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.

Middle meningeal artery patency after surgical evacuation for chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) often requires surgical evacuation, but recurrence rates remain high. Middle meningeal artery (MMA) embolization (MMAE) has been proposed as an alternative or adjunct treatment. There is concern that prior surgery might limit patency, access, penetration, and efficacy of MMAE, such that some recent trials excluded patients with prior craniotomy. However, the impact of prior open surgery on MMA patency has not been studied. METHODS: A retrospective analysis was conducted on patients who underwent MMAE for cSDH (2019-2022), after prior surgical evacuation or not. MMA patency was assessed using a six-point grading scale. RESULTS: Of the 109 MMAEs (84 patients, median age 72 years, 20.2% females), 58.7% were upfront MMAEs, while 41.3% were after prior surgery (20 craniotomies, 25 burr holes). Median hematoma thickness was 14 mm and midline shift 3 mm. Hematoma thickness reduction, surgical rescue, and functional outcome did not differ between MMAE subgroups and were not affected by MMA patency or total area of craniotomy or burr-holes. MMA patency was reduced in the craniotomy group only, specifically in the distal portion of the anterior division (p = 0.005), and correlated with craniotomy area (p < 0.001). CONCLUSION: MMA remains relatively patent after burr-hole evacuation of cSDH, while craniotomy typically only affects the frontal-distal division. However, MMA patency, evacuation method, and total area do not affect outcomes. These findings support the use of MMAE regardless of prior surgery and may influence future trial inclusion/exclusion criteria. Further studies are needed to optimize the timing and techniques for MMAE in cSDH management.

Is the European badger a new host for Dirofilaria immitis? The first records in Greece.

Dirofilaria immitis is a ubiquitous nematode parasite with zoonotic potential, transmitted by mosquitoes, that causes heartworm disease in various animal species. Dogs are the parasite's typical final host, and wild carnivores represent the parasite's reservoir in nature. Studies on D. immitis infections in wild animals are essential to assess infection pressure for domestic animals, and until now, there has been only one infection case reported in a European badger (Meles meles). The current report describes the first two European badger cases with cardiovascular dirofilariosis in Greece. Two adult male badgers were rescued in Heraklion and Chania, Crete Island, and admitted to "ANIMA -Wildlife Rehabilitation Centre" in Athens. The detailed clinical examination revealed that the first badger suffered from severe broncho-pneumonitis while the second one displayed clinical signs associated with severe brain trauma. Blood samples were taken for haematology and biochemistry analyses during their short hospitalisation period. In addition, different routine diagnostic tests were carried out, including heartworm antigen testing (ELISA) and the modified Knott's test for microfilariae. Both badgers were positive in both tests. The animals died a few hours after their admission and the detailed necropsies followed, revealed the presence of three parasites in each animal's right heart, morphologically identified as adults of D. immitis. These findings add the European badger in the list of additional potential reservoir hosts for D. immitis and highlight the potential role of wildlife for companion animals and human health.

Postoperative de novo epilepsy after resection of brain arteriovenous malformations: A national database study of 536 patients.

OBJECTIVE: We aimed to assess the incidence and risk factors for de novo epilepsy after arteriovenous malformation (AVM) resection and compare them with a nonresection cohort after propensity score matching, utilizing a national database. METHODS: Utilizing the TriNetX Research Network, we queried cases from January 1, 2004 to March 1, 2022. We included patients of all ages who underwent supratentorial AVM resection, presenting without seizures on or before surgery and without being on antiseizure medications at least 1 day before surgery. The primary outcome was seizures manifesting at least 6 weeks after surgery. Patient characteristics and outcomes were compared between the cohorts with and without postoperative epilepsy. Further cohorts were created to compare cohorts with and without embolization or rupture. After propensity score matching, we compared an additional cohort of patients with an AVM diagnosis who did not undergo resection. RESULTS: Of the 536 patients (mean age = 38.9 ± 19.6, 52% females) presenting without seizure who underwent AVM resection, 99 (18.5%) developed de novo epilepsy, with a 1-year cumulative incidence of 13.8%. Patients with epilepsy had higher rates of intracerebral hemorrhage, and intracerebral hemorrhage was less common in the embolization cohort. Patients in the ruptured cohort were older and more often males. After propensity score matching with 18 588 patients with AVM diagnosis but no resection, each group consisted of 529 patients, and de novo epilepsy at 1 year was significantly higher in the AVM resection cohort compared to the nonresection cohort (11.5% vs. 3.4%, p < .001). SIGNIFICANCE: This analysis of 536 patients provides evidence that de novo epilepsy after brain AVM resection occurs at a 1-year cumulative incidence of 13.8%, with a total of 19.4% developing de novo epilepsy. Intracerebral hemorrhage was inconsistently associated with postoperative de novo epilepsy. De novo epilepsy was significantly less frequent after AVM diagnosis without resection.

TbSAP is a novel chromatin protein repressing metacyclic variant surface glycoprotein expression sites in bloodstream form Trypanosoma brucei.

The African trypanosome Trypanosoma brucei is a unicellular eukaryote, which relies on a protective variant surface glycoprotein (VSG) coat for survival in the mammalian host. A single trypanosome has >2000 VSG genes and pseudogenes of which only one is expressed from one of ∼15 telomeric bloodstream form expression sites (BESs). Infectious metacyclic trypanosomes present within the tsetse fly vector also express VSG from a separate set of telomeric metacyclic ESs (MESs). All MESs are silenced in bloodstream form T. brucei. As very little is known about how this is mediated, we performed a whole genome RNAi library screen to identify MES repressors. This allowed us to identify a novel SAP domain containing DNA binding protein which we called TbSAP. TbSAP is enriched at the nuclear periphery and binds both MESs and BESs. Knockdown of TbSAP in bloodstream form trypanosomes did not result in cells becoming more 'metacyclic-like'. Instead, there was extensive global upregulation of transcripts including MES VSGs, VSGs within the silent VSG arrays as well as genes immediately downstream of BES promoters. TbSAP therefore appears to be a novel chromatin protein playing an important role in silencing the extensive VSG repertoire of bloodstream form T. brucei.

Safety and efficacy of the p48 MW and p64 flow modulation devices: a systematic review and meta-analysis.

OBJECTIVE: Flow diverters (FDs) have demonstrated increasing safety and efficacy in treating various types of intracranial aneurysms. Although the underlying mechanism of action of all FDs is similar, differences are noted in their intrinsic characteristics, materials, and deployment techniques. The p64 flow modulation device (p64) and the newer p48 movable wire flow modulation device (p48 MW) are not yet available in the US but have been increasingly used mainly in Europe, demonstrating optimistic results. The authors performed a systematic review and meta-analysis of the literature to evaluate the safety and efficacy of the p64 and p48 MW FDs. METHODS: A literature review (between January 1960 and November 2022) of the PubMed, Scopus, Embase, Web of Science, and Cochrane Central Register of Controlled Trials databases was conducted. The primary efficacy outcome was the proportion of complete angiographic occlusion at last follow-up. Complete occlusion was defined as Raymond-Roy class 1 and O'Kelly-Marotta grade D. The primary safety outcomes were the composite safety rate of ischemic and hemorrhagic events (intra- and postprocedure) and the all-cause mortality rate. Data were analyzed using a random-effects proportions meta-analysis, and statistical heterogeneity was assessed. RESULTS: Twenty studies with 1781 patients harboring 1957 aneurysms were included in the analysis. Seventeen studies were conducted in Europe. Sixteen studies evaluated the performance of the p64 (MW). Patient ages ranged between 20 and 89 years, and most were female (78.7%). Aneurysm size ranged between 1 and 50 mm. Most aneurysms were unruptured (92.8%) and in the anterior circulation (93.1%). Single antiplatelet therapy pre- and postprocedure was used in 2 studies. Follow-up ranged from 2 to 14.5 months. For the p64 and p48 MW, complete angiographic occlusion rates were 77% (95% CI 68%-85%) and 67% (95% CI 49%-81%), adjunctive coil usage rates were 7% (95% CI 4%-12%) and 4% (95% CI 0%-24%), primary safety composite rates were 2% (95% CI 1%-4%) and 3% (95% CI 1%-11%), and mortality rates were 0.49% (95% CI 0%-1%) and 2% (95% CI 1%-6%), respectively. CONCLUSIONS: The p64 and p48 MW have primarily been used in Europe thus far. This analysis found that both devices have an acceptable efficacy and favorable safety profile. However, further studies are needed to evaluate the efficacy and safety of prescribing a single antiplatelet regimen after implantation of the newer-generation FDs with antithrombotic coating surface modification.

Patient sentiment regarding stroke: Analysis of 2,992 social media posts.

INTRODUCTION: Social media reflects personalized sentiment toward disease and increasingly impacts perceptions of treatment options. This study aims to assess patients experience with and perception of stroke through an analysis of social media posts. METHODS: A variety of terms ("stroke", "stroke survivor", "stroke rehab", "stroke recovery") were used to search for possible qualified posts on Twitter and Instagram. Twitter posts containing "#stroke" and "@stroke" were identified, yielding 2,506 Twitter posts relating to the patient's own experience. Four hundred sixty-eight public Instagram posts marked under "#stroke" and "@stroke," including direct references to the patient's own experience, were analyzed. First vs. recurrent stroke was identified when possible. The posts were coded for themes relating to patient experience with the disease. RESULTS: The most common Twitter theme was raising stroke awareness (23.4 %), while spreading positivity was the most common Instagram theme (66.7 %). Most Twitter posts (93.9 %) were from patients experiencing their first stroke, with only 6.1 % of the posts being about recurrent strokes. Women created the majority of Instagram (75.7 %) and Twitter (77.3 %) posts. Men were more likely to discuss mobility/functional outcomes (p = 0.001) and survival/death (p = 0.014), while women were more likely to recount symptoms (p = 0.014), depression (p = 0.002), fear (p<0.001), and mental health (p = 0.006). CONCLUSION: Stroke patients most often describe their quality of life and discuss raising awareness via social media. Men and women differ in the most commonly shared aspects of their stroke experience. Gauging social media sentiment may guide physicians toward better counseling and psychosocial management of stroke patients.

Robot-assisted carotid artery stenting: outcomes, safety, and operational learning curve.

OBJECTIVE: Over the past 2 decades, robots have been increasingly used in surgeries to help overcome human limitations and perform precise and accurate tasks. Endovascular robots were pioneered in interventional cardiology, however, the CorPath GRX was recently approved by the FDA for peripheral vascular and extracranial interventions. The authors aimed to evaluate the operational learning curve for robot-assisted carotid artery stenting over a period of 19 months at a single institution. METHODS: A retrospective analysis of a prospectively maintained database was conducted, and 14 consecutive patients who underwent robot-assisted carotid artery stenting from December 2019 to June 2021 were identified. The metrics for proficiency were the total fluoroscopy and procedure times, contrast volume used, and radiation dose. To evaluate operator progress, the patients were divided into 3 groups of 5, 4, and 5 patients based on the study period. RESULTS: A total of 14 patients were included. All patients received balloon angioplasty and stent placement. The median degree of stenosis was 95%. Ten patients (71%) were treated via the transradial approach and 4 patients (29%) via the transfemoral approach, with no procedural complications. The median contrast volume used was 80 mL, and the median radiation dose was 38,978.5 mGy/cm2. The overall median fluoroscopy and procedure times were 24.6 minutes and 70.5 minutes, respectively. Subgroup analysis showed a significant decrease in these times, from 32 minutes and 86 minutes, respectively, in group 1 to 21.9 minutes and 62 minutes, respectively, in group 3 (p = 0.002 and p = 0.008, respectively). CONCLUSIONS: Robot-assisted carotid artery stenting was found to be safe and effective, and the learning curve for robotic procedures was overcome within a short period of time at a high-volume cerebrovascular center.

Frailty assessment and postoperative outcomes among patients undergoing general surgery.

BACKGROUND: Frailty is an emerging concept in modern general surgery because of its correlation with adverse outcomes. More frail older patients are undergoing general surgery due to the rapid aging of the population and the effect of the "baby boom" generation. However, there is no consensus on the definition of frailty and on ways to assess its severity and effect. PURPOSE: To describe the definition and epidemiology, measurement tools, and the effect of frailty on postoperative outcomes after general surgery. METHODS: PubMed and Google Scholar databases were comprehensively searched. RESULTS: Frailty is a syndrome defined as increased vulnerability to stressors due to a decline in physiological function and reserve among organ systems, resulting in adverse outcomes. Numerous tools have been described and tested for frailty measurement, but the ideal clinical tool has not been found yet. The evidence from cohort studies and meta-analyses shows associations between preoperative frailty and adverse perioperative outcomes after general surgery. CONCLUSION: Frailty is an essential concept in general surgery. However, further studies have to identify the optimal way to preoperatively assess frailty and risk-stratify older patients.

The role of genomic location and flanking 3'UTR in the generation of functional levels of variant surface glycoprotein in Trypanosoma brucei.

Trypanosoma brucei faces relentless immune attack in the mammalian bloodstream, where it is protected by an essential coat of Variant Surface Glycoprotein (VSG) comprising ∼10% total protein. The active VSG gene is in a Pol I-transcribed telomeric expression site (ES). We investigated factors mediating these extremely high levels of VSG expression by inserting ectopic VSG117 into VSG221 expressing T. brucei. Mutational analysis of the ectopic VSG 3'UTR demonstrated the essentiality of a conserved 16-mer for mRNA stability. Expressing ectopic VSG117 from different genomic locations showed that functional VSG levels could be produced from a gene 60 kb upstream of its normal telomeric location. High, but very heterogeneous levels of VSG117 were obtained from the Pol I-transcribed rDNA. Blocking VSG synthesis normally triggers a precise precytokinesis cell-cycle checkpoint. VSG117 expression from the rDNA was not adequate for functional complementation, and the stalled cells arrested prior to cytokinesis. However, VSG levels were not consistently low enough to trigger a characteristic 'VSG synthesis block' cell-cycle checkpoint, as some cells reinitiated S phase. This demonstrates the essentiality of a Pol I-transcribed ES, as well as conserved VSG 3'UTR 16-mer sequences for the generation of functional levels of VSG expression in bloodstream form T. brucei.

Death due to fracture of thin calvarial bones after a fall: A forensic approach.

A 45-year-old male was autopsied. He had fallen backwards from a two-stairs height to the ground and passed away. A skull fracture was detected in the left occipital area, extending up to the left side of the skull base. The patient's death occurred due to the very low thickness of the calvarial bones, which led to the aforementioned fracture, and in turn resulted in subarachnoid hemorrhage and death. The cortical thickness was measured and compared with average values at standardized points. Uniform bone thinning was confirmed rather than localized. Calvarial thinning may result from various conditions. In the present case study, however, the exact mechanism which led to the low thickness of the calvarial bones of the patient is undetermined. Death due to the susceptible structure and fracture of calvarial bones has rarely been reported throughout relevant literature.

Spatial Distribution of Dermanyssus gallinae Infestations in Greece and Their Association with Ambient Temperature, Humidity, and Altitude.

Dermanyssus gallinae, the poultry red mite (PRM), is the most prevalent and harmful ectoparasite of laying hens globally. Although prevalence and risk factor studies can help veterinarians make decisions regarding farm treatments, relevant data are scarce. The present study investigated the prevalence and infestation severity of PRM in poultry farms across Greece and examined potential risk factors. AviVet traps were used to sample 84 farms (51 backyard, 33 industrial) over three years. Farm altitude, temperature, humidity, region, and production systems were assessed as potential risk factors with chi-square tests, initially for all the studied farms and then exclusively for backyard farms. The overall prevalence was 75.0% and was higher in backyard farms (80.4%) compared with industrial ones (66.7%), varying regionally from 66.7 to 90.9%. Altitude and temperature were not significant risk factors, but farms with humidity <60% had a lower infestation risk. Infestation severity did not significantly differ by risk factors. The poultry red mite is highly prevalent across Greek poultry production systems and regions. In the future, global warming, reduced acaricide options, and a ban on cage systems will all threaten a wider spatio-temporal distribution of the PRM, justifying the urgent need for effective monitoring and control methods to protect hen production and welfare and workers' health.

Efficacy of afoxolaner or the combination of afoxolaner with milbemycin oxime against Otodectes cynotis in naturally infested dogs.

Otodectes cynotis, commonly known as "the ear mite," is a highly contagious ectoparasite and a significant cause of otitis externa in canines. The objective of the current study was to determine the efficacy of the isoxazoline afoxolaner (Nexgard®), and the combination of afoxolaner with milbemycin oxime (Nexgard Spectra®), in dogs naturally infested with O. cynotis. In total, 32 infested client-owned dogs from two different sites in Greece were included. The animals were randomly divided into four equal groups based on their infestation score. Group 1 served as the negative control, group 2 received one oral administration of Nexgard (Day 0), group 3 received two monthly oral administrations of Nexgard (Days 0, 30), and group 4 received two monthly oral administrations of Nexgard Spectra (Days 0, 30), according to label instructions. Otoscopic examinations for mites and observations on debris/cerumen in the ears were carried out on Days 0, 15, 30, and 45. A quantitative assessment of ear mites by ear duct flushing and live mite counts was performed on Day 45. The results demonstrated that a single oral dose of afoxolaner and two monthly doses of afoxolaner or afoxolaner with milbemycin oxime resulted in a 99.9% reduction in live mite counts compared to the untreated control group by Day 45. Additionally, treated dogs showed improved clinical symptoms, such as ear cerumen/debris decrease, while untreated dogs experienced worsening symptoms over the study duration. No adverse events were reported. Overall, these results support the use of afoxolaner-based products to treat O. cynotis infestation in dogs.

Beyond Borders: Dirofilaria immitis Infection in Dogs Spreads to Previously Non-Enzootic Areas in Greece-A Serological Survey.

Although Dirofilaria immitis in dogs is considered enzootic in northern Greece, the available data on the occurrence of infection in southern parts of the country demonstrate its scarcity. The aim of this study was to update the current knowledge on D. immitis infection in dogs in areas of Greece previously considered non-enzootic (Central Greece, Attica, Peloponnese, North Aegean, South Aegean, Crete and the Ionian islands). In total, 1528 dog blood samples were collected from the aforementioned areas and examined by Dirochek® ELISA (Synbiotics). Additionally, data published until 2022 on the prevalence of infection in these areas were compared to the data of this study. The 'Wilson' Score interval method (Epitools) was employed. Overall, 10.8% of dogs were positive for D. immitis. In detail, the prevalence was 21.7, 13.7, 10.7, 5.4, 4.7, 6.2 and 17.0% for D. immitis, in Central Greece, Attica, Peloponnese, North Aegean, South Aegean, Crete and the Ionian islands, respectively. Infection with D. immitis is recorded for the first time in Crete. The probability of a dog becoming infected has increased 4.1 times since 2022 in previously non-enzootic areas. This study denotes the spread of D. immitis and highlights the necessity for preventive measures.

Ecological niche modeling analysis (Cx. pipiens), potential risk and projection of Dirofilaria spp. infection in Greece.

Vector-borne diseases continue to increase worldwide. Dirofilariosis is one of the most common vector-borne zoonotic diseases, mainly caused by Dirofilaria spp. (D. immitis and D. repens) and spread by culicid mosquitoes of different species. Greece is one of the countries in southern Europe where it is traditionally endemic, and its distribution is not homogeneous. The aim of this study was to develop an environmental model for Greece that reflects the suitability of the ecological niche for Dirofilaria spp. infection risk and its projection until 2080. For this purpose, we used the potential distribution of suitable habitats for Culex pipiens calculated using an ecological niche model (ENM) and the potential number of generations of Dirofilaria spp. The ecological niche model of Cx. pipiens in Greece showed good predictive power (AUC=0.897) with the parasite at a resolution of 1 km2. The variables that contributed most to the model were mean annual temperature, rivers and human footprint. The highest risk of infection was found in coastal areas and in riverside areas of the main river basins, as well as in irrigated areas of the mainland and peninsular regions and in the whole territory of island areas, and the lowest risk was found in areas of higher altitude. A positive relationship was found between the risk of dirofilariosis and the location of infected dogs, with 86.65% located in very high and high risk areas. In 2080, the percentage of territory gained by Cx. pipiens will increase by 261.52%. This model provides a high predictive value, predicted presence, and risk of Dirofilaria spp. infection and can serve as a tool for the management and control of this disease.

Intraoperative Ionizing Radiation Exposure Awareness and Associated Morbidity in Neurosurgery: A Nationwide Survey.

BACKGROUND: Neurosurgeons often use radiation to visualize blood vessels and implants intraoperatively. However, high exposure to radiation increases one's cancer risk. This study aims to investigate intraoperative ionizing radiation exposure awareness and associated morbidity among neurosurgeons. METHODS: An anonymized 30-question survey about their intraoperative radiation exposure, protective measures, radiation knowledge, and any conditions that can arise from protracted radiation exposure was disseminated to 3344 American Association of Neurological Surgeons members. RESULTS: A total of 227 (6.8%) neurosurgeons completed the survey. Most neurosurgeons (61, 27%) performed 2-4 surgeries per week necessitating radiation (61, 27%), did not use a dosimeter (134, 59%), and wore a lead apron (89%) and a thyroid shield (75%). Only 7 (3%) of respondents could correctly identify the safety limit for occupational radiation. One hundred and thirty-four (59%) respondents correctly identified the relationship between distance and radiation dose reduction. Two hundred and thirteen (94%) neurosurgeons reported concern about occupational radiation exposure. No significant association was found between occupational radiation exposure and the rate of cataracts, combined cancer, and skin cancer. Multivariate logistic regression adjusting for age and cancer history found that the likelihood of developing leukemia (P = 0.02) and nonmalignant thyroid nodular disease (P = 0.01) is positively associated with increased total occupational radiation exposure. CONCLUSIONS: There is a need for improved radiation safety awareness among neurosurgeons, especially in the context of rising usage of minimally invasive surgery. This can allow for a greater understanding of radiation-associated risks among neurosurgeons and guide the implementation of safer practices.

Endovascular biopsy in neurointerventional surgery: A systematic review.

INTRODUCTION: Endothelial cells (ECs) continuously line the cerebrovasculature. Molecular aberrations in the ECs are hallmarks and contributory factors to the development of cerebrovascular diseases, including intracranial aneurysms and arteriovenous malformations (AVMs). Endovascular biopsy has been introduced as a method to harvest ECs and obtain relevant biologic information. We aimed to summarize the literature on endovascular biopsy in neurointerventional surgery. METHODS: We conducted a comprehensive literature search in multiple databases, identifying eligible studies focusing on neurosurgical applications of endovascular biopsy. The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The relevant information was collected, including study characteristics, biopsy techniques, and key findings. RESULTS: Nine studies met the inclusion criteria and were included. The studies involved the collection of ECs using various endovascular devices including coils, guide wires, different stents, and forceps. Endothelial-enrichment techniques, such fluorescence-activated cell sorting (FACS), collected ECs and facilitated downstream applications of bulk or single-cell RNA sequencing (scRNAseq). The studies provided insights into gene expression profiles and identified potential biomarkers associated with intracranial aneurysms. However, challenges were observed in obtaining an adequate number of ECs and identifying consistent biomarkers. CONCLUSION: Endovascular biopsy of endothelial cells (ECs) in cerebrovascular pathologies shows promise for gene expression profiling. However, many studies have been limited in sample size and underpowered to identify "signature genes" for aneurysm growth or rupture. Advancements in minimally invasive biopsy methods have potential to facilitate applications of precision medicine in the treatment of cerebrovascular disorders.

Utilization and reimbursement of diagnostic cerebral angiograms: A Medicare trends analysis from 2013 to 2020.

INTRODUCTION: Increasing life expectancy has caused growing concern about maintaining viable neurointerventional practices due to altered Medicare payment structures. This study analyzes the financial trends of three common diagnostic tests for cerebrovascular disease: cerebral digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). METHODS: Medicare Part B National Summary Data files from 2013 to 2020 were queried by Current Procedural Terminology (CPT) codes for DSA (36221-36228), CTA (70496, 70498), and MRA (70544-70547, 70549). Inflation-adjusted charges and reimbursement were calculated using the U.S. City Average Consumer Price Index for Medical Services. Regression analysis was performed on charges, reimbursement, and volume. RESULTS: A total of 1,519,245 diagnostic procedures were conducted between 2013 and 2020 (782,370 angiograms, 246,603 CTAs, and 490,272 MRAs). A total of $41.005 million was reimbursed by Medicare in 2020 for these diagnostic procedures. The annual percent change in volume for all procedures was -2.90%. From 2013 to 2020, inflation-adjusted: Medicare total physician reimbursement decreased for cerebral angiograms (-4.12%, p = 0.007), CTAs (-2.77%, p = 0.458), and MRAs (-9.06%, p < 0.001). Procedural volume billed to Medicare decreased for cerebral angiograms (-4.63%, p = 0.007) and MRAs (-2.94%, p = 0.0.81) and increased for CTAs (+3.15%, p = 0.004). The greatest increase in Medicare reimbursement (+66.75%) came from CPT code 36224, "place catheter carotid artery", and the greatest decrease in Medicare reimbursement (-8.66%) came from CPT code 36226, "place catheter vertebral artery." CONCLUSIONS: This study provides an analysis of Medicare reimbursement trends for routine cerebrovascular angiogram techniques. The findings highlight a decline in Medicare reimbursements for neurointerventionalists.

Readability of cerebrovascular diseases online educational material from major cerebrovascular organizations.

INTRODUCTION: The internet is an essential resource for patients and their loved ones to understand their medical conditions, and professional medical organizations have taken great strides to develop educational material targeting patients. The average American reads at a seventh to eighth grade reading level, hence it is important to understand the readability of this medical information to ensure patients comprehend what is being presented. METHODS: In January 2023, online patient education material was downloaded from major cerebrovascular healthcare organizations and assessed using eight assessments, including Bormuth Cloze Mean, Bormuth Grade Placement, Coleman-Liau (grade levels), Coleman-Liau (predictive cloze scores), Flesch Reading Ease (FRE), and Fry. RESULTS: A total of 32 files were extracted from six organizations and analyzed across 15 readability measures. None of the organizations met the federal government guidelines for grade-level readability. This held constant across all measured tests. Two organizations had above a postgraduate level. The FRE graphs do not identify any organizations with material below a ninth grade reading level, while the American Association of Neurological Surgeons (AANS) and the Society of Interventional Radiology (SIR) have a postgraduate readability level. The Fry graphs show similar results, with AANS/CNS Cerebrovascular Section, Society of NeuroInterventional Surgery (SNIS), SIR, and AANS having college-level readability. The lowest readability across all measures is only at an early seventh grade reading level. CONCLUSIONS: Current health literacy content for cerebrovascular patients is far above the recommended readability level. We provide straightforward suggestions for how major professional organizations should improve their informational material on cerebrovascular diseases to improve patient understanding.

Multicenter US clinical experience with the Scepter Mini balloon catheter.

INTRODUCTION: Distal navigability and imprecise delivery of embolic agents are two limitations encountered during liquid embolization of cerebrospinal lesions. The dual-lumen Scepter Mini balloon (SMB) microcatheter was introduced to overcome these conventional microcatheters' limitations with few small single-center reports suggesting favorable results. METHODS: A series of consecutive patients undergoing SMB-assisted endovascular embolization were extracted from prospectively maintained registries in seven North-American centers (November 2019 to September 2022). RESULTS: Fifty-four patients undergoing 55 embolization procedures utilizing SMB were included (median age 58.5; 48.1% females). Cranial dural arteriovenous fistula embolization was the most common indication (54.5%) followed by cranial arteriovenous malformation (27.3%). Staged/pre-operative embolization was done in 36.4% of cases; and 83.6% of procedures using Onyx-18. Most procedures utilized a transarterial approach (89.1%), and SMB-induced arterial-flow arrest concurrently with transvenous embolization was used in 10.9% of procedures. Femoral access/triaxial setups were utilized in the majority of procedures (65.5% and 60%, respectively). The median vessel diameter where the balloon was inflated of 1.8 mm, with a median of 1.5 cc of injected embolic material per procedure. Technical failures occurred in 5.5% of cases requiring aborting/replacement with other devices without clinical sequelae in any of the patients, with SMB-related procedural complications of 3.6% without clinical sequelae. Radiographic imaging follow-up was available in 76.9% of the patients (median follow-up 3.8 months), with complete occlusion (100%) or >50% occlusion in 92.5% of the cases, and unplanned retreatments in 1.8%. CONCLUSION: The SMB microcatheter is a useful new adjunctive device for balloon-assisted embolization of cerebrospinal lesions with a high technical success rate, favorable outcomes, and a reasonable safety profile.