Treatment of large and giant posterior communicating artery aneurysms with the Surpass streamline flow diverter: results from the SCENT trial.

BACKGROUND: The Surpass flow diverter was developed to treat intracranial aneurysms not amenable to standard treatment. Indications for use allow placement in the internal carotid artery to the terminus, including the communicating artery segment. METHODS: The Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms (SCENT) trial is an international, multicenter, prospective, non-randomized trial comparing the outcomes of Surpass flow diverter treatment with historic control designed to evaluate the effectiveness and safety of Surpass for the treatment of wide neck (≥4 mm) large or giant intracranial aneurysms ≥10 mm. The primary effectiveness endpoint is the percentage of subjects with 100% aneurysm occlusion without significant stenosis of the parent artery and without retreatment of the target aneurysm at 12 months. The primary safety endpoint is the percentage of subjects experiencing neurologic death or major ipsilateral stroke at 12 months. We report the effectiveness and safety of flow diversion in the subgroup of posterior communicating artery (PComA) aneurysms. RESULTS: Of the 180 patients treated, 38 harbored a PComA aneurysm. Mean aneurysm size was 12.2 mm and mean neck width was 4.8 mm. The mean number of Surpass devices used was 1.1 per procedure, with 94.7% of aneurysms treated with one flow diverter. The 12 month primary effectiveness rate was 73.7% (28/38). At 36 months, 68.4% (26/38) of aneurysms remained completely occluded. The 12 month major ipsilateral stroke or neurological death rate was 10.5%. No patients with PComA occlusion after flow diverter placement (54.5%) had clinical sequelae. CONCLUSIONS: SCENT demonstrated acceptable 12 month effectiveness of flow diversion in PComA aneurysms. Despite associated PComA occlusions in many cases, arterial occlusions were clinically silent. TRIAL REGISTRATION NUMBER: URL: https://www. CLINICALTRIALS: gov. Unique identifier: NCT01716117.

Triple therapy versus dual-antiplatelet therapy for dolichoectatic vertebrobasilar fusiform aneurysms treated with flow diverters.

BACKGROUND: Dolichoectatic vertebrobasilar fusiform aneurysms (DVBFAs) have poor natural history when left untreated and high morbimortality when treated with microsurgery. Flow diversion (FD) with dual-antiplatelet therapy (DAPT) is feasible but carries high risk of perforator occlusion and progression of brainstem compression. Elaborate antithrombotic strategies are needed to preserve perforator patency while vessel remodeling occurs. We compared triple therapy (TT (DAPT plus oral anticoagulation)) and DAPT alone in patients with DVBFAs treated with FD. METHODS: Retrospective comparison of DAPT and TT in patients with DVBFAs treated with FD at eight US centers. RESULTS: The groups (DAPT=13, TT=14) were similar in age, sex, clinical presentation, baseline disability, and aneurysm characteristics. Radial access use was significantly higher in the TT group (71.4% vs 15.3%; P=0.006). Median number of flow diverters and adjunctive coiling use were non-different between groups. Acute ischemic stroke rate during the oral anticoagulation period was lower in the TT group than the DAPT group (7.1% vs 30.8%; P=0.167). Modified Rankin Scale score decline was significantly lower in the TT group (7.1% vs 69.2%; P=0.001). Overall rates of hemorrhagic complications (TT, 28.6% vs DAPT, 7.7%; P=0.162) and complete occlusion (TT, 25% vs DAPT, 54.4%; P=0.213) were non-different between the groups. Rate of moderate-to-severe disability at last follow-up was significantly lower in the TT group (21.4% vs 76.9%; P=0.007). CONCLUSIONS: Patients with DVBFAs treated with FD in the TT group had fewer ischemic strokes, less symptom progression, and overall better outcomes at last follow-up than similar patients in the DAPT group.

Virtual Interviews in Neurosurgery Resident Selection-A Work in Progress.

INTRODUCTION: Due to the COVID-19 pandemic, the ACGME recommended all interviews for the 2021 residency application cycle be held virtually. Because this is major shift from neurosurgical interviews in past years, this study aims to evaluate both applicant and interviewer satisfaction of conducting interviews virtually. METHODS: For faculty, an 11-question online survey was sent to 116 United States neurosurgery training programs. A 14-question online survey was sent to 255 neurosurgery applicants. The resulting data were analyzed qualitatively and quantitatively. RESULTS: From applicants, 118 responses were received. From faculty, 171 individual responses were received. Thirty-five percent (34.7%) of applicants agreed that they were satisfied with the virtual interview process as a whole. Although 44.5% of faculty disagreed with the statement "I would like to replace in-person interviews with virtual interviews in the future", 57.3% of faculty agreed that they were likely to implement virtual interviews in the future. CONCLUSIONS: Some things might be better assessed through in-person interviews, but there are clear benefits to virtual interviews. Future iterations of the interview process, incorporating virtual interviews, might help determine how and in which situations virtual interviews can be utilized in future residency application cycles.

Cognitive outcomes after unruptured intracranial aneurysm treatment with endovascular coiling.

BACKGROUND: We aimed to determine the effects of endovascular coiling of unruptured intracranial aneurysms (UIAs) on cognition to inform treatment decisions. We present the first study using the Montreal Cognitive Assessment (MoCA) to determine neurocognitive changes after endovascular coiling. METHODS: We prospectively collected data on all patients with UIAs undergoing endovascular coiling, primary or assisted. Patients completed the MoCA prior to intervention and 1 month and 6 months' post-procedure. A repeated measures linear mixed effects model was used to compare pre-procedure and post-procedure cognition. RESULTS: Thirty-three patients with 33 aneurysms who underwent coiling from April 2017 to May 2020 were included (mean age 55.5, 81.8% female). All procedures used general anesthesia. There was no difference between baseline and post-procedure MoCA scores at any time interval (P>0.05). Mean MoCA scores at baseline, 1 month post-procedure, and 6 months' post-procedure were 25.4, 26.8, and 26.3 respectively. There was also no difference between pre- and post-procedure scores on any individual MoCA domain (visuospatial, naming, memory, attention, language, abstraction, delayed recall, and orientation) at any time interval (P>0.05). Seventeen patients had follow-up MRI or CT imaging, of which 11.8% showed radiographic changes or ischemia. 77.8% of patients with 6-month angiographic follow-up achieved class I, and 22.2% achieved class II Raymond-Roy Occlusion. Thirty-two out of 33 patients had follow-up mRS ≤2. CONCLUSION: Our study suggests that endovascular coiling does not diminish neurocognitive function. Patients with UIAs in our cohort also had baseline MoCA scores below the cut-off for mild cognitive impairment despite pre-procedure mRS and NIHSS of 0.

Antibiotics for acne vulgaris: using instagram to seek insight into the patient perspective.

OBJECTIVES: Monitoring of public social media posts is an underutilized method to understand patients' perspectives regarding their condition and treatment. We investigated information shared by Instagram users of oral and topical antibiotics for treatment of acne vulgaris. MATERIAL AND METHODS: We performed a retrospective observational study of public Instagram posts assigned common hashtags to denote the use of antibiotics therapy for acne over nearly eight years. RESULTS: Dissatisfaction was more prevalent among users of oral antibiotics (25.6%) compared to users of topical antibiotics (9.8%), and negative tone among this group was most commonly due to lack of improvement in skin appearance. Reported side effects paralleled known side effects for oral and topical antibiotics. CONCLUSIONS: Instagram may have utility in elucidating patient behavior and attitudes. Dermatologists should increase their social media presence in order to disqualify any incorrect information endorsed in 'popular' or commonly viewed posts.

Ambulatory neurosurgery in the COVID-19 era: patient and provider satisfaction with telemedicine.

OBJECTIVE: Telemedicine has rapidly expanded in the recent years as technologies have afforded healthcare practitioners the ability to diagnose and treat patients remotely. Due to the COVID-19 pandemic, nonessential clinical visits were greatly limited, and much of the outpatient neurosurgical practice at the authors' institution was shifted quickly to telehealth. Although there are prior data suggesting that the use of telemedicine is satisfactory in other surgical fields, data in neurosurgery are limited. This study aimed to investigate both patient and provider satisfaction with telemedicine and its strengths and limitations in outpatient neurosurgery visits. METHODS: This quality improvement study was designed to analyze provider and patient satisfaction with telemedicine consultations in an outpatient neurosurgery clinic setting at a tertiary care, large-volume, academic center. The authors designed an 11-question survey for neurosurgical providers and a 13-question survey for patients using both closed 5-point Likert scale responses and multiple choice responses. The questionnaires were administered to patients and providers during the period when the clinic restricted in-person visits. At the conclusion of the study, the overall data were analyzed qualitatively and quantitatively. RESULTS: During the study period, 607 surveys were sent out to patients seen by telehealth at the authors' academic center, and 122 responses were received. For the provider survey, 85 surveys were sent out to providers at the authors' center and other academic centers, and 40 surveys were received. Ninety-two percent of patients agreed or strongly agreed that they were satisfied with that particular telehealth visit. Eighty-eight percent of patients agreed that their telehealth visit was more convenient for them than an in-person visit, but only 36% of patients stated they would like their future visits to be telehealth. Sixty-three percent of providers agreed that telehealth visits were more convenient for them than in-person visits, and 85% of responding providers stated that they wished to incorporate telehealth into their future practice. CONCLUSIONS: Although the authors' transition to telehealth was both rapid and unexpected, most providers and patients reported positive experiences with their telemedicine visits and found telemedicine to be an effective form of ambulatory neurosurgical care. Not all patients preferred telemedicine visits over in-person visits, but the high satisfaction with telemedicine by both providers and patients is promising to the future expansion of telehealth in ambulatory neurosurgery.

Trends in academic productivity in the COVID-19 era: analysis of neurosurgical, stroke neurology, and neurointerventional literature.

BACKGROUND: Academic physicians aim to provide clinical and surgical care to their patients while actively contributing to a growing body of scientific literature. The coronavirus disease 2019 (COVID-19) pandemic has resulted in procedural-based specialties across the United States witnessing a sharp decline in their clinical volume and surgical cases. OBJECTIVE: To assess the impact of COVID-19 on neurosurgical, stroke neurology, and neurointerventional academic productivity. METHODS: The study compared the neurosurgical, stroke neurology, and neurointerventional academic output during the pandemic lockdown with the same time period in previous years. Editors from a sample of neurosurgical, stroke neurology, and neurointerventional journals provided the total number of original manuscript submissions, broken down by months, from the year 2016 to 2020. Manuscript submission was used as a surrogate metric for academic productivity. RESULTS: 8 journals were represented. The aggregated data from all eight journals as a whole showed that a combined average increase of 42.3% was observed on original submissions for 2020. As the average yearly percent increase using the 2016-2019 data for each journal exhibited a combined average increase of 11.2%, the rise in the yearly increase for 2020 in comparison was nearly fourfold. For the same journals in the same time period, the average percent of COVID-19 related publications from January to June of 2020 was 6.87%. CONCLUSION: There was a momentous increase in the number of original submissions for the year 2020, and its effects were uniformly experienced across all of our represented journals.

Cognitive outcomes after unruptured intracranial aneurysm treatment with flow diversion.

OBJECTIVE: Flow diversion is increasingly used to treat a variety of intracranial aneurysms with good safety and efficacy; however, there is some evidence that this treatment is associated with a larger postoperative ischemic burden on imaging than that with other traditional endovascular modalities. These findings typically do not manifest as neurological deficits, but any subtle effects on cognition remain unknown. In this study, the authors describe the neurocognitive performance of a cohort of patients with unruptured intracranial aneurysms (UIAs) before and after treatment with flow diversion. This is the first report of cognitive outcomes following aneurysm treatment with flow diversion. METHODS: The authors prospectively collected data on cognitive function using the Montreal Cognitive Assessment (MoCA) tool in patients with UIAs who were undergoing endovascular aneurysm treatment with flow diversion between June 2017 and July 2019. Patients completed the MoCA prior to intervention, at the 1-month follow-up after treatment, and again at 6 months after the procedure. All patients with UIAs treated with flow diversion were included regardless of age, aneurysm location, or morphology, unless their functional status precluded completion of the MoCA instrument. A repeated-measures linear mixed-effects model was used to compare preintervention and postintervention cognitive status at the time intervals outlined. RESULTS: Fifty-one patients with 61 aneurysms underwent endovascular aneurysm treatment with flow diversion (mean age 52.5 years, 90.2% females). There was no difference between baseline and postprocedure MoCA scores at any time interval (p > 0.05). The MoCA scores at baseline, 1 month postprocedure, and 6 months postprocedure were 26.1, 26.2, and 26.6, respectively. There was also no difference between pre- and postprocedure scores on any individual domain of the instrument (visuospatial, naming, attention, language, abstraction, delayed recall, and orientation) at any time interval (p > 0.05). Thirty-four patients had follow-up MRI or CT imaging, 5 of whom showed radiographic changes or ischemia. All patients with follow-up clinical evaluation had a 6-month modified Rankin Scale score ≤ 2. CONCLUSIONS: Flow diversion is increasingly used in the treatment of intracranial aneurysms. This study suggests that this treatment may not alter neurocognitive function. Larger patient samples and longer follow-ups with other tests of cognitive functions are needed to confirm these findings.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Meta-Analysis and Systematic Review.

BACKGROUND: Chronic subdural hematoma is a very common neurosurgical condition. Although conventional surgical methods, such as burr hole irrigation, have been the mainstay of treatment, middle meningeal artery (MMA) embolization has emerged as a promising adjunctive or alternative treatment. The aim of this article was to present a meta-analysis and systematic review of this topic. METHODS: A literature search using keywords "chronic subdural hematoma," "chronic subdural hemorrhage," "refractory subdural hematoma," "refractory subdural hemorrhage," and "middle meningeal artery embolization" was conducted through October 2018. Outcome variables of hematoma recurrence, surgical complications, and modified Rankin Scale score were analyzed and compared between MMA embolization and conventional surgery cohorts. RESULTS: Three double-arm studies comparing embolization and conventional surgery groups and 6 single-arm case series were identified and analyzed. Hematoma recurrence rate was significantly lower in the embolization group compared with conventional treatment group (2.1% vs. 27.7%; odds ratio = 0.087; 95% confidence interval, 0.026-0.292; P < 0.001; I2 = 0%); surgical complication rates were similar between groups (2.1% vs. 4.4%; odds ratio = 0.563; 95% confidence interval, 0.107-2.96; P = 0.497; I2 = 27.5%). Number of patients with modified Rankin Scale score >2 in the embolization (12.5%) versus conventional treatment (9.1%) group showed no statistical difference (P = 0.689). A composite hematoma recurrence rate of 3.6% was found after summing the 6 case series. Composite recurrence and complication rates in the embolization cohorts of the double-arm studies and the case series were lower than literature values for conventional surgical treatments. CONCLUSIONS: MMA embolization is a promising treatment for chronic subdural hematoma. Future randomized clinical trials are needed.