The Necessity or Not of Additional Endovascular Therapy to Medical Therapy for Symptomatic Intracranial Artery Stenosis: Insights from 30-Day and 1-Year Results.

BACKGROUND: The optimal treatment between endovascular therapy and medical treatment for symptomatic intracranial artery stenosis is still unclear. This study aimed to compare the safety and efficacy of 2 treatments based on the results from currently published randomized controlled trials (RCTs). METHODS: PubMed, Cochrane Library, EMBASE, and Web of Science were used for searching the RCTs evaluating the addition of endovascular therapy to medical therapy for treating symptomatic intracranial artery stenosis from the inception of these databases to September 30, 2022. P < 0.05 was considered statistically significant. All analyses were performed using STATA version 12.0. RESULTS: A total of 4 RCTs were involved in the current study, including 989 participants. In the 30-day results, the data showed that compared with the medical therapy alone group, the additional endovascular therapy group was associated with a higher risk of death or stroke (relative risk (RR): 2.857; 95% confidence interval (CI): 1.756-4.648; P < 0.001), ipsilateral stroke (RR: 3.525; 95% CI: 1.969-6.310; P < 0.001), death (risk differences (RD): 0.01; 95% CI: 0.004-0.03; P = 0.015), hemorrhagic stroke (RD: 0.03; 95% CI: 0.01-0.06; P < 0.001), and ischemic stroke (RR: 2.221; 95% CI: 1.279-3.858; P = 0.005). In the 1-year results, the additional endovascular therapy group was related to a greater incidence of ipsilateral stroke (RR, 2.247; 95% CI, 1.492-3.383; P < 0.001) and ischemic stroke (RR: 2.092; 95% CI: 1.270-3.445; P = 0.004). CONCLUSIONS: Given that the medical treatment alone was related to a lower risk of stroke and death in the short-term and long-term compared with endovascular therapy combined with medical therapy. Based on this evidence, these findings do not support the addition of endovascular therapy to medical therapy for treating patients with symptomatic intracranial stenosis.

Endoscopic endonasal approach for simultaneously treating a pituitary adenoma coexisting with a paraclinoid aneurysm: illustrative case.

BACKGROUND: There is a certain incidence of pituitary adenomas coexisting with intracranial aneurysms, but a concurrent therapeutic strategy of tumor removal and aneurysm clipping via endoscopic endonasal approach is rarely reported. The indications and limitations of endoscopic endonasal approach surgery for this type of lesions are worth discussing. OBSERVATIONS: The case of a pituitary tumor coexisting with a paraclinoid aneurysm was reviewed. Using an endoscopic endonasal approach, the pituitary adenoma was completely excised with extrapseudocapsular separation technique, the aneurysm was clipped at the same time, and the skull base defect was reconstructed in multilayer fashion. No tumor recurrence was found, and aneurysm clipping was complete at the 6-month follow-up after surgery. LESSONS: For patients harboring a pituitary adenoma with a selected paraclinoid aneurysm, simultaneous tumor resection and aneurysm clipping via endoscopic endonasal approach are feasible. This strategy has the advantages of saving medical resources, promoting the patient's rapid postoperative recovery, and reducing possible antiplatelet therapy after interventional therapy. However, surgery needs to strictly follow the indications in experienced hands, and the therapeutic effect needs to be verified by more cases and longer follow-up results.

A better strategy using barbed sutures for wound closure in total knee arthroplasty.

Aim: The purpose of this study was to conduct a meta-analysis to systematically compare the clinical outcomes between knee barbed sutures (KBS) and knee traditional sutures (KTS) for wound closure in total knee arthroplasty (TKA). Method: This study retrieved potential academic articles comparing the clinical outcomes between KBS and KTS in TKA from the MEDLINE database, the PubMed database, the EMBASE database and the Cochrane Library. The reference articles for the identified studies were carefully reviewed to ensure that all available documents were represented in the study. Results: A total of 14 articles (eight randomized controlled trials [RCTs], six non-RCTs) were involved in our study. The overall participants of barbed Sutures group were 1255, whereas it was 1247 in the traditional sutures. Our meta-analysis showed that KBS is preferable for wound closure of TKA as its shorter lower total cost (weighted mean difference [WMD] = -276.281, 95% CI = -480.281 to -72.280; p = 0.008) and wound closure time (WMD = -4.895,95% CI = -6.105 to -3.685; p < 0.001). However, there was no difference in any complications (p = 0.572), wound complications (p = 0.550), superficial infection (p = 0.918), deep infection (p = 0.654), wound dehiscence (p = 0.649), suture abscess (p = 0.939), arthrofibrosis (p = 0.970), needle sticks (p = 0.158), suture breakage (p = 0.371) and knee society scores (KSS; p = 0.073). Conclusion: The use of KBS in TKA is associated with significantly shortened wound closure times and total closure cost without increased risk of intraoperative needle sticks and suture breakage and postoperative incision complications. Given the relevant possible biases in our study, adequately powered and more RCTs with long-term follow-up are needed to compare the efficacy and safety between KBS and KTS.

Neuroendoscopic minimally invasive surgery and small bone window craniotomy hematoma clearance in the treatment of hypertensive cerebral hemorrhage.

OBJECTIVE: To analyze the effects of neuroendoscopic minimally invasive surgery and small bone window craniotomy hematoma clearance through comparing clinical indicators of the two operation modes and to provide a reference for selection of proper minimally invasive surgery. METHODS: One hundred and twenty-six patients with hypertensive cerebral hemorrhage who received diagnosis and treatment in our hospital between December 2015 and December 2017 were selected and grouped into an observation group (n=63) and a control group (n=63) using random number table. Patients in the observation group were treated by neuroendoscopic surgery, while patients in the control group were treated by small bone window craniotomy. The surgical condition, clinical effect and prognosis of the two groups were analyzed and compared. RESULTS: Patients in the observation group completed surgery in a shorter time and bled less during operation compared to the control group, and the hematoma clearance rate of the observation group was obviously higher than that of the control group; the differences had statistical significance (P<0.05). The nerve deficiency scale (NDS) scores of the two groups at the postoperative 3rd month were lower than those before surgery (P<0.05), and the activity of daily life (ADL) score at the postoperative 3rd month was higher than that before surgery (P<0.05). The observation group had lower NDS score and higher ADL score compared to the control group, and the differences had statistical significance (P<0.05). The incidence of complications of the observation group was lower than that of the control group after surgery, and the rate of favourable prognosis of the observation group was higher than that of the control group at the postoperative 3rd month (P<0.05). CONCLUSION: Neuroendoscopic surgery is more effective and safe, causes less bleeding and has better prognosis and nerve function recovery compared to small bone window craniotomy in the treatment of hypertensive cerebral hemorrhage.

Predictable Risk Factors of Spontaneous Venous Thromboembolism in Patients Undergoing Spine Surgery.

OBJECTIVE: The purpose of this study was to conduct a meta-analysis to identify the risk factors for formation of venous thromboembolism (VTE) in patients after spine surgery. METHODS: This study retrieved potential academic articles on the related factors for VTE formation in patients after spine surgery from MEDLINE, PubMed, EMBASE, and the Cochrane Library. The reference articles for the identified studies were carefully reviewed to ensure that all available documents were represented in the study. RESULTS: A total of 21 articles (20 retrospective studies and 1 prospective study) involving 2,870,105 patients were identified in the analysis, including 7829 patients who presented with VTE after spine surgery; the incidence of VTE was 0.273%. Our meta-analysis showed that compared with patients who did not have VTE after spine surgery, there was significantly more blood loss (weighted mean difference [WMD], 93.295; 95% confidence interval [CI], 60.521-126.069; P < 0.001), higher age (WMD, 6.011; 95% CI, 3.647-9.376; P < 0.001), thoracolumbar surgery (odds ratio [OR], 0.233; 95% CI, 0.198-0.274; P < 0.001), and longer duration of surgery (WMD, 45.672; 95% CI, 10.433 to -80.911; P = 0.011) among the patients with VTE. Patients with a history of hypertension (OR, 1.785; 95% CI, 1.516-2.103; P < 0.001), diabetes (OR, 1.535; 95% CI, 1.286-1.832; P < 0.001), and preoperative walking disability (OR, 4.882; 95% CI, 2.044-11.663; P < 0.001) showed a significantly higher rate of VTE after spine surgery. However, no significant differences were found in gender (P = 0.289), fusion surgery (P = 0.979), body mass index (P = 0.157), history of heart disease (P = 0.397), and level of D-dimer (P = 0.220). CONCLUSIONS: A higher rate of postoperative VTE is closely associated with the elderly, longer duration of surgery, thoracolumbar surgery, greater blood loss, and patients with a history of hypertension, preoperative walking disability, or diabetes after spinal surgery; these risk factors should be guarded against.

Occipital artery to upper posterior circulation bypass through the presigmoid approach in revascularization of the posterior circulation: An anatomical study.

We describe a novel extracranial (EC)-to-intracranial (IC) bypass technique between the occipital artery and upper posterior circulation (UPC) for revascularization of the posterior circulation through the presigmoid approach. Five formalin-fixed human heads were examined to demonstrate the detailed anatomy of the occipital artery and UPC and illustrate the step-by-step bypass procedure. The occipital artery, a branch of the external carotid artery, can be anastomosed to the P2/P3 segment of the posterior cerebral artery and S1/S2 segments of the superior cerebellar artery as an alternative to EC bypass donor segments for treatment of affection requiring revascularization. Presigmoid approach for the anastomosis of the occipital artery to the UPC provides a shorter distance, due to resection of some bones.

Systematic and Comprehensive Comparison of Incidence of Restenosis Between Carotid Endarterectomy and Carotid Artery Stenting in Patients with Atherosclerotic Carotid Stenosis.

OBJECTIVE: The purpose of the present study was to conduct a meta-analysis to systematically compare the incidence rates of in-stent restenosis after carotid artery stenting (CAS) and restenosis after carotid endarterectomy (CEA) for patients with atherosclerotic carotid stenosis. METHODS: We retrieved potential academic reports comparing restenosis between CEA and CAS from the MEDLINE, PubMed, and EMBASE databases and the Cochrane Library from the date of the first CEA (January 1951) to July 20, 2018. The references of the identified studies were carefully reviewed to ensure that all available reports were included in the present study. RESULTS: Our meta-analysis included 27 studies (15 randomized controlled trials, 12 nonrandomized controlled trials) and 20,479 participants with atherosclerotic carotid stenosis. A statistically significant difference was found in the cumulative incidence of restenosis >70% between CEA and CAS (risk difference, -0.033, 95% confidence interval [CI] -0.054 to -0.013; P = 0.002). For the restenosis >70% outcomes, although CEA was relevant with a lower rate of restenosis than CAS within 6 months (odds ratio [OR], 0.495; 95% CI, 0.285-0.861; P = 0.013) and 1 year (OR, 0.626; 95% CI, 0.483-0.811; P < 0.001), no statistically significant differences were found at 1.5 years (P = 0.210), 2 years (P = 0.123), 4 years (P = 0.124), 5 years (P = 0.327), or 10 years (P = 0.839). For the restenosis >50% outcomes, a significant difference was found in the rate of restenosis between the CEA and CAS groups within 1 year (OR, 0.317; 95% CI, 0.228-0.441; P < 0.001) but not at 1.5 years (P = 0.301), 2 years (P = 0.686), or 5 years (P = 0.920). No nominally significant effects were demonstrated with respect to the cumulative incidence of occlusion (P = 0.195) or the cumulative incidence of restenosis for symptomatic patients (P = 0.170) between CEA and CAS. CONCLUSIONS: Although CAS was preferred over CEA, regardless of restenosis >50% or >70% after revascularization within 1 year, no significant difference was observed with extension of the follow-up period to >1 year. CAS was not associated with a greater cumulative incidence of occlusion or the cumulative incidence of restenosis for symptomatic patients.