Unruptured Intradural Posterior Circulation Dissecting/Fusiform Aneurysms Natural History and Treatment Outcome.

BACKGROUND: The natural history and outcome of unruptured posterior circulation dissecting fusiform aneurysms is not fully understood. These have a high risk of morbidity and mortality, not only due to natural history but also due to the challenging and controversial treatment approaches currently available compared to other types of intracranial aneurysms. METHODS: We performed a retrospective study of a prospectively collected aneurysm database at a quaternary neurovascular hospital. We included consecutive patients with unruptured intradural vertebrobasilar dissecting aneurysms between January 2000 and July 2016 who were followed to 2020. Description of baseline, procedural, and outcomes data was performed. Comparisons of patient who had aneurysm rupture on follow-up, increase in 2 or more points of mRS in follow-up and progression of the aneurysm was performed. RESULTS: Seventy patients with 78 fusiform posterior circulation aneurysms were identified. Thirty-nine (55.7%) patients were male with a mean age of 51.7 years (SD ± 17.6). When multiple, aneurysms were more likely to be fusiform (60%) than saccular (40.0%). Baseline diameter (measured on CTA/MRA/DSA), length as well as symptomatic presentation were significantly higher in aneurysms which grew over time. Coronary disease, diabetes and growth were associated an >2 increase in mRS. Diabetes as well as initial symptomatic presentation were associated with rupture. CONCLUSIONS: Unruptured dissecting/fusiform aneurysm are associated with a considerable rate of rupture during follow-up. Growth is associated with morbidity even in the absence of rupture. Initial large size, coronary disease, diabetes, and to a lesser extent female gender may merit closer follow-up and/or prophylactic treatment.

Mechanical thrombectomy first versus direct angioplasty or stenting for the treatment of intracranial atherosclerotic stenosis-related large vessel occlusion: protocol for a systematic review and meta-analysis.

INTRODUCTION: Mechanical thrombectomy (MT) using stent retrievers or a direct aspiration first-pass technique has proven to yield better results over intravenous thrombolysis in treating acute ischaemic stroke caused by large vessel occlusion (LVO). However, the treatment of intracranial atherosclerotic stenosis-related LVO remains unclear and has been a critical problem in daily clinical practice, as it can cause a relatively high failure rate for MT. Whether direct angioplasty and/or stenting is clinically feasible and shows advantage in reducing delay to revascularisation with better functional outcome compared with MT with rescue angioplasty and/or stenting remains unclear. This study seeks to provide direct and practical clinical evidence for clinicians. METHODS AND ANALYSIS: The main databases of PubMed, the Cochrane library, Embase and Web of Science will be screened for related studies published after1 January 2015. Primary outcomes include successful recanalisation and 90-day favourable outcome. Secondary outcomes include puncture to revascularisation time, vascular complication (perforation, dissection and vasospasm), intracerebral haemorrhage, hospital-related complications and 90-day mortality. The Newcastle-Ottawa Scale will be adopted to assess risk bias of observational studies. The I 2 statistic will be used to assess heterogeneity. ETHICS AND DISSEMINATION: No primary data of patients are needed. Therefore, ethics approval is unnecessary. The results of this systematic review and meta-analysis will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42021268061.

Sex differences in outcomes after mechanical thrombectomy for acute ischemic stroke in the 'real world': protocol for a systematic review and meta-analysis study.

INTRODUCTION: Mechanical thrombectomy (MT) had been regarded as the first-line therapy for acute ischaemic stroke patients. The sex differences in post-MT treatment outcomes were analysed by randomised controlled trial (RCT) studies with inconsistent conclusions. We suggest the results from the real-world data may differ from RCT containing studies. Therefore, the sex difference in non-clinical trial populations needs to be clarified. METHODS AND ANALYSIS: In order to obtain relative studies comprehensively, we will search the main document databases, consisting of Web of Science, Medline in Ovid, Embase in Ovid and Cochrane Library, and trials registers, including Clinical Trails register. The clinical outcomes of real-world studies published between January 2015 and March 2022 will be included. The assessment methods of bias risk will be performed according to study type. The inclusion of studies, evaluation of risk and publication bias, data extraction will be implemented by two reviewers, respectively. The primary outcomes include successful recanalisation and 90-day favourable outcome. Secondary outcomes include vascular complication, hospital-related complications, death during hospital stay and follow-up, and intracerebral haemorrhage. The risk bias of observational studies will be evaluated by Newcastle-Ottawa Scale. I2 statistic will be used to perform the assessment of study heterogeneity. ETHICS AND DISSEMINATION: With no need of ethics approval in this review, results in this review ground on public data. The results of the study will be eventually presented at international conferences or in a related journal. PROSPERO REGISTRATION NUMBER: CRD42021242597.

Safety of endovascular therapy for symptomatic intracranial artery stenosis: a national prospective registry.

INTRODUCTION: The safety outcomes of endovascular therapy for intracranial artery stenosis in a real-world stetting are largely unknown. The Clinical Registration Trial of Intracranial Stenting for Patients with Symptomatic Intracranial Artery Stenosis (CRTICAS) was a prospective, multicentre, real-world registry designed to assess these outcomes and the impact of centre experience. METHODS: 1140 severe, symptomatic intracranial arterial stenosis (ICAS) patients treated with endovascular therapy were included from 26 centres, further divided into three groups according to the annual centre volume of intracranial angioplasty and stent placement procedures over 2 years: (1) high volume for ≥25 cases/year; (2) moderate volume for 10-25 cases/year and (3) low volume for <10 cases/year. RESULTS: The rate of 30-day stroke, transient ischaemic attack or death was 9.7% (111), with 5.4%, 21.1% and 9.7% in high-volume, moderate-volume and low-volume centres, respectively (p<0.05). Multivariable logistic regression confirmed high-volume centres had a significantly lower primary endpoint compared with moderate-volume centres (OR=0.187, 95% CI: 0.056 to 0.627; p≤0.0001), while moderate-volume and low-volume centres showed no significant difference (p=0.8456). CONCLUSION: Compared with the preceding randomised controlled trials, this real-world, prospective, multicentre registry shows a lower complication rate of endovascular treatment for symptomatic ICAS. Non-uniform utilisation in endovascular technology, institutional experience and patient selection in different volumes of centres may have an impact on overall safety of this treatment.

Endovascular treatment versus standard medical treatment for acute basilar artery occlusion: protocol for a systematic review and meta-analysis.

INTRODUCTION: Acute basilar artery occlusion (BAO) can cause posterior circulation stroke. There are two predominant therapies for BAO: standard medical treatment (SMT) and SMT plus endovascular thrombectomy (EVT). However, a conclusive systematic comparison of the safety and efficacy of SMT and those of SMT plus EVT for the treatment of BAO is lacking. Thus, a systematic review and meta-analysis is needed to evaluate the safety and efficacy of SMT and SMT plus EVT for the treatment of BAO. METHODS AND ANALYSIS: This protocol is drafted referring to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols guidelines. We will search eligible studies from four main databases including MEDLINE, Web of Science, Cochrane Library and Embase. Randomised controlled trials (RCTs) and observational studies published before 1 October 2020 will be included. Two reviewers in our team will conduct the study selection and data extraction independently. Risk of bias will be assessed by Cochrane Collaboration criteria and the Newcastle-Ottawa scale for RCTs and observational studies, respectively. We will assess the good functional outcomes defining the modified Rankin scale score ≤2 at 90 days after treatment, short-term stroke severity as National Institutes of Health Stroke Scale score at 24 hours after intervention, and successful recanalisation as a modified Thrombolysis in Cerebral Infarction scale score of ≥2b after intervention. Also, safety outcomes will be assessed. The performance of this meta-analysis will depend on the quantity of included studies. The assessment of study heterogeneity will be performed by the I2 statistic. If there is mild heterogeneity (I2<20%) of intervention outcomes in included studies, the fixed-effect model will be applied; otherwise, the random-effect model will be performed. Subgroup analyses and an assessment of publication bias will also be conducted with sufficient data. ETHICS AND DISSEMINATION: No collection of primary data from patients is needed. Therefore, the ethical approval is unnecessary. The results may be presented in a peer-reviewed journal and related conferences. PROSPERO REGISTRATION NUMBER: CRD42020176764.

#Fake news: a systematic review of mechanical thrombectomy results among neurointerventional stroke surgeons on Twitter.

OBJECTIVE: Twitter is a popular social media platform among physicians. Neurointerventionalists frequently document their lifesaving mechanical thrombectomy cases on Twitter with very favorable results. We fear that there may be some social media publication bias to tweeted mechanical thrombectomy cases with neurointerventionalists being more likely to tweet cases with favorable outcomes. We used these publicly documented cases to analyze post-intervention Twitter-reported outcomes and compared these outcomes with the data provided in the gold standard literature. METHODS: Two reviewers performed a search of Twitter for tweeted cases of acute ischemic strokes treated with mechanical thrombectomy. Data were abstracted from each tweet regarding baseline characteristics and outcomes. Twitter-reported outcomes were compared with the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke (HERMES) trial individual patient meta-analysis. RESULTS: When comparing the tweeted results to HERMES, tweeted cases had a higher post-intervention rate of modified Thrombolysis In Cerebral Infarction (mTICI) scale score of 2c/3 (94% vs 71%, respectively; p<0.0001) and rate of National Institutes of Health Stroke Scale (NIHSS) score ≤2 (81% vs 21%, respectively; p<0.0001). There were no reported complications; thus, tweeted cases also had significantly lower rates of complications, including symptomatic intracerebral hemorrhage (0% vs 4.4%, respectively; p<0.0001), type 2 parenchymal hemorrhage (0% vs 5.1%, respectively; p<0.0001), and mortality (0% vs 15.3%, respectively; p<0.0001). CONCLUSIONS: There is a significant difference between social media and reality even within the 'MedTwitter' sphere, which is likely due to a strong publication bias in Twitter-reported cases. Content on 'MedTwitter', as with most social media, should be accepted cautiously.

Rationale and design for the detection and neurological impact of cerebrovascular events in non-cardiac surgery patients cohort evaluation (NeuroVISION) study: a prospective international cohort study.

OBJECTIVES: Covert stroke after non-cardiac surgery may have substantial impact on duration and quality of life. In non-surgical patients, covert stroke is more common than overt stroke and is associated with an increased risk of cognitive decline and dementia. Little is known about covert stroke after non-cardiac surgery.NeuroVISION is a multicentre, international, prospective cohort study that will characterise the association between perioperative acute covert stroke and postoperative cognitive function. SETTING AND PARTICIPANTS: We are recruiting study participants from 12 tertiary care hospitals in 10 countries on 5 continents. PARTICIPANTS: We are enrolling patients ≥65 years of age, requiring hospital admission after non-cardiac surgery, who have an anticipated length of hospital stay of at least 2 days after elective non-cardiac surgery that occurs under general or neuraxial anaesthesia. PRIMARY AND SECONDARY OUTCOME MEASURES: Patients are recruited before elective non-cardiac surgery, and their cognitive function is measured using the Montreal Cognitive Assessment (MoCA) instrument. After surgery, a brain MRI study is performed between postoperative days 2 and 9 to determine the presence of acute brain infarction. One year after surgery, the MoCA is used to assess postoperative cognitive function. Physicians and patients are blinded to the MRI study results until after the last patient follow-up visit to reduce outcome ascertainment bias.We will undertake a multivariable logistic regression analysis in which the dependent variable is the change in cognitive function 1 year after surgery, and the independent variables are acute perioperative covert stroke as well as other clinical variables that are associated with cognitive dysfunction. CONCLUSIONS: The NeuroVISION study will characterise the epidemiology of covert stroke and its clinical consequences. This will be the largest and the most comprehensive study of perioperative stroke after non-cardiac surgery. TRIAL REGISTRATION NUMBER: NCT01980511; Pre-results.

Rupture of aneurysms in the immediate post-coiling period.

PURPOSE: We present a series of cases featuring re-rupture of posterior communicating artery aneurysms in the immediate post-coiling period, where clots obscured the neck of the aneurysm during the procedure. We report on the incidence of re-rupture and discuss possible mechanisms behind this phenomenon. METHODS: This study included 462 aneurysms over a 10-year period which were treated with endovascular coiling. 137 of these were ruptured aneurysms. Radiographic and clinical information pertaining to the patients was collected. The immediate post-coiling period was defined as ≤3 days following the procedure. RESULTS: The incidence of re-rupture in the immediate post-coiling period was 1.4% (2/137). Of these two, one received recombinant tissue plasminogen activator and both received acetylsalicylic acid. One patient presented with adjacent hematoma on re-rupture. In both cases, clot obscured the aneurysm neck during the procedure. CONCLUSIONS: Re-rupture of intracranial aneurysms in the immediate post-coiling period is an exceedingly rare complication, and the events leading to it have not been discussed at length. Repeat treatment, follow-up imaging and close observation are merited in the setting of re-rupture of a posterior communicating artery aneurysm.