Agreement between CT-Angiography and Digital Subtraction Angiography in Predicting Angiographic Vasospasm in Patients with Subarachnoid Hemorrhage.

Background/Objectives: Digital subtraction angiography (DSA) is the gold standard in the diagnosis of cerebral vasospasm, frequently observed after subarachnoid hemorrhage (SAH). However, less-invasive methods, such as computed tomography angiography (CTA), may be equally accurate. To further clarify comparability, this study evaluated the reliability of CTA in detecting cerebral vasospasm. Methods: This retrospective study included 51 patients with SAH who underwent both CTA and DSA within 24 h. The smallest diameter of the proximal cerebral arterial segments was measured in both modalities at admission and during the vasospasm period. The mean difference in diameter, the intraclass correlation coefficient (ICC) of CTA and DSA, the difference in grade of vasospasm and sensitivity, the specificity and the positive predictive value (PPV) for CTA were calculated. Results: A total of 872 arterial segments were investigated. At time of admission, arterial diameters were significantly smaller on CTA compared to DSA in all segments (-0.26 ± 0.12 mm; p < 0.05). At time of suspected vasospasm (day 9 ± 5), these differences remained significant only for the M1 segment (-0.18 ± 0.37 mm, p = 0.02), the P1 segment (-0.13 ± 0.24 mm, p = 0.04) and the basilar artery (-0.20 ± 0.37 mm, p = 0.0.04). The ICC between CTA and DSA was good (0.5-0.8). The sensitivity of CTA for predicting angiographic vasospasm was 99%, the specificity was 50% and the PPV was 92%. Conclusions: Arterial diameters measured on CTA may underestimate the arterial caliber observed in DSA; however, these absolute differences were minor. Importantly, vessel diameter alone does not fully reflect malperfusion, requiring additional imaging techniques such as CT perfusion.

An evaluation of physical and augmented patient-specific intracranial aneurysm simulators on microsurgical clipping performance and skills: a randomized controlled study.

OBJECTIVE: In the era of flow diversion, there is an increasing demand to train neurosurgeons outside the operating room in safely performing clipping of unruptured intracranial aneurysms. This study introduces a clip training simulation platform for residents and aspiring cerebrovascular neurosurgeons, with the aim to visualize peri-aneurysm anatomy and train virtual clipping applications on the matching physical aneurysm cases. METHODS: Novel, cost-efficient techniques allow the fabrication of realistic aneurysm phantom models and the additional integration of holographic augmented reality (AR) simulations. Specialists preselected suitable and unsuitable clips for each of the 5 patient-specific models, which were then used in a standardized protocol involving 9 resident participants. Participants underwent four sessions of clip applications on the models, receiving no interim training (control), a video review session (video), or a video review session and holographic clip simulation training (video + AR) between sessions 2 and 3. The study evaluated objective microsurgical skills, which included clip selection, number of clip applications, active simulation time, wrist tremor analysis during simulations, and occlusion efficacy. Aneurysm occlusions of the reference sessions were assessed by indocyanine green videoangiography, as well as conventional and photon-counting CT scans. RESULTS: A total of 180 clipping procedures were performed without technical complications. The measurements of the active simulation times showed a 39% improvement for all participants. A median of 2 clip application attempts per case was required during the final session, with significant improvement observed in experienced residents (postgraduate year 5 or 6). Wrist tremor improved by 29% overall. The objectively assessed aneurysm occlusion rate (Raymond-Roy class 1) improved from 76% to 80% overall, even reaching 93% in the extensively trained cohort (video + AR) (p = 0.046). CONCLUSIONS: The authors introduce a newly developed simulator training platform combining physical and holographic aneurysm clipping simulators. The development of exchangeable, aneurysm-comprising housings allows objective radio-anatomical evaluation through conventional and photon-counting CT scans. Measurable performance metrics serve to objectively document improvements in microsurgical skills and surgical confidence. Moreover, the different training levels enable a training program tailored to the cerebrovascular trainees' levels of experience and needs.

Radiosurgery as a Stand-Alone Treatment Option for Cerebral Dural Arteriovenous Fistulas: the Vienna Series.

BACKGROUND: Gamma Knife radiosurgery (GKRS) has been demonstrated to be an effective and safe treatment method for dural arteriovenous fistulas (DAVFs). However, only few studies, mostly with limited patient numbers, have evaluated radiosurgery as a sole and upfront treatment option for DAVFs. METHODS: Thirty-three DAVF patients treated with GKRS as a stand-alone management at our institution between January 1992 and January 2020 were included in this study. Obliteration rates, time to obliteration, neurologic outcome, and complications were evaluated retrospectively. RESULTS: Complete overall obliteration was achieved in 20/28 (71%) patients. The postradiosurgery actuarial rates of obliteration at 2, 5, and 10 years were 53, 71, and 85%, respectively. No difference in time to obliteration between carotid-cavernous fistulas (CCFs; 14/28, 50%, 17 months; 95% confidence interval [CI]: 7.4-27.2) and non-CCFs (NCCFs; 14/28, 50%, 37 months; 95% CI: 34.7-38.5; p = 0.111) were found. Overall, the neurologic outcome in our series was highly favorable at the time of the last follow-up. A complete resolution of symptoms was seen in two-thirds (20/30, 67%) of patients. One patient with multiple DAVFs suffered from an intracranial hemorrhage of the untreated lesion and died during the follow-up period, resulting in a yearly bleeding risk of 0.5%. No complications after radiosurgery were observed in our series. CONCLUSION: Our results show that GKRS is a safe and effective stand-alone management option for selected DAVF patients.

Retrospective comparison of percutaneous balloon compression and radiofrequency-thermocoagulation in the management of trigeminal neuralgia.

PURPOSE: To compare percutaneous balloon compression (PBC) and radiofrequency thermocoagulation (RFTC) for the treatment of trigeminal neuralgia. METHODS: This was a retrospective single-center analysis of data from 230 patients with trigeminal neuralgia who underwent 202 PBC (46%) and 234 RFTC (54%) from 2002 to 2019. Comparison of demographic data and trigeminal neuralgia characteristics between procedures as well as assessment of 1) initial pain relief by an improved Barrow Neurological Institute (BNI) pain intensity scale of I-III; 2) recurrence-free survival of patients with a follow-up of at least 6 months by Kaplan-Meier analysis; 3) risk factors for failed initial pain relief and recurrence-free survival by regression analysis; and 4) complications and adverse events. RESULTS: Initial pain relief was achieved in 353 (84.2%) procedures and showed no significant difference between PBC (83.7%) and RFTC (84.9%). Patients who suffered from multiple sclerosis (odds ratio 5.34) or had a higher preoperative BNI (odds ratio 2.01) showed a higher risk of not becoming pain free. Recurrence-free survival in 283 procedures was longer for PBC (44%) with 481 days compared to RFTC (56%) with 421 days (p=0.036) but without statistical significance. The only factors that showed a significant influence on longer recurrence-free survival rates were a postoperative BNI ≤ II (P=<0.0001) and a BNI facial numbness score ≥ 3 (p = 0.009). The complication rate of 22.2% as well as zero mortality showed no difference between the two procedures (p=0.162). CONCLUSION: Both percutaneous interventions led to a comparable initial pain relief and recurrence-free survival with a low and comparable probability of complications. An individualized approach, considering the advantages and disadvantages of each intervention, should guide the decision-making process. Prospective comparative trials are urgently needed.

Outcome of 107 conservatively managed unruptured brain arteriovenous malformations: a single center's 30-year experience.

OBJECTIVE: Since the publication of A Randomized Trial of Unruptured Brain AVMs (ARUBA), the management of unruptured brain arteriovenous malformations (bAVMs) has been controversially discussed. Long-term follow-up data on the exclusively conservative management of unruptured bAVMs are scarce. The authors evaluated the long-term outcomes of patients with unruptured untreated bAVMs in a real-life cohort. METHODS: A retrospective observational cohort of 107 patients (of 897 bAVM patients referred to the authors' institution) with a diagnosis of unruptured and conservatively managed bAVMs is presented. AVMs of all Spetzler-Martin grades were observed. The mean follow-up period was 84 months. In 44% of patients, a follow-up period of 5 years or longer was observed. A national death register comparison completed the outcome analysis. RESULTS: The median age at diagnosis, sex distribution, neurological presentation, and modified Rankin Scale score were comparable to the patients in the medical management arm of the ARUBA study. Patients were mainly young, predominantly male, and in good clinical condition. Similar to the ARUBA cohort, 77% of this study's cohort presented in an excellent clinical status at the time of last follow-up. However, 17% of patients had at least one hemorrhage, resulting in an overall annual hemorrhage risk of 2.7% in the observation period. Moreover, the cumulative 1-, 5-, and 10-year overall hemorrhage rates were 3.0%, 11.3%, and 15.3%, respectively. Consequently, the long-term follow-up AVM-related mortality rate amounted to 8%. The estimated median overall survival after AVM diagnosis was 19.3 years (95% CI 14.0-24.6 years). A multivariate Cox regression model revealed temporal and deep-seated localization as an independent risk factor for AVM hemorrhage, while the presence of seizures reached borderline significance as a risk factor. CONCLUSIONS: The authors' results represent the long-term course of unruptured untreated bAVMs. Their data support the conclusion that even in the post-ARUBA era, tailored active treatment options may be offered to patients with unruptured bAVMs. For patient counseling, individual risk factors should be weighed against the center's treatment-specific risks.

Combined standard bypass and parent artery occlusion for management of giant and complex internal carotid artery aneurysms.

BACKGROUND: Complex aneurysms do not have a standard protocol for treatment. In this study, we investigate the safety and efficacy of microsurgical revascularization combined with parent artery occlusion (PAO) in giant and complex internal carotid artery (ICA) aneurysms. METHODS: Between 1998 and 2017, 41 patients with 47 giant and complex ICA aneurysms were treated by an a priori planned combined treatment strategy. Clinical and radiological outcomes were stratified according to mRS and Raymond classification. Bypass patency was assessed. Median follow-up time was 3.9 years. RESULTS: After successful STA-MCA bypass, staged endovascular (n=37) or surgical (n=1) PAO was executed in 38 patients following a negative balloon occlusion test. Intolerance to PAO led to stent/coil treatments in two patients. Perioperative bypass patency was confirmed in 100% of completed STA-MCA bypass procedures. Long-term overall bypass patency rate was 99%. Raymond 1 occlusion and good outcome were achieved in 95% and 97% (mRS 0-2) of cases, respectively. No procedure-related mortality was encountered. Eighty-four percent of patients with preoperative cranial nerve compression syndromes improved during follow-up. CONCLUSIONS: The combined approach of STA-MCA bypass surgery followed by parent artery occlusion achieves high aneurysm occlusion and low morbidity rates in the management of giant and complex ICA aneurysms. This combined indirect approach represents a viable alternative to flow diversion in patients with cranial nerve compression syndromes or matricidal aneurysms, and may serve as a backup strategy in cases of peri-interventional complications or lack of suitable endovascular access.

Microvascular decompression in trigeminal neuralgia: predictors of pain relief, complication avoidance, and lessons learned.

OBJECTIVE: To analyze characteristics associated with long-term pain relief after microvascular decompression (MVD) for trigeminal neuralgia (TGN). Description of associated morbidity and complication avoidance. METHODS: One hundred sixty-five patients with TGN underwent 171 MVD surgeries at the authors' institution. Patient characteristics and magnetic resonance imaging (MRI) datasets were obtained through the hospital's archiving system. Patients provided information about pre- and post-operative pain characteristics and neurologic outcome. Favorable outcome was defined as a Barrow Neurological Institute (BNI) pain intensity score of I to III with post-operative improvement of I grade. RESULTS: Type of TGN pain with purely paroxysmal pain (p = 0.0202*) and TGN classification with classical TGN (p = 0.0372*) were the only significant predictors for long-term pain relief. Immediate pain relief occurred in 90.6% of patients with a recurrence rate of 39.4% after 3.5 ± 4.6 years. MRI reporting of a neurovascular conflict had a low negative predictive value of 39.6%. Mortality was 0% with major complications observed in 8.2% of patients. Older age was associated with lower complication rates (p = 0.0009***). Re-MVD surgeries showed improved long-term pain relief in four out of five cases. CONCLUSIONS: MVD is a safe and effective procedure even in the elderly. It has the unique potential to cure TGN if performed on a regular basis, and if key surgical steps are respected. Early MVD should be offered in case of medical treatment failure and paroxysmal pain symptoms. The presence of a neurovascular conflict on MRI is not mandatory. In case of recurrence, re-MVD is a good treatment option that should be discussed with patients. HIGHLIGHTS: • Long-term analysis of pain relief after MVD. • Positive predictors for outcome: classical TGN and purely paroxysmal pain. • Presence of neurovascular conflict in MRI is not mandatory for MVD surgery. • Analysis of complications and surgical nuances for avoidance. • MVD is a safe procedure also in the elderly.

Greenstick fracture of the ulnar shaft following physical therapy in an adult: A case report.

RATIONALE: Greenstick fractures most commonly occur in the pediatric population, especially in those under 10 years of age. Greenstick fractures are "extremely" rare in adults. This report presents the case of a greenstick fracture of the ulnar shaft in an adult following physical therapy for a radial neck fracture and ulnar shaft fracture post-internal fixation. Greenstick fracture can occur during physical therapy near the drill holes created during surgery. PATIENT CONCERNS: A 23-year-old man without any past medical history had sustained a greenstick fracture of the ulnar shaft after rehabilitation for a left radial and ulnar fracture that had been previously treated with internal fixation. DIAGNOSES: Five months after removal of the implants, the patient complained of left elbow tenderness and a "breaking" sound that occurred during physical therapy. The results of a subsequent X-ray revealed a greenstick fracture of the left ulnar shaft. INTERVENTIONS: Splinting of the fracture. OUTCOMES: After 2 months of splint fixation, the pain and range of motion in the affected arm were improved, and sequential X-rays showed callus formation and increased density of the ulnar shaft. LESSONS: Greenstick fractures occur not only in children but also in adults in specific circumstances. The cortex of long bones may be further weakened by drill holes created during surgery, and fractures may occur during physical therapy. During treatment, physicians, and therapists should pay more attention to the patient who has undergone implant removal to avoid greenstick fractures, especially in the locations near drill holes.

Diagnostic reliability of the Berlin classification for complex MCA aneurysms-usability in a series of only giant aneurysms.

BACKGROUND AND OBJECTIVE: The main challenge of bypass surgery of complex MCA aneurysms is not the selection of the bypass type but the initial decision-making of how to exclude the affected vessel segment from circulation. To this end, we have previously proposed a classification for complex MCA aneurysms based on the preoperative angiography. The current study aimed to validate this new classification and assess its diagnostic reliability using the giant aneurysm registry as an independent data set. METHODS: We reviewed the pretreatment neuroimaging of 51 patients with giant (> 2.5 cm) MCA aneurysms from 18 centers, prospectively entered into the international giant aneurysm registry. We classified the aneurysms according to our previously proposed Berlin classification for complex MCA aneurysms. To test for interrater diagnostic reliability, the data set was reviewed by four independent observers. RESULTS: We were able to classify all 51 aneurysms according to the Berlin classification for complex MCA aneurysms. Eight percent of the aneurysm were classified as type 1a, 14% as type 1b, 14% as type 2a, 24% as type 2b, 33% as type 2c, and 8% as type 3. The interrater reliability was moderate with Fleiss's Kappa of 0.419. CONCLUSION: The recently published Berlin classification for complex MCA aneurysms showed diagnostic reliability, independent of the observer when applied to the MCA aneurysms of the international giant aneurysm registry.

Simultaneous study of antioxidant activity, DNA protection and anti-inflammatory effect of Vernonia amygdalina leaves extracts.

Vernonia amygdalina (VA) has been reported to have antioxidant potential; however, its DNA protection and anti-inflammatory properties remain unclear. We aimed to investigate whether aqueous (WEVAL) and alcoholic (EEVAL) VA extracts exert similar antioxidant, DNA protection and anti-inflammatory effects and attempted to explore the mechanism underlying the anti-inflammatory effects. These results demonstrated that WEVAL had greater polyphenolic and flavonoid contents, as well as a stronger reducing power, DPPH radical scavenging and DNA protective activity. Moreover, both extracts reduced lipopolysaccharide (LPS)-induced expression of COX-II, iNOS, pro-inflammatory factors, including NO, TNF-α, IL-1ß, and IL-10. Compared with WEVAL, EEVAL was a more potent inflammatory inhibitor. Both extracts similarly inhibited LPS-induced MAPK (p38) and NF-κB expression. Our findings indicate that WEVAL and EEVAL have diverse antioxidant and anti-inflammatory effects. WEVAL had a stronger antioxidant and DNA protection activity; contrastingly, EEVAL had a stronger anti-inflammatory ability. The anti-inflammatory activity involves reduced pro-inflammatory cytokines through NF-κB down-regulation and MAPK inhibition. These results demonstrated that production of WEVAL and EEVAL from VA leaves may provide a safe and efficacious source of pharmaceutical applications, with antioxidant, DNA protective and anti-inflammation activities.

Peri-interventional Behavior of the Neutrophil to Lymphocyte Ratio in Patients with Intracranial Aneurysms.

OBJECTIVE: The neutrophil-to-lymphocyte ratio (NLR) has been investigated as an independent predictive marker for clinical outcomes in vascular diseases. This study aimed to investigate the peri-interventional behavior of the NLR in patients with ruptured and unruptured intracranial aneurysms (IAs). METHODS: A total of 117 patients with IAs, who were treated at our department and had available complete data, were retrospectively identified during a 10-year period. Routine laboratory parameters, including the neutrophil and lymphocytes counts, were evaluated before and after treatment. RESULTS: The baseline NLR showed significant differences between patients with ruptured and unruptured IAs (6.3 vs. 1.8; P < 0.001). In patients with ruptured IAs, the baseline NLR decreased significantly during the follow-up visits, whereas in unruptured IAs, the NLR remained low. Furthermore, higher baseline NLR values could also be observed in patients with ruptured IAs and fatal outcome than in surviving patients (8.0 vs. 5.4; P = 0.220). In patients with poor functional outcome, defined as modified Rankin score ≥3, the NLR was significantly higher before treatment (P = 0.047), at day 10 (P = 0.025), and 1 month after treatment (P = 0.001). CONCLUSIONS: The peri-interventional NLR was significantly different between patients with ruptured and unruptured IAs. In patients with ruptured IAs, elevated baseline NLR levels were associated with poor postoperative functional outcomes and decreased postoperatively, implying the potential prognostic value of NLR in patients with IAs.

Evaluation of the radiosurgical treatment of cerebral arteriovenous malformations: a retrospective single-center analysis of three decades.

BACKGROUND: Gamma Knife radiosurgery (GKRS) in the treatment of arteriovenous malformations (AVMs) is still controversially discussed. OBJECTIVE: To present long-term follow-up data on patients after Gamma Knife radiosurgery for cerebral AVMs. METHODS: Overall, 516 patients received radiosurgery for cerebral AVMs between 1992 and 2018 at our department, of whom 265 received radiosurgery alone and 207 were treated with a combined endovascular-radiosurgical approach. Moreover, 45 patients were treated with a volume-staged approach. Two eras were analyzed, the pre-modern era between 1992 and 2002 and the modern era thereafter. RESULTS: In GKRS-only treated patients, median time to nidus occlusion was 3.8 years. Spetzler-Ponce (SP) class was a significant predictor for time to obliteration in the whole sample. Median time to obliteration for the combined treatment group was 6.5 years. Patients in the pre-modern era had a significantly higher obliteration rate than those treated in the modern era. Overall, the calculated yearly hemorrhage risk in the observation period after first GKRS was 1.3%. Permanent post-radiosurgical complications occurred in 4.9% of cases but did not differ between the treatment groups or treatment eras. The obliteration rate was significantly lower and the hemorrhage rate was higher in volume-staged treated patients than in conventionally treated patients. CONCLUSION: GKRS is an effective treatment option for SP class A and B cerebral AVMs. After combined endovascular-radiosurgical treatment, the outcome of selected SP class C AVMs aligns with that of SP class B lesions. Both the combined therapy and radiosurgery alone constitute sound methods for treatment of cerebral AVMs.

The Impact of Intra-Arterial Papaverine-Hydrochloride on Cerebral Metabolism and Oxygenation for Treatment of Delayed-Onset Post-Subarachnoid Hemorrhage Vasospasm.

BACKGROUND: Delayed posthemorrhagic vasospasm remains among the major complications after aneurysmal subarachnoid hemorrhage (SAH) and can result in devastating ischemic strokes. As rescue therapy, neurointerventional procedures are used for selective vasodilatation. OBJECTIVE: To investigate the effects of intra-arterial papaverine-hydrochloride on cerebral metabolism and oxygenation. METHODS: A total of 10 consecutive patients, suffering from severe aneurysmal SAH were prospectively included. Patients were under continuous multimodality neuromonitoring and required intra-arterial papaverine-hydrochloride for vasospasm unresponsive to hypertensive therapy. Cerebral metabolism (microdialysis), brain tissue oxygen tension (ptiO2), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) were analyzed for a period of 12 h following intervention. RESULTS: A median dose of 125 mg papaverine-hydrochloride was administered ipsilateral to the multimodality probe. Angiographic improvement of cerebral vasospasm was observed in 80% of patients. During intervention, a significant elevation of ICP (13.7 ± 5.2 mmHg) and the lactate-pyruvate ratio (LPR) (54.2 ± 15.5) was observed, whereas a decrease in cerebral glucose (0.9 ± 0.5 mmol/L) occurred. Within an hour, an increase of cerebral lactate (5.0 ± 2.0 mmol/L) and glycerol (104.4 ± 89.8 µmol/L) as well as a decrease of glucose (0.9 ± 0.4 mmol/L) were measured. In 2 to 5 h after treatment, the LPR significantly decreased (pretreatment: 39.3 ± 15.3, to lowest 30.5 ± 6.7). Cerebral pyruvate levels increased in 1 to 10 h (pretreatment: 100.1 ± 33.1 µmol/L, to highest 141.4 ± 33.7 µmol/L) after intervention. No significant changes in ptiO2 or CPP occurred. CONCLUSION: The initial detrimental effects of the endovascular procedure itself were outweighed by an improved cerebral metabolism within 10 h thereafter. As the effect was very limited, repeated interventions or continuous application should be considered.

Endogenous arterial blood pressure increase after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Spontaneous blood pressure rise is a frequently observed phenomenon following aneurysmal subarachnoid hemorrhage (SAH). Facing the risk of aneurysmal rebleeding and the occurrence of delayed cerebral ischemia it is unclear how to react to these endogenous-driven blood pressure changes, as their predictive value for clinical course and functional outcome is still unknown. PATIENTS AND METHODS: Endogenous blood pressure characteristics within 21 days after SAH were retrospectively analyzed in 93 patients. Any use of vasopressors for active induction of hypertension marked the end of data collection. Mean arterial blood pressure (MAP) was related to the onset of cerebral vasospasm and patient characteristics (Hunt&Hess, age, pre-existing hypertension, antihypertensive therapy, sedation). Predictors for cerebral infarction and functional outcome were calculated using a logistic regression model. RESULTS: A significant MAP increase was observed in all patients from day 3 to day 7. Patients developing cerebral vasospasm had an overall steeper increase of MAP during this period (11.1 ± 11.4 mmHg vs. 6.5 ± 8.9 mmHg, p = 0.04). MAP rise started already 3 days before detection of vasospasm. Lower MAP values were recorded in patients with poor Hunt&Hess grade, under sedation and thus in patients with poor outcome. MAP had no impact on the development of cerebral infarction. In univariate analysis MAP on day 5 (OR 0.95, 95 %-CI: 0.89-0.99), MAP on day 6 (OR 0.95, 95 %-CI: 0.91-1.00), Hunt&Hess grade (OR 1.72, 95 %-CI: 1.14-2.60), sedation (OR 17.04, 95 %-CI: 2.08-139.51) and stroke (OR 5.82, 95 %-CI: 1.63-20.82) were predictors for poor outcome. In multivariable analysis, only sedation (OR 13.72, 95 %-CI: 1.62-115.94) and ischemic stroke (OR 4.48, 95 %-CI: 1.16-17.31) remained significant. CONCLUSION: Spontaneous MAP increase occured in all patients following SAH. It was highly influenced by clinical parameters, thereby limiting its prognostic value for functional outcome. However, a steep increase of MAP might be an early clinical marker to identify patients at risk for developing cerebral vasospasm.

Novel Software-Derived Workflow in Extracranial-Intracranial Bypass Surgery Validated by Transdural Indocyanine Green Videoangiography.

BACKGROUND: The introduction of image-guided methods to bypass surgery has resulted in optimized preoperative identification of the recipients and excellent patency rates. However, the recently presented methods have also been resource-consuming. In the present study, we have reported a cost-efficient planning workflow for extracranial-intracranial (EC-IC) revascularization combined with transdural indocyanine green videoangiography (tICG-VA). METHODS: We performed a retrospective review at a single tertiary referral center from 2011 to 2018. A novel software-derived workflow was applied for 25 of 92 bypass procedures during the study period. The precision and accuracy were assessed using tICG-VA identification of the cortical recipients and a comparison of the virtual and actual data. The data from a control group of 25 traditionally planned procedures were also matched. RESULTS: The intraoperative transfer time of the calculated coordinates averaged 0.8 minute (range, 0.4-1.9 minutes). The definitive recipients matched the targeted branches in 80%, and a neighboring branch was used in 16%. Our workflow led to a significant craniotomy size reduction in the study group compared with that in the control group (P = 0.005). tICG-VA was successfully applied in 19 cases. An average of 2 potential recipient arteries were identified transdurally, resulting in tailored durotomy and 3 craniotomy adjustments. Follow-up patency results were available for 49 bypass surgeries, comprising 54 grafts. The overall patency rate was 91% at a median follow-up period of 26 months. No significant difference was found in the patency rate between the study and control groups (P = 0.317). CONCLUSIONS: Our clinical results have validated the presented planning and surgical workflow and support the routine implementation of tICG-VA for recipient identification before durotomy.

Single-stage bone resection and cranioplastic reconstruction: comparison of a novel software-derived PEEK workflow with the standard reconstructive method.

The combined resection of skull-infiltrating tumours and immediate cranioplastic reconstruction predominantly relies on freehand-moulded solutions. Techniques that enable this procedure to be performed easily in routine clinical practice would be useful. A cadaveric study was developed in which a new software tool was used to perform single-stage reconstructions with prefabricated implants after the resection of skull-infiltrating pathologies. A novel 3D visualization and interaction framework was developed to create 10 virtual craniotomies in five cadaveric specimens. Polyether ether ketone (PEEK) implants were manufactured according to the bone defects. The image-guided craniotomy was reconstructed with PEEK and compared to polymethyl methacrylate (PMMA). Navigational accuracy and surgical precision were assessed. The PEEK workflow resulted in up to 10-fold shorter reconstruction times than the standard technique. Surgical precision was reflected by the mean 1.1±0.29mm distance between the virtual and real craniotomy, with submillimetre precision in 50%. Assessment of the global offset between virtual and actual craniotomy revealed an average shift of 4.5±3.6mm. The results validated the 'elective single-stage cranioplasty' technique as a state-of-the-art virtual planning method and surgical workflow. This patient-tailored workflow could significantly reduce surgical times compared to the traditional, intraoperative acrylic moulding method and may be an option for the reconstruction of bone defects in the craniofacial region.

Patients with Rheumatoid Arthritis Were Associated with a Risk of Rotator Cuff Diseases.

Rheumatoid arthritis (RA) commonly causes inflammation in the joints and periarticular structures. The association between RA and rotator cuff (RC) has been reported; however, epidemiological studies on RA and RC tendons are scant. Therefore, we investigated RC disease (RCD) risk and analyzed the effects of RA medication, steroids, and methotrexate, on the risk of RCD for patients with RA. We conducted a retrospective cohort study with a 6-year longitudinal follow-up in Taiwan. Patients who received RA diagnoses between 2004 and 2008 were enrolled in the study cohort. The non-RA control cohort comprised age- and sex-matched controls. Propensity score matching was used for other comorbidities and treatments. The hazard ratios (HRs) and adjusted HRs (aHRs) were estimated after confounders were adjusted for. Effects of steroid and methotrexate use on RCD risk were also analyzed. We enrolled 4521 RA patients (study cohort) and 22,605 matched controls. RCD incidence was 145 and 91 per 100,000 person-years in the RA and control cohorts, respectively. In the RA cohort, the crude HR for RCD was 1.62 (95% confidence interval (CI), 1.41⁻1.86, p < 0.001), and the aHR was 1.56 (95% CI, 1.36⁻1.79, p < 0.001). The methotrexate nonusers exhibited an aHR (vs. controls) of 1.61 (95% CI, 1.40⁻1.85, p < 0.001), but the methotrexate users did not have a significantly higher aHR than the controls. The steroid nonusers had an aHR (vs. controls) of 1.69 (95% CI, 1.46⁻1.96, p < 0.001), but the aHR of the steroid users was not significantly higher than the control aHR. Patients with RA had a higher risk for RCD compared with the non-RA control cohort. Steroids or methotrexate use significantly reduces the risk of RCD occurrence in patients with RA. Treatment for RCD symptoms and controlling inflammatory process are important to ensure high-quality care for patients with RA.

Intra-Arterial Papaverine-Hydrochloride and Transluminal Balloon Angioplasty for Neurointerventional Management of Delayed-Onset Post-Aneurysmal Subarachnoid Hemorrhage Vasospasm.

OBJECTIVE: After subarachnoid hemorrhage, delayed onset vasospasm can result in devastating ischemic stroke. The phenomenon of delayed cerebral ischemia (DCI) is not yet fully understood, and the correlation of angiographic vasospasm and cerebral infarction is still unclear. Therefore, we investigated the effect of endovascular treatment on the angiographic response and occurrence of DCI. METHODS: Eighty patients with subarachnoid hemorrhage and serious cerebral vasospasm underwent endovascular treatment using intra-arterial papaverine-hydrochloride (IAP) or transluminal balloon angioplasty (TBA). The angiographic response and infarction rate were classified using the pre- and postinterventional angiographic images and computed tomography scans. RESULTS: In 90% of patients, vasospasm could be improved. In most cases (78.8%), IAP was used. Retreatment after IAP was necessary in 32.9% of patients but never after TBA. A total of 233 vascular territories were treated in 128 procedures. Angiographic improvement was observed in 66.5% of territories, which was significantly associated with early intervention (P = 0.02), the use of TBA (P = 0.01), and the dose of papaverine-hydrochloride (P = 0.01). DCI occurred in 47.5% of the patients. Territorial infarction was associated with a poor Hunt and Hess grade (P = 0.03), day of aneurysm treatment (P = 0.01), severe vasospasm before (P = 0.02) and after (P = 0.03) treatment, and number of interventions (P = 0.01). However, the infarction rate was independent of the angiographic response. CONCLUSION: The discrepancy of excellent angiographic results and the high incidence of DCI might stem from an inaccurate or a delayed diagnosis of impending ischemia. In view of the limited time window, optimized peri-interventional management and continuous cerebral multimodality neuromonitoring might be crucial for the ideal timing of endovascular procedures to prevent cerebral infarctions.

Immediate Flow Disruption as a Prognostic Factor After Flow Diverter Treatment: Long-Term Experience with the Pipeline Embolization Device.

OBJECTIVE: To report long-term results after Pipeline Embolization Device (PED) implantation, characterize complex and standard aneurysms comprehensively, and introduce a modified flow disruption scale. METHODS: We retrospectively reviewed a consecutive series of 40 patients harboring 59 aneurysms treated with 54 PEDs. Aneurysm complexity was assessed using our proposed classification. Immediate angiographic results were analyzed using previously published grading scales and our novel flow disruption scale. RESULTS: According to our new definition, 46 (78%) aneurysms were classified as complex. Most PED interventions were performed in the paraophthalmic and cavernous internal carotid artery segments. Excellent neurologic outcome (modified Rankin Scale 0 and 1) was observed in 94% of patients. Our data showed low permanent procedure-related mortality (0%) and morbidity (3%) rates. Long-term angiographic follow-up showed complete occlusion in 81% and near-total obliteration in a further 14%. Complete obliteration after deployment of a single PED was achieved in all standard aneurysms with 1-year follow-up. Our new scale was an independent predictor of aneurysm occlusion in a multivariable analysis. All aneurysms with a high flow disruption grade showed complete occlusion at follow-up regardless of PED number or aneurysm complexity. CONCLUSIONS: Treatment with the PED should be recognized as a primary management strategy for a highly selected cohort with predominantly complex intracranial aneurysms. We further show that a priori assessment of aneurysm complexity and our new postinterventional angiographic flow disruption scale predict occlusion probability and may help to determine the adequate number of per-aneurysm devices.

Multiuse of Disposable Microsurgical Instruments as a Cost-Efficient Alternative for Training and Research.

Microsurgery demands significant preclinical training, often hampered by the high costs of the required microsurgery instruments. We hypothesized that recently available disposable microsurgery instruments provide sufficient quality and significantly reduced costs. In a comparative analysis with standard reusable instruments, participants performed equally with both instrument sets and recommended the disposable instruments for microsurgery training and research applications.