Comparative Efficacy of Flow Diverter Devices in the Treatment of Carotid Sidewall Intracranial Aneurysms: a Retrospective, Multicenter Study.

BACKGROUND: The comparative efficacy and safety of first-generation flow diverters (FDs), Pipeline Embolization Device (PED) (Medtronic, Irvine, California), Silk (Balt Extrusion, Montmorency, France), Flow Re-direction Endoluminal Device (FRED) (Microvention, Tustin, California), and Surpass Streamline (Stryker Neurovascular, Fremont, California), is not directly established and largely inferred. PURPOSE: This study aimed to compare the efficacy of different FDs in treating sidewall ICA intracranial aneurysms. METHODS: We conducted a retrospective review of prospectively maintained databases from eighteen academic institutions from 2009-2016, comprising 444 patients treated with one of four devices for sidewall ICA aneurysms. Data on demographics, aneurysm characteristics, treatment outcomes, and complications were analyzed. Angiographic and clinical outcomes were assessed using various imaging modalities and modified Rankin Scale (mRS). Propensity score weighting was employed to balance confounding variables. The data analysis used Kaplan-Meier curves, logistic regression, and Cox proportional-hazards regression. RESULTS: While there were no significant differences in retreatment rates, functional outcomes (mRS 0-1), and thromboembolic complications between the four devices, the probability of achieving adequate occlusion at the last follow-up was highest in Surpass device (HR: 4.59; CI: 2.75-7.66, p < 0.001), followed by FRED (HR: 2.23; CI: 1.44-3.46, p < 0.001), PED (HR: 1.72; CI: 1.10-2.70, p = 0.018), and Silk (HR: 1.0 ref. standard). The only hemorrhagic complications were with Surpass (1%). CONCLUSION: All the first-generation devices achieved good clinical outcomes and retreatment rates in treating ICA sidewall aneurysms. Prospective studies are needed to explore the nuanced differences between these devices in the long term.

The Impact of Preprocedural Platelet Function Testing on Periprocedural Complication Rates Associated With Pipeline Flow Diversion: An International Multicenter Study.

BACKGROUND AND OBJECTIVES: Dual antiplatelet therapy (DAPT) is necessary to minimize the risk of periprocedural thromboembolic complications associated with aneurysm embolization using pipeline embolization device (PED). We aimed to assess the impact of platelet function testing (PFT) on reducing periprocedural thromboembolic complications associated with PED flow diversion in patients receiving aspirin and clopidogrel. METHODS: Patients with unruptured intracranial aneurysms requiring PED flow diversion were identified from 13 centers for retrospective evaluation. Clinical variables including the results of PFT before treatment, periprocedural DAPT regimen, and intracranial complications occurring within 72 h of embolization were identified. Complication rates were compared between PFT and non-PFT groups. Differences between groups were tested for statistical significance using the Wilcoxon rank sum, Fisher exact, or χ 2 tests. A P -value <.05 was statistically significant. RESULTS: 580 patients underwent PED embolization with 262 patients dichotomized to the PFT group and 318 patients to the non-PFT group. 13.7% of PFT group patients were clopidogrel nonresponders requiring changes in their pre-embolization DAPT regimen. Five percentage of PFT group [2.8%, 8.5%] patients experienced thromboembolic complications vs 1.6% of patients in the non-PFT group [0.6%, 3.8%] ( P = .019). Two (15.4%) PFT group patients with thromboembolic complications experienced permanent neurological disability vs 4 (80%) non-PFT group patients. 3.7% of PFT group patients [1.5%, 8.2%] and 3.5% [1.8%, 6.3%] of non-PFT group patients experienced hemorrhagic intracranial complications ( P > .9). CONCLUSION: Preprocedural PFT before PED treatment of intracranial aneurysms in patients premedicated with an aspirin and clopidogrel DAPT regimen may not be necessary to significantly reduce the risk of procedure-related intracranial complications.

Expanding the reach of the trans-middle cerebellar peduncle approach: pontine cavernous malformations, tissue transgression beyond the safe entry zone, and the invisible triangle.

OBJECTIVE: In the authors' microsurgical experience, the trans-middle cerebellar peduncle (MCP) approach to the lateral and central pons has been the most common approach to brainstem cavernous malformations (BSCMs). This approach through a well-tolerated safe entry zone (SEZ) allows a wide vertical or posterior trajectory, reaching pontine lesions extending into the midbrain, medulla, and pontine tegmentum. Better understanding of the relationships among lesion location, surgical trajectory, and long-term clinical outcomes could determine areas of safe passage. METHODS: A single-surgeon cohort study of all primary trans-MCP BSCM resections was conducted from July 1, 2017, to June 30, 2021. Preoperative and postoperative MR images were independently reviewed by 3 investigators blinded to the intervention, using a standardized rubric to define BSCM regions of interest (ROIs) involved with a lesion or microsurgical tract. Statistical testing, including the chi-square test with the Bonferroni correction, logistic regression, and structural equation modeling, was performed to analyze relationships between ROIs and clinical outcomes. RESULTS: Thirty-one patients underwent primary trans-MCP BSCM resection during the study period. The median age was 50 years (IQR 24-49 years); 19 (61%) patients were female, and 12 (39%) were male. Seven (23%) patients had familial cavernous malformation syndromes. The median follow-up was 9 months (range 6-37 months). At the last follow-up, composite neurological outcomes were favorable: 22 (71%) patients had 0 (n = 12, 39%) or 1 (n = 10, 32%) major persistent deficit, 5 patients (16%) had 2 deficits, 2 (7%) had 3 deficits, and 1 patient each (3%) had 4 or 6 deficits. Unfavorable composite outcomes were significantly associated with lesions (OR 7.14, p = 0.04) or surgical tracts (OR 12.18, p < 0.001) extending from the superior cerebellar peduncle (SCP) into the contralateral medial midbrain. The ipsilateral dorsal pons was the most frequently implicated ROI involving a surgical tract and the development of new postoperative deficits. This region involved the rhomboid pontine territory and transgression of the pontine tegmentum (OR 7.53, p < 0.001). Structural equation modeling supported medial midbrain and pontine tegmentum transgression as the primary drivers of morbidity. CONCLUSIONS: Trans-MCP resection is a safe and effective treatment for BSCMs, including lesions with marked superior or inferior ipsilateral extension. Two trajectories are associated with increased neurological risk: first, a superomedial trajectory to lesions extending into the midbrain that transgresses the SCP, its decussation, or both; and second, a posteromedial trajectory to lesions extending into the pontine tegmentum. The corticospinal tract, SCP, and pontine tegmentum form an invisible triangle within the pontine white matter tolerant of transgression. When the surgeon works within this triangle, most deep pontine BSCMs, including large lesions, those with contralateral or posterior extension, and others extending into the midbrain and medulla, can be resected safely with the trans-MCP approach.

The Impact of Dual Antiplatelet Therapy Duration on Unruptured Aneurysm Occlusion After Flow Diversion: A Multicenter Study.

OBJECTIVE: Endoluminal flow diversion reduces blood flow into intracranial aneurysms, promoting thrombosis. Postprocedural dual antiplatelet therapy (DAPT) is necessary for the prevention of thromboembolic complications. The purpose of this study is to therefore assess the impact that the type and duration of DAPT has on aneurysm occlusion rates and iatrogenic complications after flow diversion. METHODS: A retrospective review of a multicenter aneurysm database was performed from 2012 to 2020 to identify unruptured intracranial aneurysms treated with single device flow diversion and ≥12-month follow-up. Clinical and radiologic data were analyzed with aneurysm occlusion as a function of DAPT duration serving as a primary outcome measure. RESULTS: Two hundred five patients underwent flow diversion with a single pipeline embolization device with 12.7% of treated aneurysms remaining nonoccluded during the study period. There were no significant differences in aneurysm morphology or type of DAPT used between occluded and nonoccluded groups. Nonoccluded aneurysms received a longer mean duration of DAPT (9.4 vs 7.1 months, P = 0.016) with a significant effect of DAPT duration on the observed aneurysm occlusion rate (F(2, 202) = 4.2, P = 0.016). There was no significant difference in the rate of complications, including delayed ischemic strokes, observed between patients receiving short (≤6 months) and prolonged duration (>6 months) DAPT (7.9% vs 9.3%, P = 0.76). CONCLUSIONS: After flow diversion, an abbreviated duration of DAPT lasting 6 months may be most appropriate before transitioning to low-dose aspirin monotherapy to promote timely aneurysm occlusion while minimizing thromboembolic complications.

Experience and Balance: Long-Term Trends in Preferred Skull Base Approach for a Case Series of Cavernous Malformation Resections.

BACKGROUND: Skull base approaches are a foundation of modern cerebrovascular surgery; however, their application over time has varied. OBJECTIVE: To assess trends in skull base approach selection for cavernous malformation (CM) resection. METHODS: This is a retrospective case series of all first-time CM resections by a single surgeon from 1997 to 2021. Cases were classified by craniotomy and approach. Four sets of common comparator skull base approaches were identified by coauthor consensus: pterional and orbitozygomatic; retrosigmoid, extended retrosigmoid (xRS), and far-lateral; suboccipital and torcular; and trans-cerebellar peduncle (MCP) and transcerebellopontine angle. Counts were binned by 5-year or 10-year clusters for descriptive statistical assessment of temporal trends. RESULTS: In total, 372 primary CM resections met the study criteria and were included. Orbitozygomatic approach use increased during the second 5-year period, after which the pterional approach rapidly became and remained the preferred approach. During the first two 5-year periods, the far-lateral approach was preferred to the retrosigmoid and xRS approaches, but the xRS approach grew in popularity and accounted for >50% of operations in this comparator group. Trans-MCP use compared with the transcerebellopontine angle approach closely mirrored the change in xRS use. The midline suboccipital approach accounted for a larger proportion (range, 62%-88%) of cases than the torcular approach (range, 12%-38%) across all periods. CONCLUSION: The xRS and trans-MCP approaches have been increasingly used over time, while the orbitozygomatic and far-lateral approaches have become less common. These trends seem to reflect versatility, efficiency, and safety of these techniques.

Approach Selection Strategies for Repeat Resection of Brain Cavernous Malformations: Cohort Study.

BACKGROUND: Neurosurgical management of cerebral cavernous malformations (CMs) often benefits from using skull base approaches. Although many CMs are cured by resection, residual or recurrent disease may require repeat resection. OBJECTIVE: To review approach selection strategies for reoperation of CMs to aid decision-making for repeat procedures. METHODS: In this retrospective cohort study, a prospectively maintained single-surgeon registry was queried for patients with CMs who underwent repeat resection from January 1, 1997, to April 30, 2021. RESULTS: Of 854 consecutive patients, 68 (8%) underwent 2 operations; 40 had accessible data on both. In most reoperations (33/40 [83%]), the index approach was repeated. In most reoperations using the index approach (29/33 [88%]), that approach was deemed ideal (no equivalent or superior alternative), whereas in some (4/33 [12%]), the alternative approach was deemed unsafe because of conformation of the tract. Among patients with reoperations using an alternative approach (7/40 [18%]), 2 with index transsylvian approaches underwent bifrontal transcallosal approaches, 2 with index presigmoid approaches underwent extended retrosigmoid revisions, and 3 with index supracerebellar-infratentorial approaches underwent alternative supracerebellar-infratentorial trajectory revisions. Among patients with reoperations with an alternative approach considered or selected (11/40 [28%]), 8 of 11 patients had a different surgeon for the index resection than for the repeat resection. The extended retrosigmoid-based approaches were used most often for reoperations. CONCLUSION: Repeat resection of recurrent or residual CMs is a challenging neurosurgical niche at the intersection of cerebrovascular and skull base disciplines. Suboptimal index approaches may limit surgical options for repeat resection.

Intraoperative Complications of Anterior Lumbar Interbody Fusion: A 5-Year Experience of a Group of Spine Surgeons Performing Their Own Approaches.

BACKGROUND: Spine surgery has evolved at an accelerated pace, allowing the development of more efficient surgical techniques while providing a decreasing rate of morbimortality. One example of these approaches is the anterior lumbar interbody fusion (ALIF). The aim of this study was to evaluate the surgical complication rate when performing ALIF without the help of a vascular "access" surgeon. METHODS: A retrospective descriptive study was conducted at the Hospital Universitario San Ignacio between 2014 and 2018 and included all patients who underwent ALIF during this time. A nonsystematic review was performed assessing approach-related complications in ALIF and the impact of "access" surgeons in surgical outcomes. RESULTS: A total of 337 patients were included and 508 levels were fused. ALIF was performed as ALIF-360° (27%), ALIF-lateral lumbar interbody fusion (LLIF) (8.9%), and stand-alone ALIF (62%). Most procedures were single-level fusions (51.9%), 45.4% involved 2 levels, and 2.6% were 3-level fusions. The mortality rate was 0%, and only 9 cases of vascular injury were observed and described. Left and common iliac veins were the predominant affected structures. Only a single case required blood transfusion without any other treatment or intensive care unit surveillance. CONCLUSIONS: Our study is consistent with literature reports about ALIF complications, finding an incidence of 1.7%. Therefore, ALIF is an excellent alternative for spine procedures, especially for the levels L5-S1 that require sagittal balance restoration. The approaches were performed without a vascular "access" surgeon and presented complication rates similar to those described in the literature.

Fibroblastic meningioma mimicking an intracerebral hemorrhage: case report.

A 50-year-old woman presented to the emergency room complaining of severe headache. A non-contrasted head CT was obtained, which demonstrated a hyperdense image compatible with an intracerebral hemorrhage in the posterior region of the left temporal lobe. The patient displayed no neurological deficit during the consultation and a subsequent MRI showed a temporoinsular bleeding lesion that was suggestive of an atypic meningioma or a metastatic lesion. Afterwards, neck, chest and abdomen CT scans were performed, and the imaging ruled out a secondary neoplasm. The patient underwent surgical resection of the lesion, and a solid tumor was found with no bleeding associated. The pathology reported a WHO I fibroblastic meningioma.

Actividades de prevención y factores de riesgo en diabetes mellitus y pie diabético / Prevention activities and risk factors in diabetes mellitus and diabetic foot

Objetivos: determinar prevalencia actividades de prevención por médicos y pacientes. Identificar factores de riesgo: pie, metabólicos, alimentarios y estado nutricional. Métodos: estudio descriptivo, transversal octubre 2009-junio 2011, pacientes hospitalizados con diabetes mellitus, mayores de edad; aprobación comité ética. Encuesta médica, evaluación nutricional,medición A1c y lípidos, educación mediante cartilla autocuidado. Análisis descriptivo: variables cuantitativas y cualitativas, coeficientes correlación de Pearson; programas Excel 2007 y SPSS-versión-15.0. Resultados: pacientes encuestados 263; hombres 44.1% y mujeres 55.9%; edad promedio63.6±13.3; tiempo diagnóstico diabetes 11.4 ± 8.5 años. Escolaridad primaria 58.9%, estrato socioeconómico 1-2 (71.3%). Antecedente: úlceras 14.8%, amputación 1.9%, disestesias 49.8%, claudicación intermitente 22.7%, examen pies por médico 42.9%. Actividades prevención por médicos son precarias porque no: educan 59.5% sobre autocuidado pie, examinan pies 57.1%, preguntan sobre: disestesias 68.3%, claudicación intermitente 74.8%. Autocuidado pacientes diario inadecuado porque, no revisan: pies 27.4%, interior calzado 28.1%; no realizan: secado interdigital 8%, lubricación pies 58.8%; sin automonitoreo 63.2%; corte inadecuado uñas 68.1%; no usan: medias 21.7%, calzado terapéutico 98.5%; sin colaboración familiar 55.1%. Descontrol metabólico: A1c 9.6% ± 2.7; c-LDL 99.1 mg% ± 31.3; triglicéridos: 171.9 mg% ± 97.9. Sin consejería por nutricionista 39.4%; con preobesidad-obesidad 58.9%. Correlación: IMC y cintura punto medio (r=0.750, p=0.000); IMC y porcentaje grasa corporal (r=0.586,p=0.000). Hábitos alimentación: preferencia alimentos fritos 42.3%; bajo consumo: proteína animal (12.7%), lácteos (31.8%), frutas (64.7%) y verduras (57.9%); alto consumo almidones (43.4%). Conclusiones: las actividades de prevención por médicos y pacientes son deficientes. Se evidenciaron factores de riesgo para diabetes mellitus y pie diabético: hiperlipidemia, hiperglucemia, obesidad y hábitos alimentarios inadecuados.

Objectives: to determine prevalence and prevention activities by physicians and patients. Identify risk factors: foot, metabolic, dietary and nutritional status. Methods: a descriptive, cross-sectional study, from October 2009 to June 2011 in adult patients hospitalized with diabetes mellitus. Ethics Committee approval. Medical questionnaire, nutritional assessment, measurement A1c and lipids, education through self care booklet. Descriptive analysis: quantitative and qualitative variables, Pearson correlation coefficients; Excel 2007 and SPSS version-15.0 programs. Results: 263 patients were surveyed; 44.1% men and 55.9% women; mean age 63.6 ± 13.3; time of diabetes diagnosis 11.4 ± 8.5 years. 58.9% had primary schooling, socioeconomic status 1-2 (71.3%). Clinical antecedents: ulcers 14.8%, 1.9% amputation, dysesthesias 49.8%, 22.7% intermittent claudication, foot exam by physician 42.9%. Prevention activities by doctors are precarious because 59.5% do not educate about foot self-care, 57.1% examine feet, 68.3% ask about dysesthesias, 74.8% about intermittent claudication. Inadequate daily feet self-care by patients because they don`t inspect their feet 27.4% or the inner shoes 28.1%; 8% do not make interdigital drying; 58.8% do not lubricate their feet; 63.2% make no self-monitoring; 68.1% have inadequate nail cutting; 21.7% do not use stockings, 98.5% do not have therapeutic footwear; 55.1% have no family collaboration. Metabolic dyscontrol: A1c 9.6 ± 2.7%; LDL-C 99.1% ± 31.3 mg; triglycerides: 171.9 ± 97.9 mg%. 39.4% do not have nutritionist counseling; 58.9% present pre-obesity-obesity. Correlation: BMI and waist midpoint circumference (r = 0.750, p = 0.000); BMI and body fat percentage (r = 0.586, p = 0.000). Eating habits: fried food preference 42.3%; Low consumption: animal protein (12.7%), dairy (31.8%), fruits (64.7%) and vegetables (57.9%); high starch consumption (43.4%). Conclusions: prevention efforts by doctors and patients are deficient. Risk factors for diabetes mellitus and diabetic foot observed were: hyperlipidemia, hyperglycemia, obesity and inadequate eating habits.