Sex-dependent characteristics and outcomes after clipping of unruptured intracranial aneurysms: a multicenter propensity score-matched study.

OBJECTIVE: Disparities in the epidemiology and growth rates of aneurysms between the sexes are known. However, little is known about sex-dependent outcomes after microsurgical clipping of unruptured intracranial aneurysms (UIAs). The aim of this study was to examine sex differences in characteristics and outcomes after microsurgical clipping of UIAs and to perform a propensity score-matched analysis using an international multicenter cohort. METHODS: This retrospective cohort study involved the participation of 15 centers spanning four continents. It included adult patients who underwent clipping of UIAs between January 2016 and December 2020. Patients were stratified according to their sex and analyzed for differences in morbidities and aneurysm characteristics. Based on this stratification, female patients were matched to male patients in a 1:1 ratio with a caliper width of 0.1 using propensity score matching. Endpoints included postoperative complications, neurological performance, and aneurysm occlusion at discharge and 24 months after clip placement. RESULTS: A total of 2245 patients with a mean age of 57.3 (range 20-87) years were included. Of these patients, 1675 (74.6%) were female. Female patients were significantly older (mean 57.6 vs 56.4 years, p = 0.03) but had fewer comorbidities. Aneurysms of the internal carotid artery (7.1% vs 4.2%), posterior communicating artery (6.9% vs 1.9%), and ophthalmic artery (6.0% vs 2.8%) were more commonly treated surgically in females, while clipping of aneurysms of the anterior communicating artery was more frequent in males (17.0% vs 25.3%; all p < 0.001). After propensity score matching, female patients were found to have had significantly fewer pulmonary complications (1.4% vs 4.2%, p = 0.01). However, general morbidity (24.5% vs 25.2%, p = 0.72) and mortality (0.5% vs 1.1%, p = 0.34), as well as neurological performance (p = 0.58), were comparable at discharge in both sexes. Lastly, rates of aneurysm occlusion at the time of discharge (95.5% vs 94.9%, p = 0.71) and 24 months after surgery (93.8% vs 96.1%, p = 0.22) did not significantly differ between male and female patients. CONCLUSIONS: Despite overall differences between male and female patients in demographics, comorbidities, and treated aneurysm location, sex did not relevantly affect surgical performance or perioperative complication rates.

Management of failed flow diversion for intracranial aneurysm beyond the first 6 months of follow-up: an international Delphi consensus.

OBJECTIVE: The placement of flow-diverting devices has become a common method of treating unruptured intracranial aneurysms of the internal carotid artery. The progressive improvement of aneurysm occlusion after treatment-with low complication and rupture rates-has led to a dilemma regarding the management of aneurysms in which occlusion has not occurred within 6-24 months. The authors aimed to identify clinical consensus regarding management of intracranial aneurysms displaying persistent filling 6-24 months after flow diversion and to ascertain questions that may drive future investigation. METHODS: An international panel of 67 experts was invited to participate in a multistep Delphi consensus process on the treatment of intracranial aneurysms after failed flow diversion. RESULTS: Of the 67 experts invited, 23 (34%) participated. Qualitative analysis of an initial survey with open-ended questions resulted in 51 statements regarding management of aneurysms showing persistent filling after flow diversion. The statements were grouped into 8 categories, and in the second round, respondents rated the degree of their agreement with each statement on a 5-point Likert scale. Flow diverters with surface modifiers did not influence administration of dual-antiplatelet therapy according to 83%. Consensus was also reached regarding the definition of treatment failure at specific time points, including at 6 months if there is aneurysm growth or persistent rapid flow through the entirety of the aneurysm (96%), at 12 months if there is aneurysm growth or symptom onset (78%), and at 24 months if there is persistent filling regardless of size and filling characteristics (74%). Although experts agreed that the degree of intimal hyperplasia or in-device stenosis could not be ascertained by noninvasive imaging alone (83%), only 65% chose digital subtraction angiography as the preferred modality. At 6 and 12 months, retreatment is preferred if there is persistent filling with aneurysm growth (96%, 96%), device malposition (48%, 87%), or a history of subarachnoid hemorrhage (65%, 70%), respectively, and at 24 months if there is persistent filling without reduction in aneurysm size (74%). Experts favored treatment with an additional flow diverter (87%) over aneurysm clipping, applying the same principles for follow-up (83%) and treatment failure (91%) as for the first flow diverter. CONCLUSIONS: The authors present the consensus practices of experts in the management of intracranial aneurysms without occlusion 6-24 months after treatment with a flow-diverting device.

Neuro-imaging in intracerebral hemorrhage: updates and knowledge gaps.

Intracerebral hemorrhage (ICH) is characterized by hematoma development within the brain's parenchyma, contributing significantly to the burden of stroke. While non-contrast head computed tomography (CT) remains the gold standard for initial diagnosis, this review underscores the pivotal role of magnetic resonance imaging (MRI) in ICH management. Beyond diagnosis, MRI offers invaluable insights into ICH etiology, prognosis, and treatment. Utilizing echo-planar gradient-echo or susceptibility-weighted sequences, MRI demonstrates exceptional sensitivity and specificity in identifying ICH, aiding in differentiation of primary and secondary causes. Moreover, MRI facilitates assessment of hemorrhage age, recognition of secondary lesions, and evaluation of perihematomal edema progression, thus guiding tailored therapeutic strategies. This comprehensive review discusses the multifaceted utility of MRI in ICH management, highlighting its indispensable role in enhancing diagnostic accuracy as well as aiding in prognostication. As MRI continues to evolve as a cornerstone of ICH assessment, future research should explore its nuanced applications in personalized care paradigms.

Early Experience With Artificial Intelligence Software to Detect Intracranial Occlusive Stroke in Trauma Patients.

Objective Identifying ischemic stroke is a diagnostic challenge in the trauma subpopulation. We describe our early experience with artificial intelligence-assisted image analysis software for automatically identifying acute ischemic stroke in trauma patients.  Methods Patients were retrospectively screened for (i) admission to the trauma service at a level one trauma center between 2020 and 2022, (ii) radiologist-confirmed intracranial occlusion, (iii) occlusion identified on computed tomography angiography performed within 24 hours of admission, (iv) no intracranial hemorrhage, and (v) contemporaneous analysis with the large vessel occlusion (LVO) detection program. Baseline characteristics, stroke detection, response-activation, and outcome data were summarized.  Results Of 9893 trauma patients admitted, 88 (0.89%) patients had a cerebral stroke diagnosis, of which 10 patients (10/88; 11.4%) met inclusion criteria. Most patients were admitted following a fall (8/10; 80%). Six (6/10; 60.0%) patients had LVOs. The program correctly detected 83.3% (5/6) of patients, and these patients were triaged in less than one hour from arrival on average. The program did not falsely identify non-LVOs as LVOs for any patients. Conclusions Identifying adjunct tools to aid timely identification and treatment of ischemic stroke in trauma patients is necessary to increase the chances for meaningful neurological recovery. Our early experience exhibited potential for using automated software to aid occlusion identification and subsequent stroke team mobilization. Future studies in larger cohorts will expand upon these preliminary findings to establish the accuracy and clinical benefit of automated stroke detection tool integration for the trauma population.

Correlating Age and Hematoma Volume with Extent of Midline Shift in Acute Subdural Hematoma Patients: Validation of an Artificial Intelligence Tool for Volumetric Analysis.

OBJECTIVE: Decision for intervention in acute subdural hematoma patients is based on a combination of clinical and radiographic factors. Age has been suggested as a factor to be strongly considered when interpreting midline shift (MLS) and hematoma volume data for assessing critical clinical severity during operative intervention decisions for acute subdural hematoma patients. The objective of this study was to demonstrate the use of an automated volumetric analysis tool to measure hematoma volume and MLS and quantify their relationship with age. METHODS: A total of 1789 acute subdural hematoma patients were analyzed using qER-Quant software (Qure.ai, Mumbai, India) for MLS and hematoma volume measurements. Univariable and multivariable regressions analyzed association between MLS, hematoma volume, age, and MLS:hematoma volume ratio. RESULTS: In comparison to young patients (≤ 70 years), old patients (>70 years) had significantly higher average hematoma volume (old: 62.2 mL vs. young 46.8 mL, P < 0.0001), lower average MLS (old: 6.6 mm vs. young: 7.4 mm, P = 0.025), and lower average MLS:hematoma volume ratio (old: 0.11 mm/mL vs. young 0.15 mm/mL, P < 0.0001). Young patients had an average of 1.5 mm greater MLS for a given hematoma volume in comparison to old patients. With increasing age, the ratio between MLS and hematoma volume significantly decreases (P = 0.0002). CONCLUSIONS: Commercially available, automated, artificial intelligence (AI)-based tools may be used for obtaining quantitative radiographic measurement data in patients with acute subdural hematoma. Our quantitative results are consistent with the qualitative relationship previously established between age, hematoma volume, and MLS, which supports the validity of using AI-based tools for acute subdural hematoma volume estimation.

The natural history of aneurysms incompletely occluded by placement of a flow diverter: a multiinstitutional study.

OBJECTIVE: Treatment of intracranial aneurysms by flow diversion is safe and effective and is increasingly popular. However, the correct treatment paradigm for aneurysms incompletely treated by initial placement of a flow diverter has not been established, nor have the subsequent natural history and occlusion rates of such aneurysms. The authors sought to outline the natural history of such aneurysms, which to date have been considered partially treated. METHODS: The authors retrospectively reviewed consecutive cases from 6 high-volume neurointerventional services, including all cases in which the first follow-up imaging after placement of a flow diverter showed incomplete occlusion of the aneurysm, and for which subsequent clinical and/or radiological follow-up was available. All included patients were treated with the Pipeline Flex embolization device or the Pipeline Flex embolization device with Shield Technology. Subsequent radiographic and clinical outcome data were collected and analyzed using the Kaplan-Meier survival function. RESULTS: A total of 263 patients with persistently patent aneurysms on first follow-up imaging after flow diversion were identified. Of these, 204 had clinical follow-up and 152 had additional imaging follow-up. Of this final cohort, 148 aneurysms were unruptured, and 4 were ruptured. The average aneurysm size by maximum dimension was 10.8 mm. The average recorded follow-up was 27.8 months in the cohort, with some patients followed for as long as 9 years from treatment. Over the course of 403 person-years of follow-up, no delayed aneurysm ruptures were recorded. Both with and without retreatment, aneurysms showed a trend toward progressive occlusion over time. Complications related to device placement were low. CONCLUSIONS: Aneurysms that have been incompletely treated by flow diversion have a benign natural history with progression toward occlusion over time, with or without retreatment.

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).

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.

Surgical management of stylocarotid Eagle syndrome in a patient with bilateral internal carotid artery dissection: illustrative case.

BACKGROUND: Eagle syndrome is characterized by an elongated styloid process, which can cause acute neurological symptoms when the projection impinges on local structures. One method by which Eagle syndrome can cause acute stroke is via internal carotid artery dissection. OBSERVATIONS: A patient presented with acute aphasia and right-arm weakness. Imaging revealed a left internal carotid artery dissection, which was treated with stenting. Three years later, the patient presented with left-sided weakness, and imaging revealed a new right internal carotid artery dissection. Closer review of the patient's imaging revealed bilateral elongated styloid processes. The patient subsequently underwent staged bilateral styloidectomy and returned to his prior baseline postoperatively. LESSONS: This case report describes a patient with Eagle syndrome who had two internal carotid artery dissections separated by several years. A literature review revealed that styloidectomy is well tolerated in patients with carotid dissection due to Eagle syndrome. Patients with carotid dissection due to Eagle syndrome remain at risk for contralateral dissection, and prophylactic contralateral styloidectomy should be considered.

Tenzing 7 delivery catheter with or without a leading microwire for single pass aspiration thrombectomy: A multicenter experience.

INTRODUCTION: Aspiration mechanical thrombectomy traditionally includes use of an inner microcatheter and leading microwire to navigate an aspiration catheter (AC) to the site of occlusion. Early clinical experience suggests that a leading microwire is often not needed with the Tenzing 7 (T7, Route 92 Medical, San Mateo, CA), a soft tapered tip ledge-reducing delivery catheter. This multicenter experience aims to describe AC delivery success in single-pass thrombectomy using T7 with and without a leading microwire. METHODS: A retrospective review was conducted of consecutive patients who underwent single-pass thrombectomy with T7 at six institutions between 2020 and 2022. We examined the percentage of successful AC delivery, puncture-to-revascularization time, and procedural complication rate. RESULTS: A leading microwire with T7 was used in 19/89 (21%) of patients, and it was not used with T7 in 70/89 (79%) of patients. Successful AC delivery was similar with and without microwires (97% vs. 90%, p = 0.15). Median puncture-to-revascularization times were similar (17 min microwire vs. 16 min no-microwire, p = 0.12). No complications were associated with microwire use; one (1.4%) patient had a T7-related vasospasm resolved with verapamil during thrombectomy without a leading microwire. Differences in complication rates were not statistically significant (p = 0.46). CONCLUSION: In our real-world clinical experience, leading microwire use was infrequently necessary with the T7 delivery catheter. Successful AC delivery and complication rates were similar with and without microwire use in single-pass T7 thrombectomies. Initial pass with T7 may be performed without use of leading microwire, reserving microwire use for refractory cases or known difficult-to-navigate vasculature.

Single center experience using 3†mm trevo stent retrievers in medium vessel occlusion thrombectomy.

BACKGROUND: Endovascular mechanical thrombectomy has been shown to benefit select patients with acute ischemic stroke caused by medium vessel occlusion, aided by recent advancements in endovascular mechanical thrombectomy devices that facilitate navigation through narrower vasculature. In this study, we aim to evaluate the safety and efficacy of using the 3 mm Trevo NXT stent retriever (Stryker, Kalamazoo, MI) for endovascular mechanical thrombectomy in patients with acute ischemic stroke caused by medium vessel occlusion. METHODS: From our single-center registry, we performed a retrospective review of all acute ischemic stroke patients from 2018 to 2022 who underwent endovascular mechanical thrombectomy for medium vessel occlusion with a 3 mm Trevo NXT. We examined efficacy outcomes (modified thrombolysis in cerebral infarction and puncture-to-revascularization time), clinical outcomes (National Institutes of Health Stroke Scale), and procedural complication rate. RESULTS: Between 2018 and 2022, 44 patients (52.2% female, mean age 71.1 years, median National Institutes of Health Stroke Scale of 15 [8-22.8]) met our inclusion criteria. The 3 mm Trevo NXT was used in the first pass in 56.9% of individuals, with 72.4% achieving successful recanalization (modified thrombolysis in cerebral infarction ≥ 2B). The 3 mm Trevo NXT was used as "rescue" after initial revascularization failure in 43.1% of individuals, achieving successful recanalization in 60.0% of passes. Acute complications were reported in 2.4% of cases. Median National Institutes of Health Stroke Scale at 24 h after intervention was 12 (4-20.8). CONCLUSIONS: Our results suggest that endovascular mechanical thrombectomy using the 3 mm Trevo NXT is a safe and effective treatment option for medium vessel occlusion. The utility of novel stent retrievers in the treatment of medium vessel occlusion should be further explored in future multicenter studies.

Common Carotid-Greater Saphenous-M2 Bypass for Myoepithelial Carcinoma Encasing the Carotid Artery.

Revascularization of the anterior circulation using a high-capacitance graft is sometimes necessary for treatment of cervical tumors encasing the internal carotid artery (ICA). In this surgical video, we aim to demonstrate the technical nuances of high-flow extra-to-intracranial bypass using a saphenous vein graft. The patient is a 23-year-old female who presented with a 4-month history of an enlarging left-sided neck mass, dysphagia, and 25-lb weight loss. Computed tomography and magnetic resonance imaging demonstrated an enhancing lesion encasing the cervical ICA. The patient underwent an open biopsy that established a diagnosis of a myoepithelial carcinoma. The patient was advised to undergo attempted gross total resection, which would require sacrifice of the cervical internal carotid artery. After the patient failed a balloon test occlusion of the left ICA, it was decided to perform a cervical ICA to middle cerebral artery M2 bypass using a saphenous vein graft, followed by tumor resection in staged fashion. Postoperative imaging demonstrated complete tumor removal and filling of the left anterior circulation via the saphenous vein graft. Video 1 discusses important preoperative and postoperative considerations, as well as highlights the technical nuances of this complex procedure. High-flow ICA to middle cerebral artery bypass using a saphenous vein graft can be employed to facilitate gross total resection of malignant tumors encasing the cervical internal carotid artery.

Safety and efficacy of the Pipeline Flex embolization device with Shield Technology for the acute treatment of ruptured internal carotid artery pseudoaneurysms: a multi-institution case series.

OBJECTIVE: Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms. METHODS: The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected. RESULTS: Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0-2. Complete occlusion at follow-up was observed in 82.6% of patients. CONCLUSIONS: PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.

Bibliometric Analysis of the Top 100 Cited Articles on Stereotactic Radiosurgery for Trigeminal Neuralgia.

Background Stereotactic radiosurgical rhizolysis of the trigeminal nerve is an established modality increasingly employed to alleviate the symptoms of refractory trigeminal neuralgia. This study analyzes the academic impact of the top 100 cited articles on the radiosurgical management of trigeminal neuralgia. Methods The Scopus database was searched for articles containing "radiosurgery" and one or more of "trigeminal neuralgia," "trigeminus neuralgia," and "tic douloureux." The top 100 articles written in English were arranged in descending order by citation count. Documents were evaluated for authors, publication year, journal and impact factor, total citations, nationality, study type, radiosurgical modality, and the affiliated institution. Quantitative and qualitative analyses were performed on the data. Results The most cited articles were published between 1971 and 2019. The average citation per year was 4.3. The most targeted anatomic area was the "root entry zone" or proximal portion of the cisternal segment of the trigeminal nerve. The most utilized modality was Gamma Knife radiosurgery. The country with the highest number of publications was the United States. Thirty-six percent of the articles were published in the Journal of Neurosurgery . Lunsford, Kondziolka, Flickinger, and Régis, respectively, were the most frequently listed co-authors. The most prolific institute was the University of Pittsburgh Medical Center. Conclusion Stereotactic radiosurgery is an important modality in the management of medically or surgically refractory trigeminal neuralgia. This analysis assesses its contributions over the past five decades to identify trends in treatment practices for neurosurgeons and to highlight areas where further study is needed.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Review.

Middle meningeal artery embolization (MMAE) for chronic subdural hematomas (cSDHs) has evolved as a potential treatment alternative for these lesions. The indications for using this treatment modality and the pathophysiology of cSDHs are an area of considerable interest. A retrospective review was performed including all major papers addressing this topic. Although considered a relatively new treatment option, MMAE for cSDHs is gaining widespread popularity. There are many questions that need to be addressed regarding its indications, some of which are the subject of ongoing clinical trials. The efficacy of this treatment modality in carefully selected patients has also provided new insights into the potential pathophysiology of cSDHs. This concise review will focus on the current evidence supporting the use of embolization in the treatment of this disease and highlight unanswered relevant clinical questions regarding MMAE indications and technique.

Bibliometric analysis of the top 100 cited articles on stereotactic radiosurgery of intracranial meningiomas.

BACKGROUND: Sterotactic radiosurgery is becoming an integral modality in the management of intracranial meningiomas, both as the primary treatment or as adjuvant therapy. This study analyzes the scholarly impact of the top 100 cited articles on the stereotactic radiosurgical management of intracranial meningiomas. METHODS: A ranked list of the 100 most-cited articles was generated using the Scopus database by searching the keywords 'intracranial meningioma' and 'stereotactic radiosurgery'. All articles were then evaluated on multiple criteria regarding both the publication of the articles (year of publication, journal, country of origin, and authors) as well as their methods and foci (type of study, location of studied meningiomas, and type of radiosurgical modality). Quantitaitve and qualitative analyses were then performed from the collected data. RESULTS: The most frequently cited articles on stereotactic radiosurgical management of intracranial meningiomas were published between 1990 and 2016. The average citation-per-year across all papers in the list was 6.1. The most studied anatomic area of intracranial meningiomas was the skull base, with the cavernous sinus being the most well-studied specific site. The most utilized stereotactic radiosurgical modality was Gamma Knife radiosurgery. The country with the highest number of publications was the United States. Twenty-six percent of the articles were published in the journal Neurosurgery; Lunsford, Kondziolka, Flickinger, Sheehan, and Pollock were respectively the most frequent listed authors among this list. The most active academic institute publishing on this topic was the University of Pittsburgh Medical Center. CONCLUSION: Stereotactic radiosurgery is an integral modality in the management of intracranial meningiomas. This bibliometric analysis sheds the light on the ways in which intracranial meningiomas have been studied in the past two decades in order to identify trends among neurosurgeons and radiation oncologists and to reveal areas of rising and declining focus.

Microsurgical Obliteration of Craniocervical Junction Dural Arteriovenous Fistulas: Multicenter Experience.

BACKGROUND: Dural arteriovenous fistulas (dAVFs) located at craniocervical junction are extremely rare (1%-2% of intracranial/spinal dAVFs). Their angio-architectural complexity renders endovascular embolization to be challenging given multiple small feeders with risk of embolysate reflux into vertebral artery and limited transvenous access. The available literature discussing microsurgery for these lesions is limited to few case reports. OBJECTIVE: To report a multicenter experience assessing microsurgery safety/efficacy. METHODS: Prospectively maintained registries at 13 North American centers were queried to identify craniocervical junction dAVFs treated with microsurgery (2006-2021). RESULTS: Thirty-eight patients (median age 59.5 years, 44.7% female patients) were included. The most common presentation was subarachnoid/intracranial hemorrhage (47.4%) and myelopathy (36.8%) (92.1% of lesions Cognard type III-V). Direct meningeal branches from V3/4 vertebral artery segments supplied 84.2% of lesions. All lesions failed (n = 5, 13.2%) or were deemed inaccessible/unsafe to endovascular treatment. Far lateral craniotomy was the most used approach (94.7%). Intraoperative angiogram was performed in 39.5% of the cases, with angiographic cure in 94.7% of cases (median imaging follow-up of 9.2 months) and retreatment rate of 5.3%. Favorable last follow-up modified Rankin Scale of 0 to 2 was recorded in 81.6% of the patients with procedural complications of 2.6%. CONCLUSION: Craniocervical dAVFs represent rare entity of lesions presenting most commonly with hemorrhage or myelopathy because of venous congestion. Microsurgery using a far lateral approach provides robust exposure and visualization for these lesions and allows obliteration of the arterialized draining vein intradurally as close as possible to the fistula point. This approach was associated with a high rate of angiographic cure and favorable clinical outcomes.

Intermediate-porosity stent for coil-reconstruction of mixed saccular-fusiform basilar trunk aneurysm.

Vertebrobasilar junction and basilar trunk aneurysms are extremely difficult to treat, with significant morbidity associated with bypass-trapping procedures. As a result, endovascular techniques including flow diversion and stent-assisted coil embolization have become the mainstay of treatment.1-3 Traditional flow diverters pose risk of occlusion of basilar perforator arteries while traditional stents used as adjuncts for coil-embolization often have high porosity and cannot function as flow diverters. On the other hand, the LVIS stent uniquely provides more porosity than other flow diverters,4,5 allowing patency of perforators while also being amenable to stent-assisted coiling. We present a case of a mixed saccular and fusiform basilar trunk aneurysm that underwent LVIS stent-assisted coil embolization. Using bifemoral access with triaxial systems, one microcatheter was placed in the aneurysm sac and another was used to deploy a stent from the basilar apex into the right vertebral artery. A durable angiographic outcome was observed at 9 months.

The Lateral Supraorbital Craniotomy Approach for Anterior Circulation Aneurysms: A Modern Surgical Case Series in the Endovascular Era.

BACKGROUND: The lateral supraorbital (LSO) approach is a minimally invasive modification of the standard pterional approach to anterior circulation aneurysms. This study aimed to describe a dual-trained cerebrovascular neurosurgeon's first 18-month experience with the LSO approach, including decision-making criteria and lessons learned. METHODS: This retrospective case series analyzed 50 consecutive patients treated with LSO craniotomy for aneurysm clipping by a single surgeon. Aneurysms were separated into 3 categories by location: internal carotid artery, anterior communicating artery, and middle cerebral artery. Surgical characteristics were evaluated for differences by location and rupture status. RESULTS: Aneurysm clipping via LSO was performed on 57 aneurysms in 50 patients. Fixed retraction was employed less often in patients with internal carotid artery aneurysms than in patients with anterior communicating artery, middle cerebral artery, or multiple aneurysms (10% vs. 68.2%, 45.5%, and 42.9, P = 0.02). Of patients, 26 (52%) presented with subarachnoid hemorrhage; the majority of patients (92.3%) had Hunt and Hess grade I-III. No differences were noted in intraoperative rupture rates, fixed retractor use, operative duration, or estimated blood loss by rupture status. Adverse events included permanent frontalis nerve palsy in 1 patient (2%), temporalis atrophy in 1 patient, and transient aphasia in 1 patient. No postoperative hematomas or strokes were observed. CONCLUSIONS: The LSO approach can safely and effectively treat anterior circulation aneurysms and should be considered a viable minimally invasive option for aneurysm clipping. Further studies comparing the LSO approach with other cranial approaches are needed.