Antithrombotic Therapy in Cerebral Cavernous Malformations: A Systematic Review, Meta-Analysis, and Network Meta-Analysis.

BACKGROUND: Cerebral cavernous malformations are complex vascular anomalies in the central nervous system associated with a risk of intracranial hemorrhage. Traditional guidelines have been cautious about the use of antithrombotic therapy in this patient group, citing concerns about potential bleeding risk. However, recent research posits that antithrombotic therapy may actually be beneficial. This study aims to clarify the association between antithrombotic therapy, including antiplatelet and anticoagulant medications, and the risk of intracranial hemorrhage in patients with cerebral cavernous malformations. METHODS AND RESULTS: A comprehensive literature search was conducted in PubMed, Web of Science, and Scopus databases, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Nine single-center, nonrandomized cohort studies involving 2709 patients were included. Outcomes were analyzed using random-effects model, and a network meta-analysis was conducted for further insight. Of the 2709 patients studied, 388 were on antithrombotic therapy. Patients on antithrombotic therapy had a lower risk of presenting with intracranial hemorrhage (odds ratio [OR], 0.56 [95% CI, 0.45-0.7]; P<0.0001). In addition, the use of antithrombotic therapy was associated with lower risk of intracranial hemorrhage from a cerebral cavernous malformation on follow-up (OR, 0.21 [95% CI, 0.13-0.35]; P<0.0001). A network meta-analysis revealed a nonsignificant OR of 0.73 (95% CI, 0.23-2.56) when antiplatelet therapy was compared with anticoagulant therapy. CONCLUSIONS: Our study explores the potential benefits of antithrombotic therapy in cerebral cavernous malformations. Although the analysis suggests a possible role for antithrombotic agents, it is critical to note that the evidence remains preliminary. Fundamental biases in study design, such as ascertainment and assignment bias, limit the weight of our conclusions. Therefore, our findings should be considered hypothesis-generating and not definitive for clinical practice change.

The Artificial Intelligence Revolution in Stroke Care: A Decade of Scientific Evidence in Review.

BACKGROUND: The emergence of artificial intelligence (AI) has significantly influenced the diagnostic evaluation of stroke and has revolutionized acute stroke care delivery. The scientific evidence evaluating the role of AI, especially in areas of stroke treatment and rehabilitation is limited but continues to accumulate. We performed a systemic review of current scientific evidence evaluating the use of AI in stroke evaluation and care and examined the publication trends during the past decade. METHODS: A systematic search of electronic databases was conducted to identify all studies published from 2012 to 2022 that incorporated AI in any aspect of stroke care. Studies not directly relevant to stroke care in the context of AI and duplicate studies were excluded. The level of evidence and publication trends were examined. RESULTS: A total of 623 studies were examined, including 101 reviews (16.2%), 9 meta-analyses (1.4%), 140 original articles on AI methodology (22.5%), 2 case reports (0.3%), 2 case series (0.3%), 31 case-control studies (5%), 277 cohort studies (44.5%), 16 cross-sectional studies (2.6%), and 45 experimental studies (7.2%). The highest published area of AI in stroke was diagnosis (44.1%) and the lowest was rehabilitation (12%). A 10-year trend analysis revealed a significant increase in AI literature in stroke care. CONCLUSIONS: Most research on AI is in the diagnostic area of stroke care, with a recent noteworthy trend of increased research focus on stroke treatment and rehabilitation.

Causes and Predictors of 30-Day Readmission in Patients With Stroke Undergoing Mechanical Thrombectomy: A Large Single-Center Experience.

BACKGROUND AND OBJECTIVES: The 30-day readmission rate has emerged as a metric of quality care and is associated with increased health care expenditure. We aim to identify the rate and causes of 30-day readmission after mechanical thrombectomy and provide the risk factors of readmission to highlight high-risk patients who may require closer care. METHODS: This is a retrospective study from a prospectively maintained database of 703 patients presenting for mechanical thrombectomy between 2017 and 2023. All patients who presented with a stroke and underwent a mechanical thrombectomy were included in this study. Patients who were deceased on discharge were excluded from this study. RESULTS: Our study comprised 703 patients, mostly female (n = 402, 57.2%) with a mean age of 70.2 years ±15.4. The most common causes of readmission were cerebrovascular events (stroke [n = 21, 36.2%], intracranial hemorrhage [n = 9, 15.5%], and transient ischemic attack [n = 1, 1.7%]).Other causes of readmission included cardiovascular events (cardiac arrest [n = 4, 6.9%] and bradycardia [n = 1, 1.7%]), infection (wound infection postcraniectomy [n = 3, 5.2%], and pneumonia [n = 1, 1.7%]). On multivariate analysis, independent predictors of 30-day readmission were history of smoking (odds ratio [OR]: 2.2, 95% CI: 1.1-4.2) P = .01), distal embolization (OR: 3.2, 95% CI: 1.1-8.7, P = .03), decompressive hemicraniectomy (OR: 9.3, 95% CI: 3.2-27.6, P < .01), and intracranial stent placement (OR: 4.6, 95% CI: 2.4-8.7) P < .01). CONCLUSION: In our study, the rate of 30-day readmission was 8.3%, and the most common cause of readmission was recurrent strokes. We identified a history of smoking, distal embolization, decompressive hemicraniectomy, and intracranial stenting as independent predictors of 30-day readmission in patients with stroke undergoing mechanical thrombectomy.

Resuming Anticoagulants in Patients With Intracranial Hemorrhage: A Meta-Analysis and Literature Review.

BACKGROUND AND OBJECTIVES: Intracerebral hemorrhage (ICH) is one of the most disabling cerebrovascular events. Several studies have discussed oral anticoagulant (OAC)-related ICH; however, the optimal timing of resuming OAC in patients with ICH is still a dilemma. In this literature review/meta-analysis, we will summarize, discuss, and provide the results of studies pertaining to OAC resumption in patients with ICH. METHODS: Using PubMed, Ovid Medline, and Web science, a systemic literature review was performed in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses statement on December 20, 2022. Inclusion criteria for the meta-analysis were all studies reporting mean, median, and standard deviation for the duration of anticoagulants resumption after ICH. Thirteen studies met the above criteria and were included in the meta-analysis. RESULTS: Of the 271 articles found in the literature, pooled analysis was performed in 13 studies that included timing of OAC resumption after ICH. The pooled mean duration to OAC resumption after the index ICH was 31 days (95% CI: 13.7-48.3). There was significant variation among the mean duration to OAC resumption reported by the studies as observed in the heterogeneity test ( P -value ≈0). CONCLUSION: Based on our meta-analysis, the average time of resuming OAC in patients with ICH is around 30 days. Several factors including the type of intracranial hemorrhage, the type of OAC, and the indication for OACs should be taken into consideration for future studies to try and identify the best time to resume OAC in patients with ICH.

Comparison of PED/PED Flex and PED Shield in the treatment of unruptured intracerebral aneurysms.

OBJECTIVE: The object of this study was to compare the efficacy and safety profile of the Pipeline embolization device (PED)/Pipeline Flex embolization device (PED Flex) with that of the Pipeline Flex embolization device with Shield Technology (PED Shield). After introducing the first-generation PED and the second-generation PED Flex with its updated delivery system, the PED Shield was launched with a synthetic layer of phosphorylcholine surface modification to reduce thrombogenicity. METHODS: This is a retrospective review of unruptured aneurysms treated with PED/PED Flex versus PED Shield between 2017 and 2022 at the authors' institution. Patients with ruptured aneurysms, adjunctive treatment, failed flow diverter deployment, and prior treatment of the target aneurysm were excluded. Baseline characteristics were collected for all patients, including age, sex, past medical history (hypertension, hyperlipidemia, diabetes mellitus), smoking status, aneurysm location, and aneurysm dimensions (neck, width, height) and morphology (saccular, nonsaccular). The primary outcome was procedural and periprocedural complication rates. RESULTS: The study cohort comprised 200 patients with 200 aneurysms, including 150 aneurysms treated with the PED/PED Flex and 50 treated with the PED Shield. With respect to intraprocedural and periprocedural complications, length of stay, length of follow-up, and functional outcome at discharge, there was no significant difference between the two cohorts. At the midterm follow-up, the rate of in-stent stenosis (PED/PED Flex: 14.2% vs PED Shield: 14.6%, p = 0.927), aneurysm occlusion (complete occlusion: 79.5% vs 80.5%, respectively; neck remnant: 4.7% vs 12.2%; dome remnant: 15.7% vs 7.3%; p = 0.119), and the need for retreatment (5.3% vs 0%, p = 0.097) were comparable between the two cohorts. CONCLUSIONS: This study suggests that, as compared to first- and second-generation PED and PED Flex, the third-generation PED Shield offers similar rates of complications, aneurysm occlusion, and in-stent stenosis at the midterm follow-up.

Women in neurosurgery: a cross-sectional demographic study of female neurosurgery residents in the United States.

OBJECTIVE: Over the past several decades, the number of women applying to medical school has increased significantly. However, parallel recruitment and retention of women in the field of neurosurgery continues to lag. The aim of this study was to identify the ratio and trend of female neurosurgery residents to the total number of residents during the past 7 years across all US neurosurgery residency programs. METHODS: The authors conducted a cross-sectional demographic study investigating the ratio of female neurosurgery residents to the total number of neurosurgery residents across US neurosurgical programs from 2016 to 2022. Using the Fellowship and Residency Electronic Interactive Database, all neurosurgical residency programs in the US were collected. Data were further divided into postgraduate years 1-7 to dissect the data collection per residency year. One hundred fourteen programs were included in the study. RESULTS: The number of female neurosurgery residents was 71 (29.8%) in 2022, 58 (25.2%) in 2021, 65 (27.9%) in 2020, 62 (27.3%) in 2019, 46 (21.4%) in 2018, 33 (15.2%) in 2017, and 34 (15.9%) in 2016. The trend line showed a significant increase using the Mann-Kendall test (p = 0.035). The total number of international medical graduate (IMG) female neurosurgery residents was 3 (4.2%) in 2022, 4 (6.9%) in 2021, 3 (4.6%) in 2020, 1 (1.6%) in 2019, 1 (2.2%) in 2018, 1 (3%) in 2017, and 2 (5.9%) in 2016. CONCLUSIONS: The number of women matching into neurosurgery residency programs is modestly increasing, especially for IMG women. Future steps toward fewer gender disparities should focus on career advancement and leadership diversification in organized and academic neurosurgery.

Morphological characteristics of brain aneurysms among age groups.

BACKGROUND: Patient's age is an important factor in determining the risk of aneurysm rupture. However, there is limited data on how aneurysm morphology differs among age groups. We studied morphological characteristics of brain aneurysms among age groups in a large cohort. METHODS: Aneurysms from the Stroke Thrombectomy and Aneurysm Registry (STAR) were analyzed. The following parameters were included: location, size, neck, width, height, aspect ratio, and regular versus irregular morphology. The risk of rupture presentation was estimated using logistic regression. RESULTS: A total of 1407 unruptured and 607 ruptured saccular aneurysms were included. The most common locations of ruptured aneurysms in patients younger than 70 years-old were the middle cerebral artery (MCA) and the anterior communicating artery (ACOM). The most common location of ruptured aneurysms in patients older than 70 years-old were the posterior communicating artery (PCOM) and ACOM. The size of unruptured aneurysms increased with age (p < .001). Conversely, the size of ruptured aneurysms was similar among age groups (p = .142). Unruptured and ruptured aneurysms became more irregular at presentation with older age (p < .001 and p .025, respectively). Irregular morphology and location were associated with rupture status across all age groups in multivariate regression. CONCLUSIONS: Younger patients have small unruptured and ruptured aneurysms, and ruptured aneurysms are mostly located in the MCA and ACOM. Older patients have larger and more irregular unruptured aneurysms, and ruptured aneurysms are mostly located in the PCOM and ACOM. An irregular morphology increases the risk of rupture in all age groups.

The Rate and Predictors of 30-Day Readmission in Patients Treated for Unruptured Cerebral Aneurysms: A Large Single-Center Study.

BACKGROUND AND OBJECTIVES: Numerous studies of various populations and diseases have shown that unplanned 30-day readmission rates are positively correlated with increased morbidity and all-cause mortality. In this study, we aim to provide the rate and predictors of 30-day readmission in patients undergoing treatment for unruptured intracranial aneurysms. METHODS: This is a retrospective study of 525 patients presenting for aneurysm treatment between 2017 and 2022. All patients who were admitted and underwent a successful treatment of their unruptured intracerebral aneurysms were included in the study. The primary outcome was the rate and predictors of 30-day readmission. RESULTS: The rate of 30-day readmission was 6.3%, and the mean duration to readmission was 7.8 days ± 6.9. On univariate analysis, factors associated with 30-day readmission were antiplatelet use on admission (odds ratio [OR]: 0.4, P = .009), peri-procedural rupture (OR: 15.8, P = .007), surgical treatment of aneurysms (OR: 2.2, P = .035), disposition to rehabilitation (OR: 9.5, P < .001), and increasing length of stay (OR: 1.1, P = .0008). On multivariate analysis, antiplatelet use on admission was inversely correlated with readmission (OR: 0.4, P = .045), whereas peri-procedural rupture (OR: 9.5, P = .04) and discharge to rehabilitation (OR: 4.5, P = .029) were independent predictors of 30-day readmission. CONCLUSION: In our study, risk factors for 30-day readmission were aneurysm rupture during the hospital stay and disposition to rehabilitation, whereas the use of antiplatelet on admission was inversely correlated with 30-day readmission. Although aneurysm rupture is a nonmodifiable risk factor, more studies are encouraged to focus on the correlation of antiplatelet use and rehabilitation disposition with 30-day readmission rates.

Transverse Sinus Stenting for the Treatment of Idiopathic Intracranial Hypertension With a Pressure Gradient of 70 mm Hg: A Technical Note and Systematic Review.

BACKGROUND AND IMPORTANCE: Venous sinus stenosis is believed to play a role in the pathogenesis of idiopathic intracranial hypertension (IIH). Venous stenting has emerged as a promising treatment option for patients with IIH because of venous sinus stenosis refractory to medical management or unsuitable for shunt placement. In this technical note, we present a case of IIH with the highest recorded pressure gradient to date. CLINICAL PRESENTATION: This technical note presents the successful use of intracranial venous stenting in a patient with IIH because of severe venous sinus stenosis, leading to significant improvement in vision and reduction in intracranial pressure. A meticulous review of the literature revealed that our patient exhibited the highest recorded pressure gradient (70 mm Hg). This remarkable finding underscores the potential effectiveness of venous stenting as a viable treatment approach. The procedure involved the placement of a Zilver stent (Cook Medical) and balloon angioplasty after stenting of the right transverse sinus stenosis, resulting in a substantial decrease in pressure gradient. Following the procedure, another venous manometry showed no more gradient with a uniform pressure in the whole venous system at 18 mm Hg. CONCLUSION: To our knowledge, this case presents the highest pressure gradient reported in the literature and contributes to the growing evidence supporting venous stenting in patients with IIH and venous sinus stenosis.

Venous sinus stenting for idiopathic intracranial hypertension patients with functioning ventriculoperitoneal shunts: A case series.

Idiopathic intracranial hypertension (IIH) is a disease defined by increased intracranial pressure and associated with a variety of symptoms ranging from headaches to tinnitus. Ventricular peritoneal shunting has been the mainstay treatment for patients with IIH. Although VPS's have shown efficacy in treating IIH, some patients complain of refractory symptoms even with functioning VPS's. Venus stenting has emerged as a new technique for treating these refractory symptoms. Despite the scarce literature pertaining its efficacy and safety profile, several small studies have shown promising results. In this case series, four patients with IIH complained of refractory symptoms despite functioning VPS's and were treated with venous stenting.

Safety of Mechanical Thrombectomy in Patients on Antiplatelet/Anticoagulation.

BACKGROUND: Mechanical thrombectomy (MT) is performed in patients who are already on anticoagulation (AC)/antiplatelet therapy (AP). However, data are insufficient regarding MT's safety and efficacy profiles in these patients. OBJECTIVE: Investigate the outcome of stroke patients already on anticoagulation/antiplatelet receiving MT. METHODS: We included consecutive acute ischemic stroke patients treated with MT for 10 years (2012-2022) in a comprehensive stroke center. Baseline variables, efficacy (recanalization [Thrombolysis in Cerebral Infraction] ≥ 2b), good functional outcome (modified Ranking Scale ≤ 2 at 3 months), and safety (symptomatic intracranial hemorrhage [sICH], mortality rates) were evaluated. Additionally, we conducted a subgroup analysis of patients with prior single-AP versus DAPT. RESULTS: Six hundred forty-six patients were included (54.5% women, median age 71 years), 84 (13%) were on AC, 196 (30.3%) on AP, and 366 (56.7%) in the control group. The AC and AP groups were older and had more comorbidities. sICH occurred in 7.3% of cases. There was no significant difference in sICH incidence across the groups. The AC group had a lower rate of intravenous thrombolysis (15.9%; P < 0.001), a higher rate of sICH (11.9% vs. AP 7.7% and control 6%; P = 0.172), and higher mortality at discharge (17.9% vs. AP 8.7% and control 10.4%; P = 0.07). However, the groups had similar functional outcomes and mortality rates at 3 months. Successful recanalization was achieved in 92.7% and was similar across groups. Multivariable logistic regression and the subgroup analysis (single-AP vs. dual AP) did not reveal statistically significant associations. CONCLUSIONS: MT in patients with prior anticoagulation and AP presenting with acute ischemic strokeis feasible, effective, and safe.

Clinical Outcomes After Ultra-Early Cranioplasty Using Craniectomy Contour Classification as a Patient Selection Criterion.

BACKGROUND: Although not a technically difficult operation, cranioplasty is associated with high rates of complications. The optimal timing of cranioplasty to mitigate complications remains the subject of debate. OBJECTIVE: To report outcomes between patients undergoing cranioplasty at ultra-early (0-6 weeks), intermediate (6 weeks to 6 months), and late (>6 months) time frames. We report a novel craniectomy contour classification (CCC) as a radiographic parameter to assess readiness for cranioplasty. METHODS: A single-institution retrospective analysis of patients undergoing cranioplasty was performed. Patients were stratified into ultra-early (within 6 weeks of index craniectomy), intermediate (6 weeks to 6 months), and late (>6 months) cranioplasty cohorts. We have devised CCC scores, A, B, and C, based on radiographic criteria, where A represents those with a sunken brain/flap, B with a normal parenchymal contour, and C with "full" parenchyma. RESULTS: A total of 119 patients were included. There was no significant difference in postcranioplasty complications, including return to operating room ( P = .212), seizures ( P = .556), infection ( P = .140), need for shunting ( P = .204), and deep venous thrombosis ( P = .066), between the cohorts. Univariate logistic regression revealed that ultra-early cranioplasty was significantly associated with higher rate of functional independence at >6 months (odds ratio 4.32, 95% CI 1.39-15.13, P = .015) although this did not persist when adjusting for patient selection features (odds ratio 2.90, 95% CI 0.53-19.03, P = .234). CONCLUSION: In appropriately selected patients, ultra-early cranioplasty is not associated with increased rate of postoperative complications and is a viable option. The CCC may help guide decision-making on timing of cranioplasty.

A Comparison of Outcomes Between Transfemoral Versus Transradial Access for Carotid Stenting.

BACKGROUND: The transradial (TR) approach has emerged as an alternative to the transfemoral (TF) approach in carotid artery stenting (CAS) because of its perceived benefits in access site complications and overall patient experience. OBJECTIVE: To assess outcomes of TF vs TR approach for CAS. METHODS: This is a retrospective single-center review of patients receiving CAS through the TR or TF route between 2017 and 2022. All patients with symptomatic and asymptomatic carotid disease who underwent attempted CAS were included in our study. RESULTS: A total of 342 patients were included in this study: 232 underwent CAS through TF approach vs 110 through the TR route. On univariate analysis, the rate of overall complications was more than double for the TF vs TR cohort; however, this did not achieve statistical significance (6.5% vs 2.7%, odds ratio [OR] = 0.59 P = .36). The rate of cross-over from TR to TF was significantly higher on univariate analysis (14.6 % vs 2.6%, OR = 4.77, P = .005) and on inverse probability treatment weighting analysis (OR = 6.11, P < .001). The rate of in-stent stenosis (TR: 3.6% vs TF: 2.2%, OR = 1.71, P = .43) and strokes at follow-up (TF: 2.2% vs TR: 1.8%, OR = 0.84, P = .84) was not significantly different. Finally, median length of stay was comparable between both cohorts. CONCLUSION: The TR approach is safe, feasible, and provides similar rates of complications and high rates of successful stent deployment compared with the TF route. Neurointerventionalists adopting the radial first approach should carefully assess the preprocedural computed tomography angiography to identify patients amenable to TR approach for carotid stenting.

Thirty-Day Outcomes of Resolute Onyx Stent for Symptomatic Intracranial Stenosis: A Multicenter Propensity Score-Matched Comparison With Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial.

BACKGROUND: Symptomatic intracranial atherosclerotic disease (sICAD) is estimated to cause 10% of strokes annually in the United States. However, treatment remains a challenge with several different stenting options studied in the past with unfavorable results. OBJECTIVE: To report the 30-day stroke and/or death rate associated with intracranial stent placement for sICAD using Resolute Onyx Zotarolimus-Eluting Stent (RO-ZES) and provide a comparison with the results of Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. METHODS: Prospectively maintained databases across 8 stroke centers were used to identify adult patients treated with RO-ZES for sICAD between January 2019 and December 2021. Primary end point was composite of 30-day stroke, intracerebral hemorrhage, and/or death. Propensity score matching was performed using age, hypertension, lipid disorder, cigarette smoking, and symptomatic target vessel to create a matched group for comparison between RO-ZES and the SAMMPRIS medical management and treatment groups (SAMMPRIS percutaneous angioplasty and stenting [S-PTAS]). RESULTS: A total of 132 patients met the inclusion criteria for analysis (mean age: 64.2 years). Mean severity of stenosis was 81.4% (±11.4%). A total of 4 (3.03%) stroke and/or deaths were reported within 30 days of treatment in the RO-ZES group compared with 6.6% in the SAMMPRIS medical management group (OR [odds ratio] 2.26, 95% CI 0.7-9.56, P = .22) and 15.6% in the S-PTAS group (OR 5.9, 95% CI 2.04-23.4, P < .001). Propensity score match analysis of 115 patients in each group demonstrated 30-day stroke and/or death rate of 2.6% in the RO-ZES group and 15.6% in the S-PTAS group (OR 6.88, 95% CI 1.92-37.54, P < .001). CONCLUSION: Patients treated with RO-ZES had a relatively low 30-day stroke and/or death rate compared with the S-PTAS group. Further large-scale prospective studies are warranted to evaluate the safety and efficacy of RO-ZES for the treatment of sICAD.

A review of mechanical thrombectomy techniques for acute ischemic stroke.

Mechanical thrombectomy is established as standard of care in the management of acute ischemic stroke due to large vessel occlusion and evidence-based guidelines for mechanical thrombectomy have been defined. As research continues to further expand the eligibility criteria for thrombectomy and the number of thrombectomy procedures increase worldwide, there is also growing focus on innovation of thrombectomy devices, procedural techniques, and related outcomes. Thrombectomy primarily involves use of stent retrievers and distal aspiration techniques, but variations and different combinations of techniques have been reported. As this is a rapidly evolving area in stroke management, there is debate as to which, if any, of these techniques leads to improved clinical outcomes over another and there is a lack of data comparing them. In this review, currently published and distinct techniques of mechanical thrombectomy are described methodically along with illustrations to aid in understanding the subtle differences between the techniques. The perceived benefits of each variation are discussed.

The Effect of COVID-19 Vaccines on Stroke Outcomes: A Single-Center Study.

BACKGROUND: One of the defining narratives of the COVID-19 pandemic has been the acceptance and distribution of vaccine. To compare the outcomes of COVID-19 positive vaccinated and unvaccinated stroke patients. METHODS: This is a single-center retrospective study of COVID-19-vaccinated and unvaccinated stroke patients between April 2020 and March 2022. All patients presenting with stroke regardless of treatment modalities were included. National Institutes of Health Stroke Scale was used to assess stroke severity. The primary outcome was functional capacity of the patients at discharge. RESULTS: The study cohort comprised 203 COVID-19 positive stroke patients divided into 139 unvaccinated and 64 fully vaccinated patients. At discharge, the modified Rankin scale score was significantly lower in the vaccinated cohort (3[1-4] vs. 4[2-5], odds ratio = 0.508, P = 0.011). At 3 months of follow-up, the median modified Rankin scale score was comparable between both cohorts. CONCLUSIONS: Although vaccination did not show any significant difference in stroke patient outcomes on follow-up, vaccines were associated with lower rates of morbidity and mortality at discharge among stroke patients during the pandemic.

Comparison of Flow-Redirection Endoluminal Device and Pipeline Embolization Device in the Treatment of Intracerebral Aneurysms.

BACKGROUND: The use of flow diverters for treating intracranial aneurysms has been widely used in the past decade; however, data comparing pipeline embolization device (PED; Medtronic Inc) and flow-redirection endoluminal device (FRED; MicroVention) in the treatment of intracranial aneurysms remain scarce. OBJECTIVE: To compare the outcomes of PED and FRED in the treatment of intracranial aneurysms. METHODS: This is a single-center retrospective review of aneurysms treated with PED and FRED devices. Patients treated with PED or FRED were included. Cases requiring multiple or adjunctive devices were excluded. Primary outcome was complete aneurysm occlusion at 6 months. Secondary outcomes included good functional outcome, need for retreatment, and any complication. RESULTS: The study cohort comprised 150 patients, including 35 aneurysms treated with FRED and 115 treated with PED. Aneurysm characteristics including location and size were comparable between the 2 cohorts. 6-month complete occlusion rate was significantly higher in the PED cohort (74.7% vs 51.5%; P = .017) but lost significance after inverse probability weights. Patients in the PED cohort were associated with higher rates of periprocedural complications (3.5% vs 0%; P = .573), and the rate of in-stent stenosis was approximately double in the FRED cohort (15.2% vs 6.9%; P = .172). CONCLUSION: Compared with PED, FRED offers modest 6-month occlusion rates, which may be due to aneurysmal and baseline patient characteristics differences between both cohorts. Although not significant, FRED was associated with a higher complication rate mostly because of in-stent stenosis. Additional studies with longer follow-up durations should be conducted to further evaluate FRED thrombogenicity.

Prognostic significance of age within the adolescent and young adult acute ischemic stroke population after mechanical thrombectomy: insights from STAR.

OBJECTIVE: Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA) population is not well defined given its undefined rarity. Correspondingly, the goal of this study was to determine the prognostic significance of age in this specific demographic following MT for large-vessel occlusions. METHODS: A prospectively maintained international multi-institutional database, STAR (Stroke Thrombectomy and Aneurysm Registry), was reviewed for all patients aged 12-18 (adolescent) and 19-25 (young adult) years. Parameters were compared using chi-square and t-test analyses, and associations were interrogated using regression analyses. RESULTS: Of 7192 patients in the registry, 41 (0.6%) satisfied all criteria, with a mean age of 19.7 ± 3.3 years. The majority were male (59%) and young adults (61%) versus adolescents (39%). The median prestroke modified Rankin Scale (mRS) score was 0 (range 0-2). Strokes were most common in the anterior circulation (88%), with the middle cerebral artery being the most common vessel (59%). The mean onset-to-groin puncture and groin puncture-to-reperfusion times were 327 ± 229 and 52 ± 42 minutes, respectively. The mean number of passes was 2.2 ± 1.2, with 61% of the cohort achieving successful reperfusion. There were only 3 (7%) cases of reocclusion. The median mRS score at 90 days was 2 (range 0-6). Between the adolescent and young adult subgroups, the median mRS score at last follow-up was statistically lower in the adolescent subgroup (1 vs 2, p = 0.03), and older age was significantly associated with a higher mRS at 90 days (coefficient 0.33, p < 0.01). CONCLUSIONS: Although rare, MT for AIS in the AYA demographic is both safe and effective. Even within this relatively young demographic, age remains significantly associated with improved functional outcomes. The implication of age-dependent stroke outcomes after MT within the AYA demographic needs greater validation to develop effective age-specific protocols for long-term care across both pediatric and adult centers.

Stereotactic Radiosurgery for A Randomized Trial of Unruptured Brain Arteriovenous Malformations-Eligible Patients: A Meta-Analysis.

BACKGROUND: The outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) were controversial, and they suggested that intervention is inferior to medical management for unruptured brain arteriovenous malformations (AVMs). However, several studies have shown that stereotactic radiosurgery (SRS) is an acceptable therapy for unruptured AVMs. OBJECTIVE: To test the hypothesis that ARUBA intervention arm's SRS results are meaningfully inferior to those from similar populations reported by other studies. METHODS: We performed a literature review to identify SRS studies of patients who met the eligibility criteria for ARUBA. Patient, AVM, treatment, and outcome data were extracted for statistical analysis. Regression analyses were pooled to identify factors associated with post-SRS obliteration and hemorrhage. RESULTS: The study cohort included 8 studies comprising 1620 ARUBA-eligible patients who underwent SRS. At the time of AVM diagnosis, 36% of patients were asymptomatic. The mean follow-up duration was 80 months. Rates of radiologic, symptomatic, and permanent radiation-induced changes were 45%, 11%, and 2%, respectively. The obliteration rate was 68% at last follow-up. The post-SRS hemorrhage and mortality rates were 8%, and 2%, respectively. Lower Spetzler-Martin grade (odds ratios [OR] = 0.84 [0.74-0.95], P = .005), lower radiosurgery-based AVM score (OR = 0.75 [0.64-0.95], P = .011), lower Virginia Radiosurgery AVM Scale (OR = 0.86 [0.78-0.95], P = .003), and higher margin dose (OR = 1.13 [1.02-1.25], P = .025) were associated with obliteration. CONCLUSION: SRS carries a favorable risk to benefit profile for appropriately selected ARUBA-eligible patients, particularly those with smaller volume AVMs. Our findings suggest that the results of ARUBA do not reflect the real-world safety and efficacy of SRS for unruptured AVMs.