Thromboembolic Events in the Posterior Circulation after Flow Diversion - A Closer Look at the Coverage of the Posterior Cerebral Artery.

BACKGROUND: Flow diversion (FD) for bifurcation aneurysms requires excluding one of the branches from the parent artery, raising concern for ischemic events. Herein, we evaluate thromboembolic events and their relation with covering the origin of the posterior cerebral artery (PCA). METHODS: This retrospective analysis included patients with confirmed basilar and proximal PCA aneurysms treated with FD between 2013 to 2023. Procedures were classified according to the coverage of the origin of the PCA. Thromboembolic events associated with the excluded PCA were evaluated. RESULTS: Out of the total 28 aneurysms included, 7 were at the basilar-tip, 16 in the basilar trunk, and 5 in the P1-segment; fifteen were treated excluding one of the PCA. DAPT included aspirin-ticagrelor (57.1%), aspirin-clopidogrel (35.7%), and aspirin-prasugrel (3.57%). Complete and near-complete aneurysm occlusion was achieved in 80.8% of aneurysms treated in a median follow-up of 12.31 months. Thromboembolic complications occurred in three patients, two basilar perforator stroke and one basilar in stent thrombosis; but there was no statistically significant difference in these events between patients with PCA coverage and those without (p=0.46). Diminished and lack of flow was seen in eight and seven of the covered vessels. mRS≤2 was reported in 89.3% of patients in a median clinical follow-up of 5.5 months. CONCLUSION: Thromboembolic events are high in distal basilar and proximal PCA aneurysms, but PCA coverage was not associated with their occurrence. There was no difference in post-procedural disability between patients whose aneurysms were treated excluding one of the PCAs, and those who did not.

Flow Diversion as a Definitive Treatment for Recurrently Ruptured A1-A2 Anterior Cerebral Artery Aneurysm Following Clipping and Coiling.

Even after clipping of intracranial aneurysms, patients may experience incomplete occlusion or the future recurrence of their treated aneurysm. This paper presents a distinctive case of a recurrent A1-A2 anterior cerebral artery aneurysm that underwent four interventions over 16 years. The aneurysm was treated with two clippings, subsequent coiling, and flow diversion for definitive treatment. The challenges encountered in managing bifurcation aneurysms are discussed, emphasizing the importance of considering hemodynamic factors, vessel geometry, and recurrence risk factors in treatment decisions. The case highlights the need for closer follow-up of ruptured bifurcation aneurysms due to the higher likelihood of recurrence. The role of flow diverters in reinforcing vessel anatomy and preventing recurrence is also highlighted.

Clipping of a Ruptured Small Anterior Communicating Artery Aneurysm: Technical Video.

In recent years there has been a significant shift in the management of intracranial aneurysms, as most, both ruptured and unruptured, are being treated through an endovascular approach.1-3 However, there are still instances in which open surgical clipping is the best option for definitive management. Both patient factors, such as age and comorbidities, and aneurysm characteristics, such as size, morphology, and location, must be taken into consideration when treating aneurysms. This is especially true for anterior1 communicating artery aneurysms, as these have been treated successfully using multiple different techniques.4,5 There are no absolute guidelines indicating how a particular aneurysm should be treated and, therefore, one must be able to determine how to best manage a patient based on their own skill set, knowledge, and experience. We present a case of a 61-year-old woman who presented with a ruptured anterior communicating artery aneurysm. Initially she was brought to the angiography suite to undergo possible endovascular treatment of the aneurysm, but after reviewing the morphology and size of the aneurysm, we believed that this aneurysm could not be treated safely through an endovascular approach and surgical clipping was the better option. The patient consented to the procedure. In this operative video, we describe the technical aspects of the surgical procedure and the benefits of our approach (Video 1).

Differential DNA methylation associated with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review.

Recent studies suggest that differential DNA methylation could play a role in the mechanism of cerebral vasospasm (CVS) and delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Considering the significance of this matter and a lack of effective prophylaxis against DCI, we aim to summarize the current state of knowledge regarding their associations with DNA methylation and identify the gaps for a future trial. PubMed MEDLINE, Scopus, and Web of Science were searched by two authors in three waves for relevant DNA methylation association studies in DCI after aSAH. PRISMA checklist was followed for a systematic structure. STROBE statement was used to assess the quality and risk of bias within studies. This research was funded by the National Science Centre, Poland (grant number 2021/41/N/NZ2/00844). Of 70 records, 7 peer-reviewed articles met the eligibility criteria. Five studies used a candidate gene approach, three were epigenome-wide association studies (EWAS), one utilized bioinformatics of the previous EWAS, with two studies using more than one approach. Methylation status of four cytosine-guanine dinucleotides (CpGs) related to four distinct genes (ITPR3, HAMP, INSR, CDHR5) have been found significantly or suggestively associated with DCI after aSAH. Analysis of epigenetic clocks yielded significant association of lower age acceleration with radiological CVS but not with DCI. Hub genes for hypermethylation (VHL, KIF3A, KIFAP3, RACGAP1, OPRM1) and hypomethylation (ALB, IL5) in DCI have been indicated through bioinformatics analysis. As none of the CpGs overlapped across the studies, meta-analysis was not applicable. The identified methylation sites might potentially serve as a biomarker for early diagnosis of DCI after aSAH in future. However, a lack of overlapping results prompts the need for large-scale multicenter studies. Challenges and prospects are discussed.

A core-lab adjudicated analysis of single-stent assisted coiling of wide-neck bifurcation aneurysms.

BACKGROUND AND PURPOSE: Core-lab adjudicated data regarding the efficacy of the single-stent assisted aneurysm coiling technique 'L-stenting' are lacking. We present a multicenter, core-lab adjudicated study evaluating the safety and effectiveness of single-stent assisted coiling in the treatment of wide-neck bifurcation aneurysms (WNBAs). METHODS: Consecutive patients who underwent L-stenting for WNBAs at three academic institutions between 2015 and 2019 were included in this retrospective study. Clinical safety and efficacy outcomes were gathered from the patient chart, and angiographic imaging was evaluated by core lab analysis. Safety and efficacy outcomes were summarized and predictors of safety and efficacy were calculated. RESULTS: Of 128 patients treated, 124 had angiographic outcome data at last follow-up. Of those, 110 had adequate (core-lab adjudicated modified Raymond Roy (mRR) score of 1 or 2) occlusion (88.7%). During follow-up, 19 patients (14.8%) required retreatment. There were 17 complications experienced in 12 patients: intraoperative (n=8, 6.25%), perioperative (n=5, 3.9%), or delayed (n=6; n=4 attributed to device/procedure, 3.1%). Significant predictors of complete occlusion were smaller aneurysm size and use of the jailing technique (P=0.0276). Significant predictors of retreatment were larger size, neck size, and larger dome to neck ratio (P=0.0008). CONCLUSION: This study provides multicenter, core-lab adjudicated angiographic data regarding the efficacy of single-stent assisted coiling for WNBAs. This study acts as a validated comparator for future studies investigating novel devices or techniques for treating this challenging subgroup of aneurysms.

Long-Term Outcomes After Stereotactic Radiosurgery for Pediatric Brain Arteriovenous Malformations: A Systematic Review.

BACKGROUND: The long-term outcomes after stereotactic radiosurgery (SRS) for pediatric brain arteriovenous malformations (AVMs) remain poorly understood given the paucity of longitudinal studies. A systematic review was conducted to pool cumulative incidences for all outcomes. METHODS: PubMed, Embase, and Web of Science were queried to systematically extract potential references. The articles relating to AVMs treated via SRS were required to be written in English, involve pediatric patients (<18 years of age), and include a mean follow-up period of >5 years. Individual patient data were obtained to construct a pooled Kaplan-Meier plot on obliteration rates over time. RESULTS: Among the 6 studies involving 1315 pediatric patients averaging a follow-up period of 86.6 months (range, 6-276), AVM obliteration was observed in 66.1% with cumulative probabilities of 48.28% (95% confidence interval [CI], 41.89-54.68), 76.11% (95% CI, 67.50-84.72), 77.48% (95% CI, 66.37-88.59) over 3, 5, and 10 years, respectively. The cumulative incidence of post-SRS hemorrhage, tumors, cysts, and de novo seizures was 7.2%, 0.3%, 1.6%, and 1.5%, respectively. The cumulative incidence of radiation-induced necrosis, edema, radiologic radiation-induced changes (RICs), symptomatic RICs, and permanent RICs were 8.0%, 1.4%, 28.0%, 8.7%, and 4.9%, respectively. CONCLUSIONS: Studies assessing long-term outcomes after SRS are moderate in quality and retrospective. Thus, interpretation with caution is advised given the variable degree of loss to follow-up, which suggests that complication rates may be higher than the values stated in the literature. Future prospective studies are needed to validate these findings.

The Influence of Coagulopathy on Radiographic and Clinical Outcomes in Patients Undergoing Middle Meningeal Artery Embolization as Standalone Treatment for Non-acute Subdural Hematomas.

Middle meningeal artery embolization (MMAE) is emerging as a safe and effective standalone intervention for non-acute subdural hematomas (NASHs); however, the risk of hematoma recurrence after MMAE in coagulopathic patients is unclear. To characterize the impact of coagulopathy on treatment outcomes, we analyzed a multi-institutional database of patients who underwent standalone MMAE as treatment for NASH. We classified 537 patients who underwent MMAE as a standalone intervention between 2019 and 2023 by coagulopathy status. Coagulopathy was defined as use of anticoagulation/antiplatelet agents or pre-operative thrombocytopenia (platelets <100,000/µL). Demographics, pre-procedural characteristics, in-hospital course, and patient outcomes were collected. Thrombocytopenia, aspirin use, antiplatelet agent use, and anticoagulant use were assessed using univariate and multivariate analyses to identify any characteristics associated with the need for rescue surgical intervention, mortality, adverse events, and modified Rankin Scale score at 90-day follow-up. Propensity score-matched cohorts by coagulopathy status with matching covariates adjusting for risk factors implicated in surgical recurrence were evaluated by univariate and multivariate analyses. Minimal differences in pre-operative characteristics between patients with and those without coagulopathy were observed. On unmatched and matched analyses, patients with coagulopathy had higher rates of requiring subsequent surgery than those without (unmatched: 9.9% vs. 4.3%; matched: 12.6% vs. 4.6%; both p < 0.05). On matched multivariable analysis, patients with coagulopathy had an increased odds ratio (OR) of requiring surgical rescue (OR 3.95; 95% confidence interval [CI] 1.68-9.30; p < 0.01). Antiplatelet agent use (ticagrelor, prasugrel, or clopidogrel) was also predictive of surgical rescue (OR 4.38; 95% CI 1.51-12.72; p = 0.01), and patients with thrombocytopenia had significantly increased odds of in-hospital mortality (OR 5.16; 95% CI 2.38-11.20; p < 0.01). There were no differences in follow-up radiographic and other clinical outcomes in patients with and those without coagulopathy. Patients with coagulopathy undergoing standalone MMAE for treatment of NASH may have greater risk of requiring surgical rescue (particularly in patients using antiplatelet agents), and in-hospital mortality (in thrombocytopenic patients).

Safety and Outcomes of the Off-Label Treatment of Intracranial Aneurysms with Pipeline Embolization Device: A Systematic Review and Meta-analysis.

BACKGROUND: Off-label use of pipeline embolization devices (PEDs) has been increasingly used for endovascular treatment of intracranial aneurysms. Numerous articles have highlighted the safety and effectiveness of PED placement from independent centers for both on- and off-label indications. There remains a paucity of information that considers overall safety and efficacy of off-label PED placement across the existing literature. Our objective is to systematically review the safety and occlusion outcomes of PED off-label use in intracranial aneurysm embolization. METHODS: A systematic search of PubMed and Embase was performed to identify studies on off-label use of PED. The selected studies provided relevant information, including study characteristics, patient demographics, clinical outcomes, peri-procedural complications, and long-term outcomes, which were subjected to meta-analysis. RESULTS: Twelve studies met the inclusion and exclusion criteria. There were 747 patients and 791 aneurysms included for analysis. Among the patient, 69.2% were female, with an age range of 16 to 80 years. The overall incidence rates for ischemic and hemorrhagic complications were 7% (95% CI: 4%-10%) and 2% (95% CI: 0%-4%), respectively. The mortality rate was 1% (95% CI: 0%-4%). The occlusion rates of aneurysm at initial follow up and 1 year follow-up were 82% (95% CI: 72%-91%) and 81% (95%CI: 75%-86%), respectively. Meta-regression analysis indicated no correlation between occlusion rate and factors such as age, sex, aneurysm size, location, morphology, rupture, or history of treatment. CONCLUSIONS: Despite variations in results observed in single-center studies, this meta-analysis provides evidence supporting the safety and efficacy of PED off-label use.

Cerebral artery overexpression of the NMUR1 gene is associated with moyamoya disease: a weighted gene co-expression network analysis.

INTRODUCTION: This study aimed to elucidate mechanisms underlying moyamoya disease (MMD) pathogenesis and to identify potential novel biomarkers. We utilized gene coexpression networks to identify hub genes associated with the disease. METHODS: Twenty-one middle cerebral artery (MCA) samples from MMD patients and 11 MCA control samples were obtained from the Gene Expression Omnibus (GEO) dataset, GSE189993. To discover functional pathways and potential biomarkers, weighted gene coexpression network analysis (WGCNA) was employed. The hub genes identified were re-assessed through differential gene expression analysis (DGEA) via DESeq2 for further reliability verification. An additional 4 samples from the superficial temporal arteries (STA) from MMD patients were obtained from GSE141025 and a subgroup analysis stratified by arterial type (MCA vs. STA) DGEA was performed to assess if the hub genes associated with MMD are expressed significantly greater on the affected arteries compared to healthy ones in MMD. RESULTS: WGCNA revealed a predominant module encompassing 139 hub genes, predominantly associated with the neuroactive ligand-receptor interaction (NLRI) pathway. Of those, 17 genes were validated as significantly differentially expressed. Neuromedin U receptor 1 (NMUR1) and thyrotropin-releasing hormone (TRH) were 2 out of the 17 hub genes involved in the NLRI pathway (log fold change [logFC]: 1.150, p = 0.00028; logFC: 1.146, p = 0.00115, respectively). MMD-only subgroup analysis stratified by location showed that NMUR1 is significantly overexpressed in the MCA compared to the STA (logFC: 1.962; p = 0.00053) which further suggests its possible localized involvement in the progressive stenosis seen in the cerebral arteries in MMD. CONCLUSION: This is the first study to have performed WGCNA on samples directly affected by MMD. NMUR1 expression is well known to induce localized arterial smooth muscle constriction and recently, type 2 inflammation which can predispose to arterial stenosis potentially advancing the symptoms and progression of MMD. Further validation and functional studies are necessary to understand the precise role of NMUR1 upregulation in MMD and its potential implications.

General Versus Nongeneral Anesthesia for Middle Meningeal Artery Embolization for Chronic Subdural Hematomas: Multicenter Propensity Score Matched Study.

BACKGROUND AND OBJECTIVES: The choice of anesthesia type (general anesthesia [GA] vs nongeneral anesthesia [non-GA]) in middle meningeal artery embolization (MMAE) procedures for chronic subdural hematomas (cSDH) differs between institutions and left to care team discretion given lack of standard guidelines. We compare the outcomes of GA vs non-GA in MMAE. METHODS: Consecutive patients receiving MMAE for cSDH at 14 North American centers (2018-2023) were included. Clinical, cSDH characteristics, and technical/clinical outcomes were compared between the GA/non-GA groups. Using propensity score matching (PSM), patients were matched controlling for age, baseline modified Rankin Scale, concurrent/prior surgery, hematoma thickness/midline shift, and baseline antiplatelet/anticoagulation. The primary end points included surgical rescue and radiographic success rates (≥50% reduction in maximum hematoma thickness with minimum 2 weeks of imaging). Secondary end points included technical feasibility, procedural complications, and functional outcomes. RESULTS: Seven hundred seventy-eight patients (median age 73 years, 73.2% male patients) underwent 956 MMAE procedures, 667 (70.4%) were non-GA and 280 were GA (29.6%). After running 1:3 PSM algorithm, this resulted in 153 and 296 in the GA and non-GA groups, respectively. There were no baseline/procedural differences between the groups except radial access more significantly used in the non-GA group (P = .001). There was no difference between the groups in procedural technical feasibility, complications rate, length of stay, surgical rescue rates, or favorable functional outcome at the last follow-up. Subsequent 1:1 sensitivity PSM retained the same results. Bilateral MMAE procedures were more performed under non-GA group (75.8% vs 67.2%; P = .01); no differences were noted in clinical/radiographic outcomes between bilateral vs unilateral MMAE, except for longer procedure duration in the bilateral group (median 73 minutes [IQR 48.3-100] vs 54 minutes [39-75]; P < .0001). Another PSM analysis comparing GA vs non-GA in patients undergoing stand-alone MMAE retained similar associations. CONCLUSION: We found no significant differences in radiological improvement/clinical outcomes between GA and non-GA for MMAE.

Comparison of Thromboembolic Events Between Pipeline Embolization Device (PED) Shield and PED/PED Flex: A Propensity Score-Matched Analysis.

BACKGROUND AND OBJECTIVES: The pipeline embolization device (PED) Flex with Shield technology is a third-generation flow diverter used for intracranial aneurysm treatment designed to decrease thrombogenicity through a phosphorylcholine coating. Herein, we aim to compare the rate of thromboembolic events in PED with Shield technology and PED without it through propensity score matching. METHODS: We conducted a retrospective analysis of aneurysms treated with PED first-generation/PED Flex and PED with Shield between 2013 and 2023 at a single academic institution. Patients were matched through propensity score by controlling for confounding factors including age, smoking history, diabetes, previous subarachnoid hemorrhage, modified Rankin Scale pretreatment, location, aneurysm size, previous treatment, and clopidogrel or aspirin resistance. After matching, we evaluated for periprocedural and postoperative thromboembolic events. Data analysis was performed using Stata 14. RESULTS: A total of 543 patients with 707 aneurysms treated in 605 procedures were included in the analysis. From these, 156 aneurysms were treated with PED with Shield (22.07%) and 551 (77.93%) without Shield technology. Propensity score matching resulted in 84 matched pairs. The rate of thromboembolic events was 3.57% for PED Shield and 10.71% for PED first-generation/PED Flex (P = .07), while retreatment rates were 2.38% for PED Shield and 8.32% for PED Flex (P = .09). Complete occlusion at first (P = .41) and last imaging follow-up (P = .71), in-stent stenosis (P = .95), hemorrhagic complications (P = .31), and functional outcomes (P = .66) were comparable for both groups. CONCLUSION: This is the first study in the literature performing a propensity scored-matched analysis comparing PED with PED with Shield technology. Our study suggests a trend toward lower thromboembolic events for PED Shield, even after controlling for aspirin and clopidogrel resistance, and a trend toward lower aneurysm retreatment rates with PED Shield, without reaching statistical significance.

Percutaneous transluminal angioplasty or stenting of petrous and cavernous internal carotid artery stenosis - a systematic review.

Percutaneous transluminal angioplasty (PTA) and stenting have been used for the treatment of internal carotid artery (ICA) stenosis over the past two decades. A systematic review was performed to understand the efficacy of PTA and/or stenting for petrous and cavernous ICA stenosis. In total, 151 patients (mean age 64.9) met criteria for analysis, 117 (77.5%%) were male and 34 (22.5%) were female. Of the 151 patients, 35 of them (23.2%) had PTA, and 116 (76.8%) had endovascular stenting. Twenty-two patients had periprocedural complications. There was no significant difference in the complication rates between the PTA (14.3%) and stent (14.7%) groups. Distal embolism was the most common periprocedural complication. Average clinical follow up for 146 patients was 27.3 months. Eleven patients (7.5%) out of 146 had retreatment. The treatment of petrous and cavernous ICA with PTA and stenting has relatively significant procedure related complication rates and adequate long-term patency.

Direct Versus Indirect Revascularization for Moyamoya: a Large Multicenter Study.

BACKGROUND: Moyamoya is a chronic occlusive cerebrovascular disease of unknown etiology causing neovascularization of the lenticulostriate collaterals at the base of the brain. Although revascularization surgery is the most effective treatment for moyamoya, there is still no consensus on the best surgical treatment modality as different studies provide different outcomes. OBJECTIVE: In this large case series, we compare the outcomes of direct (DR) and indirect revascularisation (IR) and compare our results to the literature in order to reflect on the best revascularization modality for moyamoya. METHODS: We conducted a multicenter retrospective study in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines of moyamoya affected hemispheres treated with DR and IR surgeries across 13 academic institutions predominantly in North America. All patients who underwent surgical revascularization of their moyamoya-affected hemispheres were included in the study. The primary outcome of the study was the rate of symptomatic strokes. RESULTS: The rates of symptomatic strokes across 515 disease-affected hemispheres were comparable between the two cohorts (11.6% in the DR cohort vs 9.6% in the IR cohort, OR 1.238 (95% CI 0.651 to 2.354), p=0.514). The rate of total perioperative strokes was slightly higher in the DR cohort (6.1% for DR vs 2.0% for IR, OR 3.129 (95% CI 0.991 to 9.875), p=0.052). The rate of total follow-up strokes was slightly higher in the IR cohort (8.1% vs 6.6%, OR 0.799 (95% CI 0.374 to 1.709) p=0.563). CONCLUSION: Since both modalities showed comparable rates of overall total strokes, both modalities of revascularization can be performed depending on the patient's risk assessment.

Management of Intracranial Aneurysms that Do Not Occlude on Initial Follow-up After Treatment With the Pipeline Embolization Device.

BACKGROUND AND OBJECTIVES: The pipeline embolization device (PED) has become widely accepted as a safe and efficacious treatment for intracranial aneurysms with high rates of complete occlusion at initial follow-up. For aneurysms that are not completely occluded at initial follow-up, further treatment decision-making is varied. Furthermore, the risk of aneurysmal rupture in these incompletely occluded aneurysms after PED is not known. The objective of this study was to determine treatment decision-making that results in increased occlusion status at final follow-up and to evaluate risk of rupture in those aneurysms that do not go onto occlusion. METHODS: This study is a retrospective review of prospective data for intracranial aneurysms treated with PED at two institutions from 2013 to 2019. Aneurysms with near-complete or incomplete occlusion at initial follow-up were included in the statistical analysis. RESULTS: There were 606 total aneurysms treated at two academic institutions with PED with incomplete occlusion at initial follow-up in 134 aneurysms (22.1%). Of the 134 aneurysms that were nonoccluded at initial follow-up, 76 aneurysms (56.7%) went on to complete or near complete occlusion with final complete or near complete occlusion in 90.4% of all aneurysms treated. The time to final imaging follow-up was 28.2 months (13.8-44.3) Retreatment with a second flow diverter was used in 28 aneurysms (20.9%). No aneurysms that were incompletely occluded at initial follow-up had delayed rupture. Furthermore, older patient age was statistically significant for incomplete occlusion at initial follow-up ( P = .05). CONCLUSION: Intracranial aneurysms treated with the PED that do not occlude at initial follow-up may go on to complete occlusion with continuous observation, alteration in antiplatelet regimens, or repeat treatment. Delayed aneurysmal rupture was not seen in patients with incomplete occlusion.

Predictors for Rupture of Small (<7mm) Intracranial Aneurysms: A Systematic Review and Meta-Analysis.

INTRODUCTION: Identifying predictors for rupture of small intracranial aneurysms (sIAs) have become a growing topic in the literature given the relative paucity of data on their natural history. The authors performed a meta-analysis to identify reliable predictors. METHODS: PubMed, Scopus, and Web of Science were used to systematically extract references which involved at least 10 IAs <7mm which including a control group experiencing no rupture. All potential predictors reported in the literature were evaluated in the meta-analysis. RESULTS: Fifteen studies yielding 4,739 sIAs were included in the meta-analysis. Four studies were prospective and 11 were retrospective. Univariate analysis identified 7 predictors which contradicted or are absent in the current scoring systems, while allowing to perform subgroup analysis for further reliability: patient age (MD -1.97, 95%CI -3.47-0.48; P = 0.01), the size ratio (MD 0.40, 95%CI 0.26-0.53; P < 0.00001), the aspect ratio (MD 0.16, 95%CI 0.11-0.22; P < 0.00001), bifurcation point (OR 3.76, 95%CI 2.41-5.85; P < 0.00001), irregularity (OR 2.95, 95%CI 1.91-4.55; P < 0.00001), the pressure loss coefficient (MD -0.32, 95%CI -0.52-0.11; P = 0.002), wall sheer stress (Pa) (MD -0.16, 95%CI -0.28-0.03; P = 0.01). All morphology related predictors listed above have been confirmed as independent predictors via multivariable analysis among the individual studies. CONCLUSIONS: Morphology related predictors are superior to the classic patient demographic predictors present in most scoring systems. Given that morphology predictors take time to measure, our findings may be of great interest to developers seeking to incorporate artificial intelligence into the treatment decision-making process.

The effect of patient age on the degree of midline shift caused by chronic subdural hematomas: a volumetric analysis.

OBJECTIVE: Chronic subdural hematomas (CSDHs) are the among the most common conditions treated by neurosurgeons. Midline shift (MLS) is used as a radiological marker of CSDH severity and the potential need for urgent surgical evacuation. However, a patient's age may affect the degree of MLS for a given hematoma volume. This study aimed to investigate the correlation between the patient's age and the MLS caused by CSDH. METHODS: The database of patients treated for CSDH was reviewed in a single institution. Patients with unilateral CSDH were included. To measure CSDH volume, the preprocedural head CT scans underwent 3D volumetric reconstruction using the TeraRecon software. The effect of age on MLS after adjusting for CSDH volume was investigated using linear regression analysis. RESULTS: Sixty-nine hematomas in 69 patients were included. The age of patients ranged from 25 to 94 years (mean 71.6 years). Hematoma volume and MLS ranged from 27.8 to 215 mL (mean 99.3 mL) and 0-17 mm (mean 6.5 mm), respectively. On multivariate regression analysis, MLS showed a significant independent negative correlation with age after adjusting for CSDH volume (OR -0.11, 95% CI -0.16 to -0.06; p < 0.001), meaning that for a fixed CSDH volume, with each 10-year increase in age the MLS will reduce by 1.1 mm. Moreover, MLS-to-volume ratio showed a significant negative linear correlation with age (r2 = 0.32; p < 0.001). Ten-milliliter increments in CSDH volume resulted in a 1.09-mm increase in MLS in patients younger than 60 years, which is 2.4-fold higher compared to the 0.46-mm increase in those older than 75 years (p < 0.001). CONCLUSIONS: For a fixed CSDH volume, older age correlates with significantly lower MLS. This could be explained by higher parenchymal compliance in older individuals due to increased brain atrophy, and a larger subdural space. Clinical use of MLS to estimate severity of CSDH and gauge treatment decisions should take the patient's age into account.

Acute Coiling With Delayed Flow Diversion for Posterior Communicating Segment Internal Carotid Artery Aneurysms: A Multicenter Case Series.

BACKGROUND AND OBJECTIVES: In ruptured posterior communicating artery (PcomA) aneurysms, the protection of the aneurysm dome alone with initial subtotal coiling decreases the risk of rerupture in the acute setting but does not provide durable/definitive long-term protection against delayed rupture. Delayed flow diverter (FD) placement can be a potential alternative to definitively secure these aneurysms without increasing the risk of complications and PComA occlusion. We analyzed PComA aneurysms treated with a planned delayed FD after primary coiling and assess radiographic and clinical outcomes. METHODS: We performed a retrospective study of prospectively collected data for intracranial aneurysms treated with planned FD at 2 institutions from 2013 to 2022. PComA aneurysms that underwent primary coiling and delayed FD placement were included for analysis. RESULTS: There were 29 PComA aneurysms identified that were included in the analysis. Patients were mostly female (79.3%), with a median age of 60 years. The mean aneurysm maximum diameter was 7.2 mm ± (5.3). Immediate Raymond-Roy occlusion grade after primary coiling was I in 48.3%, II in 41.4%, and III in 10.3% of aneurysms. The median time from initial coiling to planned delayed FD placement was 6.3 months (3.2-18.6). A total of 21 (72.4%) aneurysms underwent follow-up radiological imaging. Complete and near-complete occlusion status was achieved in 76.2% of the evaluated aneurysms. There were no retreatments and no evidence of delayed aneurysm rupture. One case (3.5%) presented thromboembolic complications and 1 (3.5%) intracranial hemorrhagic complication after FD placement, which was associated with mortality. Most patients (90.5%) had a modified Rankin scale of ≤2 on the last follow-up. CONCLUSION: Primary coiling with planned staged FD placement is effective for treating ruptured PComA aneurysms with high occlusion rates and low complications.

Predictors for a Collar Sign and its Association with Outcomes in Aneurysms after Pipeline Embolization.

BACKGROUND: The collar sign has been previously described as an angiographic indicator of incomplete occlusion after deployment of a pipeline embolization device (PED) for intracranial aneurysms. In the present study, we explore the predictors for a collar sign in aneurysms treated with the PED. METHODS: Aneurysms with a collar sign at the initial follow-up angiogram were identified in a retrospective review of single-center data. The predictors of a collar sign were analyzed through univariate and multivariate analyses. RESULTS: A total of 492 cases of cerebral aneurysm treated with the PED were identified. Among them, 53 were found to have a collar sign on the initial follow-up angiogram. Univariate analysis showed that previous treatment of the same aneurysm (odds ratio [OR], 2.46; P = 0.01), a branch vessel from the aneurysm neck or dome (OR, 6.2; P < 0.001), and a smaller aneurysm neck size (OR, 0.75; P = 0.01) were all predictors for the presence of a collar sign. A larger diameter (OR, 0.92; P = 0.06), increased dome/neck ratio (OR, 1.38; P = 0.1), increased aspect ratio (OR, 1.14; 0 P =.17), and previous treatment showed a trend toward an association with a collar sign. However, after multivariate analysis, a branch from the aneurysm neck or dome (OR, 6.23; P < 0.001), aneurysm diameter (OR, 0.75; P = 0.032), an increased dome/neck ratio (OR, 4.62; P = 0.006), and previous treatment were the strongest predictors for a collar sign. CONCLUSIONS: The presence of a branch vessel arising from the aneurysm neck or dome, an increased dome/neck ratio, aneurysm diameter, and previous treatment are the strongest predictive factors for a collar sign in the angiographic follow-up of PED-treated aneurysms.