A case of convexity non-aneurysmal subarachnoid hemorrhage caused by cerebral sinus thrombosis.

BACKGROUND: Convexity subarachnoid hemorrhage (cSAH) is an uncommon presentation of subarachnoid bleeding, referring to bleeding more localized to the convexities of the brain. The diagnosis of cerebral venous sinus thrombosis (CVST) can be difficult especially when patients initially present with cSAH. The authors present a case and then discuss the pathophysiology and management. CASE PRESENTATION: A 56-year-old woman with a previous history of hypertension and ischemic heart disease presented to the emergency department after experiencing it. Two seizures following a severe headache. The patient's history was negative for recent illnesses, head trauma, history of migraines, smoking, alcohol consumption, or intravenous drug use. The patient was diagnosed with CVST based on magnetic resonance venography (MRV). Genetic studies further identified homozygous mutations in the Prothrombin and MTHFR genes. Anticoagulant therapy was initiated with 60 mg of Enoxaparin twice daily and subsequently transitioned to Warfarin after 48 h continued for 3 months, and then replaced by rivaroxaban. CONCLUSIONS: This study highlights the importance of considering CVST as a cause of SAH, emphasizes the role of advanced imaging in diagnosis, and demonstrates a successful treatment approach using both traditional and direct oral anticoagulants. The insights provided in this article can contribute to improving the management of patients with CVST-related SAH.

Safety and effectiveness of Neuroform Atlas stent-assisted coil embolization for ruptured intracranial aneurysms.

Objective: The treatment outcomes of ruptured intracranial aneurysms using the Neuroform Atlas stent were evaluated. Methods: This study represents a retrospective review that included patients who underwent endovascular treatment for ruptured aneurysms at a single institution. Between January 2018 and September 2022, endovascular treatments including simple coiling or Neuroform Atlas stent-assisted coil embolization were performed in 191 patients with ruptured intracranial aneurysms. Results: Intraprocedural rupture was observed in 11 (8.7%) patients in the Simple Coiling (SC) group, which was slightly higher than that in 4 (6.3%) patients in the Neuroform Atlas stent-assisted coiling (NASAC) group (p=0.241). However, Thromboembolic event (TEE) was slightly more prevalent in the NASAC group, with 4 (6.3%) cases as compared to the 5 (3.9%) cases in the SC group (p=0.235). The retreatment rate was slightly higher in the SC group, with 19 (26.4%) patients as compared to the 10 patients (22.2%) in the NASAC group (p=0.342). Conclusions: The use of the Neuroform Atlas stent (NAS) for ruptured aneurysms might be safe and effective.

Traumatic Spinal Subarachnoid Hemorrhage With Spinal Cord Compression: A Case Report and Literature Review.

The occurrence of spinal hematoma is rare, and differentiation between subarachnoid hemorrhage and subdural hemorrhage on neuroradiological imaging can be challenging. Spinal subarachnoid hemorrhage (SSAH) is less frequently associated with trauma and can result in severe neurological impairment. We report the case of a 53-year-old man who presented with severe motor and sensory deficits primarily of the left arm without further neurological deficits in the other extremities after a fall from a height of six meters. Magnetic resonance imaging (MRI) showed an acute intradural hematoma at the C4-C6 level with significant spinal cord compression. Surgery revealed a hematoma enclosed by an arachnoid layer. Two months later, MRI showed complete resolution of spinal cord edema and avulsion of the left C6 and partially C7 nerve roots, corresponding to electromyography findings revealing a brachial plexus avulsion. Nine months after the accident and five months after surgical repair of the brachial plexus avulsion, there was a significant improvement in the sensory and motor functions of the left arm, allowing the patient to manage daily activities independently. Patients with neurological deficits following spinal trauma should be evaluated for spinal cord compression, such as intraspinal hematoma, as soon as possible to enable early spinal decompression. We describe a rare case of traumatic SSAH and brachial plexus avulsion following successful surgical decompression of the spinal cord without clinical postoperative myelopathy.

Quantitative analysis of HSV­1 shedding as a predictor of cerebral vasospasm severity in patients with subarachnoid hemorrhage.

Cerebral vasospasm (CV) is a critical determinant of outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). Despite advances in neurocritical care, modifiable risk factors for CV remain poorly understood, and identifying them could significantly enhance patient management and treatment strategies. The present study explored the potential link between the reactivation of herpes simplex virus type 1 (HSV-1), a common resident virus in cranial nerves, and CV severity. It was hypothesized that higher HSV-1 viral load in saliva may be associated with increased CV severity. Saliva samples were collected on days 4, 7, 10 and 14 post-aSAH, and HSV-1 DNA levels were measured using quantitative PCR. CV severity was assessed using the Lindegaard ratio (LR), with an LR >3 considered the diagnostic threshold for CV. A total of 36 patients were enrolled, and 139 saliva samples were collected. HSV-1 DNA was detected in 19.4% of samples (27/139), and 44% of patients (16/36) developed CV. HSV-1 seropositive patients made up 88.9% (32/36) of the cohort, with 50% exhibiting viral shedding during the study period. None of the HSV-1 seronegative patients (11.1%, 4/36) exhibited viral shedding or developed CV. Regression analysis showed a positive association between HSV-1 viral load and CV severity, with viral load explaining 27.8% of the variability (P=0.005). Age was also significant, with older patients experiencing less severe CV (P<0.001). Supervised machine learning identified viral load thresholds that aligned with standard LR values for moderate and severe CV. While the small sample size and observational design limit the generalizability of the results, these findings suggested that earlier detection and intervention for CV could be informed by assessing HSV-1 serostatus and monitoring viral activity through saliva samples or other non-invasive methods, highlighting the need for larger, controlled studies to validate these results.

Quantification of blood and CSF volume to predict outcome after aneurysmal subarachnoid hemorrhage.

This study aimed to describe the relationship between blood and CSF volumes in different compartments on baseline CT after aSAH, assess if they independently predict long-term outcome, and explore their interaction with age. CT scans from patients participating in a prospective multicenter randomized controlled trial of patients with aSAH were segmented for blood and CSF volumes. The primary outcomes were the mRS, and the Subarachnoid Hemorrhage Outcome Tool (SAHOT) at day 28 and 180. Univariate regressions were conducted to identify significant predictors of poor outcomes, followed by principal component analysis to explore correlations between imaging variables and WFNS. A multivariate predictive model was then developed and optimized using stepwise regression. CT scans from 97 patients with a median delay from symptom onset of 271 min (131-547) were analyzed. Univariate analysis showed only WFNS, and total blood volume (TBV) were significant predictors of both short and long-term outcome with WFNS more predictive of mRS and TBV more predictive of SAHOT. Principal component analysis showed strong dependencies between the imaging predictors. Multivariate ordinal regression showed models with WFNS alone were most predictive of day 180 mRS and models with TBV alone were most predictive of SAHOT. TBV was the most significant measured imaging predictor of poor long-term outcome after aSAH. All these imaging predictors are correlated, however, and may have multiple complex interactions necessitating larger datasets to detect if they provide any additional predictive value for long-term outcome.

The polk county screening tool screening for detecting subarachnoid hemorrhage.

INTRODUCTION: The subarachnoid space in the brain contains crucial blood vessels and cerebrospinal fluid. Aneurysms in these vessels can lead to subarachnoid hemorrhage (SAH), a serious stroke subtype with high morbidity and mortality rates. SAH treatment includes procedures like coiling and clipping, but these are available only at comprehensive stroke centers (CSCs), necessitating urgent diagnosis and transfer to specialized facilities. METHODS: This IRB-approved study was conducted by Polk County Fire Rescue (PCFR) in Florida. PCFR, serving an 850,000-person population, implemented a three-step SAH protocol. The protocol uses both Ottawa SAH criteria and recurring symptoms, such as new-onset seizures and high systolic blood pressure, that were identified by EMS. Acute management included administering labetalol, levetiracetam, and ondansetron. RESULTS: Of 2175 stroke patients, 80 screened positive for SAH and were eligible for transfer. Patients had a median age of 66, and 33% had an initial systolic BP over 220 mmHg. The interfacility transfer rate dropped from 12.9 to 3.6% after implementing the protocol. CONCLUSION: The PCFR protocol's effectiveness suggests its potential for nationwide implementation. Early SAH recognition and prompt transfer to CSCs reduce complications and improve outcomes. Accurate field diagnosis by EMTs can prevent unnecessary transfers and enhance patient care. Future improvements may include portable diagnostic tools and enhanced EMT training to further improve SAH patients' pre-hospital care.

Convexity subarachnoid hemorrhage revealed contralateral internal carotid artery dissection due to Eagle syndrome: a case report.

BACKGROUND: Atraumatic localized convexity subarachnoid hemorrhage (cSAH) is an uncommon form of nonaneurysmal subarachnoid hemorrhage characterized by bleeding limited to the cerebral convexities. Ipsilateral cSAH can result from a variety of causes, such as internal carotid artery stenosis, obstruction, and dissection, although concomitant contralateral cSAH is exceptionally rare. In this case, the initial findings of cSAH led us to discovering contralateral internal carotid artery dissection (ICAD) and an elongated styloid process (ESP). ESP is recognized as a risk factor for ICAD, which is a hallmark of Eagle syndrome. This sequence of findings led to the diagnosis of Eagle syndrome, illustrating a complex and intriguing interplay between cerebrovascular conditions and anatomical variations. CASE PRESENTATION: A 47-year-old Japanese woman experienced acute onset of headache radiating to her neck, reaching its zenith approximately two hours after onset. Given the intractable nature of the headache and its persistence for three days, she presented to the emergency department. Neurological examination revealed no abnormalities, and the coagulation screening parameters were within normal ranges. Brain computed tomography (CT) revealed right parietal cSAH, while CT angiography (CTA) revealed ICAD and an ESP measuring 30.1 mm on the left side, positioned only 1.4 mm from the dissected artery. The unusual occurrence of contralateral cSAH prompted extensive and repeated imaging reviews that excluded reversible cerebral vasoconstriction syndrome (RCVS), leading to a diagnosis of left ICAD secondary to Eagle syndrome. The patient underwent conservative management, and the dissected ICA spontaneously resolved. The patient has remained recurrence-free for two and a half years. CONCLUSIONS: Managing cSAH requires diligent investigation for ICAD, extending beyond its identification to explore underlying causes. Recognizing Eagle syndrome, though rare, as a potential etiology of ICAD necessitates the importance of evaluating ESPs. The method for preventing recurrent cervical artery dissection due to Eagle syndrome is controversial; however, conservative management is a viable option.

Transcription factor EB (TFEB) promotes autophagy in early brain injury after subarachnoid hemorrhage in rats.

Subarachnoid hemorrhage (SAH) has high mortality. Early brain injury (EBI) is responsible for unfavorable outcomes for patients with SAH. The protective involvement of autophagy in hemorrhagic stroke has been proposed. The transcription factor EB (TFEB) can increase autophagic flux by promoting autophagosome formation and autophagosome-lysosome fusion, and dysregulation of TFEB activity might induce the development of several diseases. However, the biological functions of TFEB in EBI after SAH remain unknown. We established an animal model of SAH by the modified endovascular perforation method. Expression of TFEB and autophagy required genes was measured by western blotting and immunofluorescence staining. SAH grading, brain water content and neurobehavioral functions were evaluated at 24 h post-SAH. Neuronal apoptosis in cerebral cortex was assessed by TUNEL staining and Fluoro Jade B staining. TFEB was downregulated in SAH rats, and its overexpression reduced brain edema and ameliorated neurological deficits of SAH rats. Additionally, the neuronal apoptosis induced by SAH was inhibited by TFEB overexpression. Moreover, TFEB overexpression promoted autophagy after SAH. TFEB overexpression promotes autophagy to inhibit neuronal apoptosis, brain edema and neurological deficits post-SAH.

Contribution of an Automatic Algorithm for Quantifying the Volume of Aneurysmal Subarachnoid Hemorrhage to the Evaluation of the Risk of Occurrence of Delayed Cerebral Ischemia: A Cohort Study.

BACKGROUND: This study focuses on aneurysmal subarachnoid hemorrhage (aSAH) with a high risk of delayed cerebral ischemia (DCI) and acute hydrocephalus (AH). The aim was to compare the performance of an automatic algorithm for quantifying the volume of intracranial blood with the reference radiological scales to predict DCI, AH, and neurological outcome. METHODS: This was a single-center retrospective observational study of a cohort of patients with aSAH. We developed an automated blood detection algorithm based on the specific density of the blood clot. The blood clot was segmented on the first brain scan (total, supratentorial, cisternal, intraventricular). The predictive value of our model was compared, using the area under the receiver operating characteristic curve (ROCAUC), to eight radiological scales: Fisher, modified Fisher, Claassen, Barrow Neurological Institute, Hijdra, Graeb, LeRoux scales, and intraventricular hemorrhage score. RESULTS: We analyzed the scans of 145 patients with aSAH. In our cohort, 51 patients (43%) had DCI and 70 patients (54%) had AH. At 3 months, 22% of patients had died and 19% had poor outcome (Glasgow Outcome Scale extended 2-4). Cisternal blood volume was significantly correlated with cisternal Hijdra scale (R2 = 0.79; P < 0.001). The ROCAUC of cisternal blood volume was comparable to the ROCAUC of the Hijdra scale in predicting the occurrence of DCI (ROCAUC = 0.83 [95% confidence interval {CI} 0.75-0.89] vs. 0.86 [95% CI 0.79-0.9]; P = 0.23). The ROCAUC of intraventricular blood volume was not significantly different from the intraventricular hemorrhage score in predicting the occurrence of AH (ROCAUC = 0.78 [95% CI 0.70-0.84] vs. 0.79 [95% CI 0.72-0.85]; P = 0.28). The ROCAUC and supratentorial blood volumes were not significantly different from the Simplified Acute Physiology Score II in predicting the occurrence of poor neurological outcome at 3 months (ROCAUC = 0.75 [95% CI 0.67-0.82] vs. 0.81 [95% CI 0.74-0.87]; P = 0.073). CONCLUSIONS: With no manual intervention, our algorithm performed as well as the best radiological scores in predicting the occurrence of DCI, AH, and neurological outcome.

Functionally dependent status is an independent predictor for worse perioperative outcomes following craniotomy for aneurysmal subarachnoid hemorrhage.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a medical emergency, and functional status is often a predictor of adverse outcomes perioperatively. Patients with different functional statuses may have different perioperative outcomes during surgery for aSAH. This study retrospectively examines the effect of functional status on specific perioperative outcomes in patients receiving craniotomy for aSAH. Methods: Patients with aSAH who underwent neurosurgery were identified using International Classification of Diseases (ICD) codes (ICD10, I60; ICD9, 430) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2021. Subjects were stratified into two study groups: functionally dependent and functionally independent, based on their documented functional status on NSQIP. Significant preoperative differences were present between groups so a multivariable regression was performed between functionally dependent and independent patients. The 30-day perioperative outcomes of the two groups were compared. Perioperative outcomes included death, major adverse cardiovascular events (MACEs), cardiac complications, stroke, wound complications, renal complications, sepsis, clot formation, pulmonary complications, return to the operating room, operation time >4 h, length of stay longer than 7 days, discharge not to home, and bleeding. Results: For aSAH patients receiving craniotomy repair, functionally dependent patients had significantly greater rates of MACE, cardiac complications, sepsis, pulmonary complications, and discharge not to home compared to functionally independent patients. Conclusion: This study shows specific perioperative variables influenced by dependent functional status when treating aSAH through craniotomy, thus leading to a more complicated postoperative course. Additional research is needed to confirm these findings among the specific variables that we analyzed.

Increased brain volume in the early phase of aneurysmal subarachnoid hemorrhage leads to delayed cerebral ischemia.

Objective: To investigate the correlation between the swelling rate of brain volume within the first 48 h after aneurysmal subarachnoid hemorrhage and the subsequent development of delayed cerebral ischemia. Methods: A retrospective analysis was conducted on patients with spontaneous aneurysmal subarachnoid hemorrhage admitted to the Neurosurgery Intensive Care Unit of the First Affiliated Hospital of Chongqing Medical University between January 2020 and January 2023. The clinical data, treatment outcomes, and imaging data were analyzed. Brain volume was evaluated using 3D-Slicer software at two time points post-hemorrhage: within the first 24 h and between 24 and 48 h. The swelling rate of brain volume was defined as the ratio of the absolute difference between two measurements to the smaller of values. Patients were categorized into two groups based on established diagnostic criteria of delayed cerebral ischemia. Univariate and multivariate logistic regression analyses were performed to identify factors influencing delayed cerebral ischemia. Results: A total of 140 patients were enrolled in this study. 46 patients experienced delayed cerebral ischemia after bleeding. The swelling rate of brain volume was larger in the DCI group (10.66 ± 8.45) compared to the non-DCI group (3.59 ± 2.62), which showed a statistically significant difference. Additionally, advanced age, smoking history, history of hypertension, loss of consciousness, poor Hunt-Hess grade, high mFisher score, brain volume within 24 h, and IVH were also statistically different between the two groups. Multivariate logistic regression analysis revealed that the swelling rate of brain volume was an independent risk factor for DCI with adjusting the advanced age, smoking history, history of hypertension, poor Hunt-Hess grade, high mFisher score, brain volume within 24 h, and IVH. Conclusion: Brain volume significantly increased in patients with aneurysmal subarachnoid hemorrhage during the early phase (within 48 h post-onset). The larger swelling rate of brain volume is an independent risk factor for the development of delayed cerebral ischemia, and it may hold significant predictive value for the incidence of delayed cerebral ischemia.

Causal relationships between gut microbiota and Aneurysmal Subarachnoid Hemorrhage: A Bidirectional Mendelian Randomization Study.

BACKGROUND AND PURPOSE: Aneurysmal Subarachnoid Hemorrhage (aSAH) poses a significant health burden globally, necessitating a deeper understanding of its etiology and potential preventive strategies. Recent research has suggested a possible link between gut microbiota composition and the risk of vascularity, prompting investigation into this association using Mendelian Randomization (MR) analysis. Here, we aimed to elucidate the causal relationship between gut microbiota composition and aSAH risk utilizing MR analysis. METHODS: We employed four distinct MR methodologies, including inverse variance weighted (IVW), MR-Egger, weighted median, and weighted mode, to assess the causal nexus between gut microbiota composition and aSAH risk. Genetic instrumental variables (IVs) associated with gut microbiome composition were selected from a comprehensive multiethnic genome-wide association study (GWAS) involving 18,473 individuals across diverse geographic regions. Sensitivity analyses were conducted to detect potential heterogeneity and pleiotropy. RESULTS: Our Mendelian Randomization (MR) analyses unveiled a substantial and statistically significant causal relationship between gut microbiota composition and the risk of Aneurysmal Subarachnoid Hemorrhage (aSAH). Employing the Inverse Variance Weighted (IVW) method, we observed negative associations between aSAH and specific taxonomic levels of gut microbiota. Specifically, the IVW approach identified significant associations with one order, Victivallales (PIVW=0.047, OR: 0.78, 95 % CI: 0.62-0.99), one family, Porphyromonadaceae (PIVW=0.03, OR: 0.64, 95 % CI: 0.43-0.95), one class, Lentisphaeria (PIVW=0.047, OR: 0.78, 95 % CI: 0.62-0.99), and three genera: Bilophila (PIVW=0.02, OR: 0.68, 95 % CI: 0.50-0.93), Fusicatenibacter (PIVW=0.04, OR: 0.69, 95 % CI: 0.49-0.98), and Ruminococcus1 (PIVW=0.01, OR: 0.51, 95 % CI: 0.32-0.84). These findings were consistent across various MR methodologies, underscoring the robustness of our results. Sensitivity analyses further validated the stability of our findings, with no evidence of heterogeneity or pleiotropy detected. CONCLUSION: Our study provides compelling evidence supporting a causal relationship between gut microbiota composition and the risk of aSAH. These findings underscore the potential therapeutic implications of modulating gut microbiota to prevent and manage aSAH. Further research is warranted to explore the underlying mechanisms and develop targeted interventions aimed at mitigating aSAH risk through gut microbiota modulation.

BL-918 Alleviates Early Brain Injury in Rats After Subarachnoid Hemorrhage by Reducing Oxidative Stress and Promoting Mitophagy Through the ULK1/PINK1/Parkin Pathway.

BACKGROUND AND PURPOSE: Oxidative stress plays a critical role in early brain injury (EBI) following subarachnoid hemorrhage (SAH). The small molecule ULK1 agonist, BL-918, demonstrated neuroprotective effects in other central nervous system diseases; however, its role in SAH has not yet been explored. This study aimed to evaluate whether BL-918 could provide neuroprotective effects in rats following SAH. METHODS: An SAH model was established in Sprague-Dawley rats using endovascular perforation. BL-918 was administered intraperitoneally after SAH, while the ULK1 inhibitor SBI was given intraperitoneally prior to SAH modeling. PINK1 siRNA was administered into the lateral ventricle before SAH induction. The neuroprotective effects and mechanisms of BL-918 were assessed through SAH grading, brain water content measurement, blood-brain barrier permeability, neurobehavioral tests, Western blot, immunofluorescence, TUNEL staining, DHE staining, and transmission electron microscopy (TEM). RESULTS: After SAH, the expression levels of p-ULK1, PINK1, Parkin, and LC3Ⅱ increased, peaking at 24 hours post-SAH. BL-918 treatment improved neurological function in rats, reduced brain water content and blood-brain barrier permeability, and exhibited anti-oxidative stress and anti-apoptotic effects. Western blot analysis revealed that BL-918 increased the expression of p-ULK1, PINK1, Parkin, LC3Ⅱ, Bcl-xl, and Bcl-2 while inhibiting the expression of Bax and Cleaved Caspase-3. Oxidative stress-related indicators showed that BL-918 alleviated oxidative stress. Immunofluorescence and TEM results demonstrated that BL-918 promoted mitophagy and preserved mitochondrial morphology. Furthermore, the positive effects of BL-918 were reversed by SBI and PINK1 siRNA, respectively. CONCLUSION: BL-918 promoted mitophagy through the ULK1/PINK1/Parkin signaling pathway, reduced oxidative stress following SAH, and improved both short-term and long-term neurological impairments. Thus, BL-918 treatment may offer a novel therapeutic approach for patients with SAH.

Therapeutic implications for the PD-1 axis in cerebrovascular injury.

Since the discovery and characterization of the PD-1/PD-L pathway, mounting evidence has emerged regarding its role in regulating neuroinflammation following cerebrovascular injury. Classically, PD-L1 on antigen-presenting cells or tissues binds PD-1 on T cell surfaces resulting in T cell inhibition. In myeloid cells, PD-1 stimulation induces polarization of microglia and macrophages into an anti-inflammatory, restorative phenotype. The therapeutic potential of PD-1 agonism in ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage-related vasospasm, and traumatic brain injury rests on the notion of harnessing the immunomodulatory function of immune checkpoint pathways to temper the harmful effects of immune overactivation and secondary injury while promoting repair and recovery. Immune checkpoint agonism has greater specificity than the wider and non-specific anti-inflammatory effects of other agents, such as steroids. PD-1 agonism has already demonstrated success in clinical trials for rheumatoid arthritis and is being tested in other chronic inflammatory diseases. Further investigation of PD-1 agonism as a therapeutic strategy in cerebrovascular injury can help clarify the mechanisms underlying clinical benefit, develop drugs with optimal pharmacodynamic and pharmacokinetic properties, and mitigate unwanted side effects.

Coil Embolization of a Ruptured Anterior Spinal Artery Aneurysm Associated with Spinal Cord Arteriovenous Malformation.

The present report describes a patient with spinal cord arteriovenous malformation (AVM) and an associated anterior spinal artery aneurysm presenting with subarachnoid hemorrhage. Diagnostic spinal angiography revealed an intramedullary AVM, located at the T10-T11 level, and a prenidal saccular aneurysm at the junction of the radiculomedullary artery and the anterior spinal axis, fed by the right T8 segmental artery. The patient underwent successful selective coil embolization of the aneurysm. Follow-up angiography 3 months postoperatively showed no recurrence of the aneurysm.

Dietary factors and the incidence of intracranial aneurysms: a Mendelian randomization research.

BACKGROUND: Intracranial aneurysms (IAs) pose a significant threat to morbidity and mortality, yet their etiology remains inadequately comprehended. The present study employs Mendelian randomization (MR) to investigate the relationship among dietary elements with IAs, encompassing unruptured intracranial aneurysms (uIA) as well as aneurysmal subarachnoid hemorrhage (aSAH). METHODS: The current study employed a double-sample MR test utilizing genome-wide association study (GWAS) summary data from the IEU and IAs' meta-analysis to investigate the genetically predicted consumption levels of various dietary factors using GWAS data. Causation was assessed by techniques of MR-Egger, weighted mode, and median, as well as IVW. To guarantee the accuracy of the results, pleiotropy and heterogeneity evaluations were also carried out. RESULTS: The findings of the study indicate a positive correlation between the intake of alcohol, lamb/mutton, and pork with the risk of IAs (IVW all p < 0.05). Conversely, a negative correlation was observed regarding dried fruit consumption and the risk of aSAH (IVW p < 0.05). There was only scant evidence supporting the association between alcohol intake frequency and an elevated risk of uIA (IVW method p < 0.05). The MR analysis outcomes were authenticated by the MR-PRESSO method and were deemed reliable. Furthermore, sensitivity calculations, such as pleiotropy and homogeneity test, leave-one-out evaluation, and funnel charts, validated the robustness of the results. CONCLUSIONS: The findings suggest that reducing alcohol, lamb/mutton, and pork intake, and increasing dried fruit intake may be potential strategies for the prevention of IAs and aSAH. Additional research is necessary to validate these outcomes and elucidate the underlying mechanisms.

Systematic review and comparative analysis of endovascular and microsurgical management of giant ruptured fusiform mca aneurysms with illustrative cases.

BACKGROUND: Despite advances in neurosurgical techniques and technology, the management of ruptured giant fusiform MCA aneurysms remains challenging. In the literature, microsurgical intervention is the most commonly described approach. However, recent advancements in endovascular techniques have expanded therapeutic options and as a result there is no consensus on the optimal management of these aneurysms. METHODS: A literature search was performed through the PubMed, Google Scholar, and Embase databases, for surgical and endovascular management of ruptured giant fusiform MCA aneurysms. Inclusion criteria included: fusiform morphology, hemorrhage, major diameter greater than 2.5 cm and located along the MCA. RESULTS: Literature review yielded 21 studies published from 1981 to 2023 and a total of 32 patients ages 33.40 ± 18.28. The male to female ratio was 1.9:1. The average Hunt and Hess score upon presentation in the total population was 2.78 ± 1.48, and the average pre-operative mRS of the total population was 2.75 ± 1.83. The average major diameter was 3.80 ± 1.85 cm. Average follow-up was 8.9 ± 9.74 months. There was no statistical difference in age (p = 0.5609), pre-operative mRS (p = 0.2355), Hunt and Hess scale (p = 0.183), aneurysm major diameter (p = 0.594) or follow-up (0.8922) between the two modalities. There was no significant difference in clinical outcome between microsurgical and endovascular intervention, nor was there a significant difference when stratified according to sex, major diameter, or location along the MCA. Two case examples are presented after management with cerebral revascularization. CONCLUSION: Our analysis underscores the absence of statistical differences in clinical outcomes between microsurgical and endovascular strategies for ruptured giant fusiform MCA aneurysms, which highlights the need for complex surgical revascularization as represented on the illustrative cases where no endovascular option was available.

Silk vista baby flow diversion beyond the circle of Willis: A single-center experience with long-term outcomes.

INTRODUCTION: There is a lack of evidence of flow diversion (FD) safety for aneurysms treatment beyond the circle of Willis. Therefore, we provide a single-center real-world experience with the Silk Vista Baby (SVB). METHODS: A single-center database was retrospectively reviewed for aneurysms treated with SVB flow diverters. Demographic information, clinical presentation, radiographic characteristics, procedural complications, and outcomes were assessed. RESULTS: About 57 patients (66.7% female, mean age 54.3 ± 13.2) encompassing 57 aneurysms were included. Overall, 40.4% were ruptured: 68.4% saccular, 17.5% blister, 8.7% fusiform, and 5.3% dissecting. The majority were in the anterior circulation (68.4%), and in 48.2% of cases, the distal vessel diameter was inferior to 2 mm. The symptomatic ischemic rate was 5.2%, with one case due to in-stent thrombosis (1.8%). There were no hemorrhagic complications. Complication rates did not differ between ruptured and unruptured lesions (p = 0.356). There were no cases of delayed aneurysm rupture, and overall mortality was 1.8%. The median follow-up time was 18 ± 12 months. In-stent stenosis rate was 10.5% (6/57), all of which were asymptomatic. At the last follow-up, 70.2% of cases had an adequate occlusion (OKM C and D), and 96.5% had an mRS of 0-2. CONCLUSION: In our series, SVB was shown to be a safe device in the treatment of not only distal anterior circulation aneurysms but also in the management of complex posterior fossa and ruptured blister aneurysms. Multicenter studies are needed to confirm and generalize these results.

The ABCs of Subarachnoid Hemorrhage Blood Volume Measurement: A Simplified Quantitative Method Predicts Outcomes and Delayed Cerebral Ischemia.

BACKGROUND: We developed a simplified ABC/2-derived method to estimate total subarachnoid hemorrhage volume (SAHV) on noncontrast computed tomography in patients with aneurysmal SAH and compared the clinical and radiographic outcomes. METHODS AND RESULTS: In this retrospective observational cohort study, we analyzed 277 patients with SAH admitted to our Comprehensive Stroke Center between 2012 and 2022. We derived a mathematical model (model 1) by measuring SAH basal cisternal blood volume using an ABC/2-derived ellipsoid formula (A=width/thickness, B=length, C=vertical extension) on head noncontrast computed tomography in 5 major SAH cisternal compartments. We compared model 1 against a manual segmentation method (model 2) on noncontrast computed tomography. Data were analyzed using logistic regression analysis, t test, receiver operator characteristic curves, and area under the curve analysis. There was no significant difference in cisternal SAHV analysis between the 2 models (P=0.14). Mean SAHV by the simplified method was 7.0 mL (95% CI, 5.89-8.09) for good outcome and 16.6 mL (95% CI, 13.49-19.77) for poor outcome. Patients with delayed cerebral ischemia had higher SAHV, with a cutoff value of 10 mL. CONCLUSIONS: Our simplified ABC/2-derived method to estimate SAHV is comparable to manual segmentation and can be performed in low-resource settings. Higher total SAHV was associated with worse outcomes and higher risk of delayed cerebral ischemia. A potential dose-response relationship was observed, with SAHV >10 mL predicting worse outcomes and higher risk of DCI.

Usefulness of plasma glucose to potassium ratio in predicting the short-term mortality of patients with aneurysmal subarachnoid hemorrhage.

Rationale and objectives: To investigate the relationship between the glucose/potassium ratio (GPR) at admission and 30-day mortality in patients diagnosed with aneurysmal subarachnoid hemorrhage (SAH) in the emergency department (ED). Materials and methods: Patients with a modified Rankin Scale (mRS) score of ≤2 before SAH and patients aged 18 years or older were included in the study. The patients were divided into two groups based on their functional outcomes (poor-good) and 30-day mortality rates (survivor and non-survivor) and their clinical and laboratory values were compared. Results: The study included 134 patients with a mean age of 65.9 ± 16.7 years, of whom 68 (50.7 %) were female. The mean glucose and GPR levels in the poor functional outcome group were significantly higher than those in the good functional outcome group (p = 0.003, p = 0.03, respectively). The mean glucose and GPR levels in the non-survivor group were significantly higher than those in the survivor group (p = 0.004, p = 0.023, respectively). Multivariate logistic regression analysis identified GPR as an independent predictor of 30-day mortality (p = 0.043, OR: 4.041, 95 % CI: 1.45-26.147), alongside the Rankin Scale score (p = 0.002, OR: 12.714, 95 % CI: 2.578-62.706). Other variables, including age, Hunt-Hess score, and Glasgow Coma Scale, were not statistically significant. Conclusion: The findings indicate that the GPR is a significant independent predictor of short-term mortality in patients with aneurysmal subarachnoid hemorrhage. The translation of these findings into clinical practice may help achieve better outcomes in the management of SAH patients.