Spinal tumor embolization with Onyx: A systematic review and meta-analysis.

INTRODUCTION: Onyx embolization has emerged as a promising technique for spinal tumor embolization due to its high devascularization rate and low incidence of complications. OBJECTIVE: Evaluate the safety and efficacy of Onyx embolization in spinal tumor procedures. METHODS: Following the PRISMA guidelines, we conducted a systematic review and meta-analysis. To be included, the articles had to report specific outcomes of Onyx embolization for spinal tumors (complications, mortality, blood loss, tumor devascularization, or reduction in tumor blush). RESULTS: We selected 11 out of 2941 articles, encompassing 127 patients. Among them, no major complications or persistent neurological deficits were reported, and no deaths occurred as a result of the embolization procedure. Of the 63 patients with available data, two complications were observed: one infarct leading to transient neurological deficit and one clinically silent vessel perforation related to the microcatheter. Thus, the complication rate was 1% (95% confidence interval (CI): 0% to 6%). Blood loss during surgery ranged from 100 to 1500 mL (four studies). Complete tumor blush reduction was achieved in 52% of the cases (95% CI: 16% to 88%) across 32 patients. Three studies reported a median percentage of tumor devascularization of 91% (86.1% to 97.5%). CONCLUSION: Onyx embolization for spinal tumor procedures appears to be a safe technique, as evidenced by the absence of major complications or deaths. However, the determination of its efficacy remains challenging due to limited data availability and substantial heterogeneity across studies. These findings highlight the need for future research to address this knowledge gap and further validate our results.

A light in the darkness: sodium fluorescein-assisted peripheral nerve sheath tumors resection - a comprehensive systematic review and single-arm meta-analysis.

The treatment for peripheral nerve sheath tumors (PNSTs) is based on surgical excision and the primary goal is to improve symptoms whilst preserving neurological function. In order to improve this technique, surgeons may use sodium fluorescein (SF) to help visualize the neoplasm and, consequently, facilitate its removal. Aiming to assess the efficacy of this emerging surgical strategy, we conducted a systematic review and single-arm meta-analysis. We conducted a systematic search on the PubMed, Embase, and Web of Science databases, following the PRISMA guidelines. Studies without outcomes of interest, case series with less than four patients, letters, comments, technical notes, editorials, reviews, and basic research papers were excluded. The outcomes considered for this study were: the number of tumors that achieved total resection, subtotal resection, or near total resection, the approach/technique utilized by the surgeon, SF-related complications, and total complications. Five studies, with a total of 175 individuals, were included in our survey. Notably, 70% of the neoplasms presented by the patients were schwannomas. Considering extracranial lesions, we found a proportion of 96% (95% CI: 88 - 100%) in total resection, 0% (95% CI: 0-1%) in near total resection, and 4% (95% CI: 0-12%) in subtotal resection, all linked to an amount of 185 analyzed PNSTs. Furthermore, a proportion of 1% (95% CI: 0 - 2%) in SF-related complications was spotted among 183 patients. Finally, total complications analysis accounted for 11% (95% CI: 0 - 25%) among 183 individuals. We concluded that SF-assisted resection of PNSTs is a suitable and relatively safe technique, linked to minimum complications, of which the majority was not associated with the chemical compound itself. Future research is necessary to increase the number of patients available in the current literature and, therefore, enhance future analyses.

Optimizing resources: financial evaluation of flow diverters versus stent assisted coiling in large and giant cerebral aneurysm management in Brazil public health system.

BACKGROUND: Cerebral aneurysms, especially large and giant aneurysms, pose challenges in neurointerventional surgery. Treatment choices involve clinical presentation, aneurysm details, and global resource variations. Neurointerventional methods, while innovative, may be cost restrictive in certain regions. In public healthcare, cost is crucial, notably in countries like Brazil. This study examines the device specific cost estimation of flow diverters (FD) and traditional stent assisted coiling (SAC) for large and giant cerebral aneurysms, providing insights into optimizing neurosurgical interventions within the Brazilian public health system's unique challenges. METHODS: A comprehensive retrospective analysis was conducted at our medical center of cases of large and giant aneurysms treated between 2013 and 2023. Determination of the estimated number of coils for aneurysms previously treated with FDs at our center was made, with the cost of each case, and the difference between both treatments was calculated. RESULTS: We investigated the profiles of 77 patients: 40 had large aneurysms (51.9%) and 37 had giant aneurysms (48.1%). Large aneurysms had a mean cost difference of US$274 (standard deviation (SD) $2071), underscoring the device specific cost estimation of FDs over SAC in their treatment. For giant aneurysms, the mean cost difference increased to $6396 (SD $2694), indicating FDs as the more economically sound choice. CONCLUSION: Our study indicated that, for the treatment of giant aneurysms and some large aneurysms, the FD intervention was more economical than SAC.

Assessing short-term and long-term security and efficacy of anterior nucleus of the thalamus deep brain stimulation for treating drug-resistant epilepsy: A systematic review and single-arm meta-analysis.

Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) is a widespread invasive procedure for treating drug-resistant epilepsy. Nonetheless, there is a persistent debate regarding the short-term and long-term efficacy and safety of ANT-DBS. Thus we conducted a systematic review and meta-analysis. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we searched PubMed, Cochrane, Embase, and Web of Science for studies treating refractory epilepsy with ANT-DBS. Short-term analysis was considered for studies with a mean follow-up of 3 years or less. The following outcomes were assessed for data extraction: procedure responders and nonresponders, increased seizure frequency, complications, and procedure-related mortality. Of 650 studies, 25 fit our inclusion criteria, involving 427 patients. Previous surgical treatments have been reported in 214 patients (50.1%) and a median average baseline seizure frequency of 64.9 monthly seizures. In the short-term analysis, we observed a proportion of 67% (95% confidence interval [CI] 54%-79%) of responders and 33% (95% CI 21%-46%) of nonresponders. In addition, 4% (95% CI 0%-9%) of the patients presented increased seizure frequency. In the long-term analysis, we observed 72% (95% CI 66%-78%) responders and 27% (95% CI 21%-34%) nonresponders. Moreover, there was a 2% (95% CI 0%-5%) increase in seizure frequency. No procedure-related mortality was reported at any follow-up. ANT-DBS effectively treats refractory epilepsy, with lasting short-term and long-term benefits. It remains safe and efficient despite complications, showing no procedure-linked fatalities, high patient responsiveness, and minimal increased seizures. Consistent results over time and low morbidity/mortality rates emphasize its worth. Further research is necessary to diminish the discrepancy among results.

Effectiveness and Safety of Ventriculoperitoneal Shunt Versus Lumboperitoneal Shunt for Idiopathic Intracranial Hypertension: A Systematic Review and Comparative Meta-Analysis.

INTRODUCTION: Idiopathic Intracranial Hypertension (IIH) is a condition characterized by elevated intracranial pressure. Although several mechanisms have been proposed as underlying causes of IIH, no identifiable causative factor has been determined for this condition. Initial treatments focus on weight or CSF reduction, but severe cases may require surgery. This study compares outcomes in IIH patients treated with lumboperitoneal shunts (LPSs) versus ventriculoperitoneal shunts (VPSs). METHODS: This systematic-review and meta-analysis follows Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and includes studies about VPS and LPS patients, reporting one of the outcomes of interest. We conducted searches on PubMed, Embase, Web of Science, and Cochrane Library. RESULTS: Our analysis involved twelve studies, comprising 5990 patients. The estimated odds ratio (OR) for visual improvement was 0.97 (95% CI 0.26-3.62; I2 = 0%) and for headache improvement was 0.40 (95% CI 0.20-0.81; I2 = 0%), favoring LPS over VPS. Shunt revision analysis revealed an OR of 1.53 (95% CI 0.97-2.41; I2 = 77%). The shunt complications showed an OR of 0.91 (95% CI 0.68-1.22; I2 = 0%). The sub-analyses for shunt failure uncovered an OR of 1.41 (95% CI 0.92-2.18; I2 = 25%) and for shunt infection events an OR of 0.94 (95% CI 0.50-1.75; I2 = 0%). CONCLUSIONS: The interventions showed general equivalence in complications, shunt failure, and other outcomes, but LPS seems to hold an advantage in improving headaches. Substantial heterogeneity highlights the need for more conclusive evidence, emphasizing the crucial role for further studies. The findings underscore the importance of considering a tailored decision between VPS and LPS for the management of IIH patients.

Safety of local anesthesia in endovascular treatment of Aneurysms: A systematic review and Meta-Analysis.

BACKGROUND: Endovascular treatment of intracranial aneurysms (EVTIAs) is increasingly popular due to its minimally invasive nature and high success rate. While general anesthesia (GA) has been the historical preference for EVTIAs, there's growing interest in local anesthesia (LA). However, concerns persist about LA safety for EVTIAs. Therefore, we conducted a systematic review and meta-analysis to assess LA safety for EVTIAs. METHODS: Following PRISMA guidelines, we searched PubMed, Embase, and Web of Science databases. Pooled analysis with 95 % confidence intervals (CI) assessed effects, I2 statistics gauged heterogeneity, and a random-effects model was adopted. Conversion to GA, neurological or procedure-related complications, intraoperative intracranial hemorrhagic complications (IIHC), and mortality were assessed. Subanalyses for ruptured and unruptured cases were performed. RESULTS: The analysis included eleven studies, 2,133 patients, and 2,369 EVTIAs under LA. Conversion to GA rate was 1 % (95 %CI: 0 to 2 %). Neurological or procedure-related complications rate was 13 % (95 % CI: 8 % to 17 %). IIHC analysis revealed a rate of 1 % (95 % CI: 1 % to 2 %). The mortality rate was 0 % (95 %CI: 0 % to 0 %). Subanalyses revealed similar rates in ruptured and unruptured subgroups, except for a slightly high rate of complications and IIHC in the ruptured subgroup. CONCLUSION: Findings indicate that EVTIA under LA is safe, with low conversion and mortality rates, even for ruptured aneurysms. Complications rates, also in IIHC rates, are comparable to those reported for GA, emphasizing LA's comparable safety profile in EVTIAs. Considering these promising outcomes, the decision to opt for the LA approach emerges as meaningful and well-suited for the endovascular treatment of aneurysms. Beyond its safety, LA introduces inherent supplementary advantages, including shortened hospitalization periods, cost-effectiveness, and an expedited patient recovery process.

Posterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery Bypass versus Occipital Artery-Posterior Inferior Cerebellar Artery Bypass for Treating Posterior Circulation Aneurysms: A Systematic Review and Comparative Meta-Analysis.

BACKGROUND: When traditional therapies are unsuitable, revascularization becomes essential for managing posterior inferior cerebellar artery (PICA) or vertebral artery aneurysms. Notably, the PICA-PICA bypass has emerged as a promising option, overshadowing the occipital artery-PICA (OA-PICA) bypass. The objective was to compare the safety and efficacy of OA-PICA and PICA-PICA bypasses. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review and meta-analysis to evaluate the safety and efficacy of OA-PICA and PICA-PICA bypasses for treating posterior circulation aneurysms. RESULTS: We analyzed 13 studies for the PICA-PICA bypass and 16 studies on the OA-PICA bypass, involving 84 and 110 patients, respectively. The median average follow-up for PICA-PICA bypass was 8 months (2-50.3 months), while for OA-PICA, it was 27.8 months (6-84 months). The patency rate for OA-PICA was 97% (95% confidence interval [CI]: 92%-100%) and 100% (95% CI: 95%-100%) for PICA-PICA. Complication rates were 29% (95% CI: 10%-47%) for OA-PICA and 12% (95% CI: 3%-21%) for PICA-PICA. Good clinical outcomes were observed in 71% (95% CI: 52%-90%) of OA-PICA patients and 87% (95% CI: 75%-100%) of PICA-PICA patients. Procedure-related mortality was 1% (95% CI: 0%-6%) for OA-PICA and 1% (95% CI: 0%-10%) for PICA-PICA. CONCLUSIONS: Both procedures have demonstrated promising results in efficacy and safety. PICA-PICA exhibits slightly better patency rates, better clinical outcomes, and fewer complications, but with a lack of substantial follow-up and a smaller sample size. The choice between these procedures should be based on the surgeon's expertise and the patient's anatomy.

Fractionated stereotactic radiotherapy in craniopharyngiomas: A systematic review and single arm meta-analysis.

INTRODUCTION: Numerous studies have demonstrated Fractionated Stereotactic Radiotherapy's (FSRT) effectiveness in tumor control post-resection for craniopharyngiomas. Nevertheless, past literature has presented conflicting findings particularly regarding endocrine and visual function outcomes. This study aims to elucidate FSRT's efficacy and safety for this population. METHODS: Adhering to PRISMA, a systematic review and meta-analyses was conducted. Included studies had to report the effects of FSRT for treating craniopharyngiomas in a sample greater than four patients, addressing at least one of the outcomes of interest: improvement in visual acuity or field, new-onset hypopituitarism, effectiveness, and tumor progression. Relative risk with 95% confidence intervals were used to assess the outcomes. RESULTS: After retrieving a total of 1292 studies, 10 articles met the predefined criteria and thus were finally selected, amounting to a total of 256 patients. The improvement in visual acuity was estimated at 45% (95% CI: 6-83%), while the improvement in the visual field was 22% (95% CI: 0-51%). Regarding endocrine function, the new-onset hypopituitarism rate was found to be 5% (95% CI: 0-11%). Relative to FSRT effectiveness, the pooled estimate of the complete tumor response rate was 17% (95% CI: 4-30%), and the tumor progression rate was 7% (95% CI: 1-13%). Also, a 3-year progression-free survival rate of 98% (95% CI: 95-100%) was obtained. CONCLUSION: Despite limitations and risks, FSRT shows promise as a viable therapeutic option for craniopharyngiomas, offering notable benefits for visual functions and tumor control. Further research is required to better understand the associated risks, benefits, and clinical utility.

Evaluating the efficacy of stent retriever and catheter aspiration combination in refractory cerebral venous sinus Thrombosis: A comprehensive Meta-Analysis.

BACKGROUND: Cerebral Venous Sinus Thrombosis (CVST) is a rare but potentially life-threatening condition, often associated with specific risk factors. The primary treatment for CVST is anticoagulation, but some cases progress to Refractory CVST (rCVST), requiring endovascular treatment. A combination of stent retriever and catheter aspiration is emerging as a promising technique to enhance treatment effectiveness. We conducted a systematic review and meta-analysis to assess the safety and efficacy of this approach, aiming to improve recanalization success and neurological outcomes while reducing complications in rCVST patients. METHODS: A search following PRISMA guidelines was conducted across Pubmed, Embase, Web of Science, and Cochrane databases to identify studies on the use of stent retrievers and catheter aspiration for rCVST. Pooled analysis with 95 % confidence intervals was used to assess the effects. Heterogeneity was evaluated using I2 statistics and a random-effects model was used. Complete recanalization. good clinical outcomes (mRS ≤ 2), hemorrhagic, neurological, ischemic, and total complications, poor clinical outcomes (mRS > 2), and mortality were assessed. RESULTS: A meta-analysis of five retrospective studies involving 55 patients examined outcomes in CVST. The median mean age was 40 years. Complete recanalization rate: 36 % (95 % CI: 9 % to 62 %, I2 = 90 %). Good clinical outcomes: 72 % (95 % CI: 50 % to 94 %, I2 = 76 %). Hemorrhagic complications: 2 % (95 % CI: 0 % to 8 %, I2 = 15 %). Ischemic complications: 0 % (95 % CI: 0 % to 6 %, I2 = 0 %). Neurological complications: 7 % (95 % CI: 0 % to 14 %, I2 = 0 %). Poor clinical outcomes: 26 % (95 % CI: 6 % to 46 %, I2 = 70 %). Total complications: 6 % (95 % CI: 0 % to 15 %, I2 = 10 %). Mortality rate: 5 % (95 % CI: 0 % to 13 %, I2 = 19 %). CONCLUSION: This systematic review and meta-analysis scrutinized the efficacy of combining Stent Retriever and Catheter Aspiration for rCVST. Findings highlighted varied outcomes, including recanalization rates, complications, and mortality. The dichotomy between good and poor outcomes underscores the necessity for personalized therapeutic decisions. While offering a comprehensive overview, the study emphasizes literature heterogeneity, suggesting a need for more rigorous and standardized research to optimize therapeutic strategies in clinical practice.

Maxillary artery utilization in subcranial-intracranial bypass procedures: a comprehensive systematic review and pooled analysis.

The utilization of the internal maxillary artery (IMAX) in subcranial-intracranial bypass for revascularization in complex aneurysms, tumors, or refractory ischemia shows promise. However, robust evidence concerning its outcomes is lacking. Hence, the authors embarked on a systematic review with pooled analysis to elucidate the efficacy of this approach. We systematically searched PubMed, Embase, and Web of Science databases following PRISMA guidelines. Included articles used the IMAX as a donor vessel for revascularizing an intracranial area and reported at least one of the following outcomes: patency, complications, or clinical data. Favorable outcomes were defined as the absence of neurologic deficits or improvement in the baseline condition. Complications were considered any adverse event directly related to the procedure. Out of 418 retrieved articles, 26 were included, involving 183 patients. Among them, 119 had aneurysms, 41 experienced ischemic strokes (transient or not), 2 had arterial occlusions, and 3 had neoplasia. Furthermore, 91.8% of bypasses used radial artery grafts, and 87.9% revascularized the middle cerebral artery territory. The median average follow-up period was 12 months (0.3-53.1). The post-operation patency rate was 99% (95% CI: 97-100%; I2=0%), while the patency rate at follow-up was 82% (95% CI: 68-96%; I2=77%). Complications occurred in 21% of cases (95% CI: 9-32%; I2=58%), with no significant procedure-related mortality in 0% (95% CI: 0-2%; I2=0%). Favorable outcomes were observed in 88% of patients (95% CI: 81-96%; I2=0%), and only 3% experienced ischemia (95% CI: 0-6%; I2=0%). The subcranial-intracranial bypass with the IMAX shows excellent postoperative patency and considerable favorable clinical outcomes. While complications exist, the procedure carries a minimal risk of mortality. However, long-term patency presents heterogeneous findings, warranting additional research.

Endovascular treatment of brain aneurysms under conscious sedation: a systematic review of procedural feasibility and safety.

Over the last decades, minimally invasive techniques have revolutionized the endovascular treatment (EVT) of brain aneurysms. In parallel, the development of conscious sedation (CS), a potentially less harmful anesthetic protocol than general anesthesia (GA), has led to the course optimization of surgeries, patient outcomes, and healthcare costs. Nevertheless, the feasibility and safety of EVT of brain aneurysms under CS have yet to be assessed thoroughly. Herein, we systematically reviewed the medical literature about this procedure. In accordance with the PRISMA guidelines, four databases (PubMed, EMBASE, SCOPUS, and Cochrane Library) were queried to identify articles describing the EVT of brain aneurysms under CS. Successful procedural completion, complete aneurysm occlusion outcomes, intraoperative complications, clinical outcomes, and mortality rates assessed the feasibility and safety. Our search strategy yielded 567 records, of which 11 articles were included in the qualitative synthesis. These studies entailed a total of 1142 patients (40.7% females), 1183 intracranial aneurysms (78.4% in the anterior circulation and 60.9% unruptured at presentation), and 1391 endovascular procedures (91.9% performed under CS). EVT modalities under CS included coiling alone (63.2%), flow diversion (17.7%), stent-assisted coiling (10.6%), stenting alone (6.5%), onyx embolization alone (1.7%), onyx + stenting (0.2%), and onyx + coiling (0.2%). CS was achieved by combining two or more anesthetics, such as midazolam, fentanyl, and remifentanil. Selection criteria for CS were heterogenous and included patients' history of pulmonary and cardiovascular diseases, outweighing the benefits of CS versus GA, a Hunt and Hess score of I-II, a median score of 3 in the American Society of Anesthesiology scale, and patient's compliance with elective CS. Procedures were deemed successful or achieving complete aneurysm occlusion in 88.1% and 9.4% of reported cases, respectively. Good clinical outcomes were described in 90.4% of patients with available data at follow-up (mean time: 10.7 months). The procedural complication rate was 16%, and the mortality rate was 2.8%. No complications or mortality were explicitly attributed to CS. On the other hand, procedure abortion and conversion from CS to GA were deemed necessary in 5% and 1% of cases, respectively. The present study highlights the feasibility of performing EVT of brain aneurysms under CS as an alternative anesthetic protocol to GA. However, the limited nature of observational studies, methodological quality, the predominant absence of a comparative GA group, and clinical data during follow-up restrict a conclusive statement about the safety of EVT under CS. Accordingly, further research endeavors are warranted toward a higher level of evidence that can be translated into surgical practice.

Transradial artery access for carotid artery stenting: A pooled analysis.

INTRODUCTION: Carotid artery stenting (CAS) through transradial access (TRA) is emerging as an alternative to carotid endarterectomy. However, the current evidence base is limited, mainly comprising single-center studies. OBJECTIVE: This systematic review and meta-analysis aim to assess the safety and effectiveness of TRA for CAS, providing evidence to support clinical decisions. METHODS: We conducted searches on PUBMED, Cochrane Library, Embase, and Web of Science databases, including studies on TRA for CAS. Studies with fewer than 20 patients, non-primary outcomes, and non-full-text articles were excluded. RESULTS: We analyzed 14 studies involving 1,166 patients who underwent CAS via TRA. Procedural success rate was high in 13 studies, with a 95% rate (95% CI; 92%-98%). Crossover to TFA access was observed in 12 studies at 6% (95% CI: 3%-9%). Transradial access failure was reported in four studies, with a rate of 0% (95% CI: 0%-0%). Cannulation failure resulted in a rate of 4% (95% CI: 2%-7%). Asymptomatic radial artery occlusion (ARAO) occurred at a rate of 2% based on eight studies (95% CI: 0%-5%). Forearm hematoma was reported in 10 studies, with an occurrence of 1% (95% CI: 0%-2%). Cerebral vascular attacks (CAV) within 30 days were assessed in 13 studies, indicating a 2% occurrence (95% CI: 1%-2%). CONCLUSION: The findings suggest that TRA for CAS yields promising outcomes with high success rates and low complication rates. Further research should focus on randomized controlled trials and long-term outcomes to validate and extend findings.

Stellate Ganglion Block in Subarachnoid Hemorrhage: A Promising Protective Measure Against Vasospasm?

BACKGROUND: Stellate ganglion block (SGB) may have protective effects in patients at risk of vasospasm following subarachnoid hemorrhage (SAH) due to reduced sympathetic activity. However, the safety and clinical outcomes of SGB in this scenario are not definitively known. The objective was to evaluate the safety, clinical outcomes, and cerebral blood flow velocity in patients submitted to SGB or cervical sympathectomy with SAH. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review and meta-analysis of studies investigating SGB or cervical sympathectomy use in SAH were conducted. PubMed, Cochrane Library, and Embase were evaluated. Patients with mRS from 0 to 2, GOS from 4 to 5, or symptom resolution were considered favorable clinical outcomes. Related mortality was defined as death by vasospasm or delayed cerebral ischemia. RESULTS: The analysis included 8 studies comprising 182 patients. Only 2 studies employed SGB prophylactically. The results revealed favorable outcomes in 52% of patients (95% CI: 37%-65%). The overall incidence of complications was 2% (95% CI: 0% -26%). The mortality rate was 13% (95% CI: 7%-21%), with a vasospasm-related mortality rate of 11% (95% CI: 2%-20%). A decrease of cerebral blood flow velocity was reported in 4 studies. CONCLUSIONS: The notable reduction in cerebral blood flow velocity following SGB, alongside positive outcomes and a low occurrence of mortality and complications, highlights its significance as a therapeutic intervention for vasospasm following SAH. While the number of studies evaluating SGB as a preventive measure is limited, the promising results emphasize the importance of future research.

Endovascular treatment of mycotic aneurysms: An update meta-analysis.

INTRODUCTION: Intracranial mycotic or infectious aneurysms result from the infection of arterial walls, most caused by bacterial or fungal organisms. These infections can weaken the arterial wall, leading to the formation of an aneurysm, a localized dilation, or a bulge. The management can be conservative mainly based on antibiotics or invasive methods such as clipping or endovascular treatment. PURPOSE: We performed a systematic review and meta-analysis of the current literature on endovascular treatment of mycotic aneurysms, analyzing the safety and efficacy associated with this procedure. METHODS: We systematically searched on PUBMED, Cochrane Library, Embase, and Web of Science databases. Our search strategy was carefully crafted to conduct a thorough investigation of the topic, utilizing a comprehensive combination of relevant keywords. This meta-analysis included all studies that reported endovascular treatment of mycotic aneurysms. To minimize the risk of bias, studies with fewer than four patients, studies where the main outcome was not found, and studies with no clear differentiation between microsurgical and endovascular treatment were excluded. RESULTS: In a comprehensive analysis of 134 patients, it was observed that all except one patient received antibiotics as part of their treatment. Among the patients, 56% (a total of 51 out of 90 patients) underwent cardiac surgery. Additionally, three patients required a craniotomy following endovascular treatment. 12 patients experienced morbidity related to the procedures performed, indicating complications arising from the interventions. Furthermore, four aneurysms experienced rebleeding while treatment. A pooled analysis of the endovascular treatment of the mycotic aneurysm revealed a good level of technical success, achieving a 100% success rate in 12 out of 14 studies (97-100%; CI 95%; I2 = 0%), as illustrated in Fig. 2. Similarly, the aneurysm occlusion rate demonstrated a notable efficacy, with a success rate of 97% observed in 12 out of 14 studies (97-100%; CI 95%; I2 = 0%), as depicted in Fig. 3. CONCLUSION: The results strongly support the efficacy of endovascular treatment in achieving technical success, complete aneurysm occlusion, and favorable neurological outcomes. Additionally, the notably low incidence of complications and procedure-related mortality reaffirms the safety and benefits associated with this intervention.

Efficacy and Safety of Extracranial-Intracranial Bypass Surgery for Posterior Circulation Aneurysms: A Systematic Review and Single-Arm Meta-Analysis.

OBJECTIVE: Treating complex posterior circulation aneurysms poses challenges, and extracranial to intracranial (EC-IC) bypass techniques are potential therapeutic options. However, the safety and efficacy of this approach for posterior circulation aneurysms remain unclear. The study's objective was to assess the safety and efficacy of EC-IC bypass in these aneurysms. METHODS: Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review on EC-IC revascularization for posterior circulation aneurysms. Included studies had at least 4 patients and reported data on mortality, patency, complications, or clinical outcomes. Favorable clinical outcomes were defined as modified Rankin Scale below 3 or Glasgow Outcome Scale above 3, and complications were any issues related to the bypass procedure. RESULTS: From 3036 articles reviewed, 22 studies involving 196 patients who underwent 210 EC-IC bypass procedures for posterior circulation aneurysms were selected. The median follow-up period of 14 studies was 31.66 months (6-61 months). Final follow-up indicated a high bypass patency rate of 96% [95% confidence interval [CI]: 91%-100%; I2 = 12%], with a mortality rate of 5% [95% CI: 1%-9%; I2 = 0%]. Additionally, 83% [95% CI: 70%-96%; I2 = 77%] of patients showed good outcomes at the last follow-up. Complications were observed in 40% [95% CI: 26%-55%; I2 = 80%]. Heterogeneity was associated with specific studies. CONCLUSIONS: EC-IC bypass procedures are a viable treatment option for posterior circulation aneurysms, with high bypass patency rates and favorable clinical outcomes. However, complications, especially neurological deficits, exist. Open revascularization remains essential for neurovascular surgeons dealing with complex aneurysms.

Ventriculoatrial Shunt Versus Ventriculoperitoneal Shunt: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Ventriculoperitoneal shunt (VPS) is usually the primary choice for cerebrospinal fluid shunting for most neurosurgeons, while ventriculoatrial shunt (VAS) is a second-line procedure because of historical complications. Remarkably, there is no robust evidence claiming the superiority of VPS over VAS. Thus, we aimed to compare both procedures through a meta-analysis. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, the authors systematically searched the literature for articles comparing VAS with VPS. The included articles had to detail one of the following outcomes: revisions, infections, shunt-related mortality, or complications. In addition, the cohort for each shunt model had to encompass more than 4 patients. RESULTS: Of 1872 articles, 16 met our criteria, involving 4304 patients, with 1619 undergoing VAS and 2685 receiving VPS placement. Analysis of revision surgeries showed no significant difference between VAS and VPS (risk ratio [RR] = 1.10, 95% CI: 0.9-1.34; I2 = 84%, random effects). Regarding infections, the analysis also found no significant difference between the groups (RR = 0.67, 95% CI: 0.36-1.25; I2 = 74%, random effects). There was no statistically significant disparity between both methods concerning shunt-related deaths (RR = 2.11, 95% CI: 0.68-6.60; I2 = 56%, random effects). Included studies after 2000 showed no VAS led to cardiopulmonary complications, and only 1 shunt-related death could be identified. CONCLUSION: Both methods show no significant differences in procedure revisions, infections, and shunt-related mortality. The literature is outdated, research in adults is lacking, and future randomized studies are crucial to understand the profile of VAS when comparing it with VPS. The final decision on which distal site for cerebrospinal shunting to use should be based on the patient's characteristics and the surgeon's expertise.