneurysms in 23 (11.7%). The rate of positive findings on diagnostic angiograms ranged from 27.3% to 80% according to the indication. Access site-related complications were observed after 2 punctures (0.7%). Procedure-related complications occurred in 3 patients (1.1%). In adolescents, the rates of general anesthesia use and sheathless access were significantly lower (each p < 0.001), and the rates of radial artery access (p < 0.001); 5-French (5F) (p = 0.01), 6F (p < 0.001), and 8F (p = 0.03) access; and closure device usage (p < 0.001) were significantly higher. In infants, the rates of ultrasound guidance, 4F access, and failure of the primary puncture site were significantly higher (each p < 0.001). CONCLUSIONS: Head and neck angiograms in the pediatric population were feasible and safe in the authors' overall experience. Technical differences were observed across the infant, childhood, and adolescent groups, but safe outcomes were similar throughout these age ranges.

A look at the global impact of COVID-19 pandemic on neurosurgical services and residency training.

Background: The COVID-19 pandemic has left an indelible effect on healthcare delivery and education system, including residency training. Particularly, neurosurgical departments worldwide had to adapt their operating model to the constantly changing pandemic landscape. This review aimed to quantify the reduction in neurosurgical operative volume and describe the impact of these trends on neurosurgical residency training. Methods: We performed a comprehensive search of PubMed and EMBASE between December 2019 and October 2022 to identify studies comparing pre-pandemic and pandemic neurosurgical caseloads as well as articles detailing the impact of COVID-19 on neurosurgery residency training. Statistical analysis of quantitative data was presented as pooled odds ratio (OR) and 95% confidence intervals (CI). Results: A total of 49 studies met the inclusion criteria, of which 12 (24.5%) were survey-based. The case volume of elective surgeries and non-elective procedures decreased by 70.4% (OR=0.296, 95%CI 0.210-0.418) and 68.2% (OR=0.318, 95%CI 0.193-0.525), respectively. A significant decrease was also observed in functional (OR=0.542, 95%CI 0.394-0.746), spine (OR=0.545, 95%CI 0.409-0.725), and skull base surgery (OR=0.545, 95%CI 0.409-0.725), whereas the caseloads for tumor (OR=1.029, 95%CI 0.838-1.263), trauma (OR=1.021, 95%CI 0.846-1.232), vascular (OR=1.001, 95%CI 0.870-1.152), and pediatric neurosurgery (OR=0.589, 95%CI 0.344-1.010) remained relatively the same between pre-pandemic and pandemic periods. The reduction in caseloads had caused concerns among residents and program directors in regard to the diminished clinical exposure, financial constraints, and mental well-being. Some positives highlighted were rapid adaptation to virtual educational platforms and increasing time for self-learning and research activities. Conclusion: While COVID-19 has brought about significant disruptions in neurosurgical practice and training, this unprecedented challenge has opened the door for technological advances and collaboration that broaden the accessibility of resources and reduce the worldwide gap in neurosurgical education.

Volumetric resolution of chronic subdural hematomas treated with surgical evacuation versus middle meningeal artery embolization during immediate, early, and late follow up: propensity-score matched cohorts.

BACKGROUND: Literature on volumetric resolution and recurrence over time between surgical evacuation alone (SEA) and standalone middle meningeal artery embolization (MMAE) in comparable chronic subdural hematoma (cSDH) patients is limited. METHODS: A retrospective database analysis of cSDH patients managed with either SEA or MMAE was conducted. Propensity-score matching was performed for axial and coronal lengths, maximum diameter, and midline shift. Volumetric measurements at multiple time intervals and recurrence were compared between the groups. RESULTS: 48 matched hematoma pairs in patients with similar demographics, comorbidities, medications, and symptoms were obtained. Median volume was significantly lower at 24 hours in the SEA group (12.6 mL vs 52.7 mL, p<0.001) but not at remaining intervals. Median volume reduction was significantly greater in the SEA group at 24 hours (39.1 mL vs 8.8 mL in the MMAE group, p<0.001) and at 3-12 weeks (50.8 mL vs 23.7 mL, p<0.001), but not at remaining intervals. The SEA group had a significantly greater median hematoma resolution rate at 24 hours (39.1 mL/day vs 8.8 mL/day, p<0.001) and 3-12 weeks (1 mL/day vs 0.4 mL/day, p<0.001), but not at remaining intervals. Near-complete resolution at 3-12 weeks and 12-60 weeks was not significantly different between groups. Overall, the recurrence rate was significantly higher in the SEA group (22.9% vs 4.2%, p=0.01). CONCLUSIONS: In comparable cSDH patients, SEA resulted in better volumetric outcomes in immediate postoperative and early follow-up periods, as expected. However, this difference was not significant at more distant follow-up intervals. Furthermore, surgical patients experienced a significantly higher rate of recurrence.