Flow Diversion for the Treatment of Posterior Inferior Cerebellar Aneurysms: A Novel Classification of Posterior Inferior Cerebellar Artery Origin.

BACKGROUND AND OBJECTIVES: Flow diversion (FD) for posterior circulation aneurysms, such as proximal posterior inferior cerebellar artery (PICA) aneurysms, remains "off-label" and controversial. Although there are reports of using FD in the vertebral artery (VA) to treat PICA aneurysms, the differences between structural PICA-origin variants have not been explored. We analyzed PICA aneurysms treated with FD, assessed radiographic and clinical outcomes, and presented a novel classification of the PICA origin in relationship to aneurysm anatomy. METHODS: We performed a retrospective study of prospective data for intracranial aneurysms treated with FD at a major academic institution from 2013 to 2022. Proximal PICA aneurysms that underwent FD placement in the V4 segment of the vertebral artery were included for analysis. A literature review was performed on PubMed to evaluate previously published cases. The PICA origin was characterized by 4 distinct subtypes. Type 1 describes the PICA originating adjacent/separate to the aneurysm neck, Type 2 with the PICA originating from the aneurysm neck, Type 3 with the PICA originating from the aneurysm dome, and Type 4 (True PICA aneurysm) with the aneurysm located proximally on PICA, distal to the PICA-VA junction. RESULTS: Thirteen proximal PICA aneurysms were identified and included in the analysis. Patients were primarily female (76.9%), with a median age of 62 years. The aneurysm median maximum diameter was 5.8 mm. From the total sample (institutional and literature review cases), type 1 had a 100% complete and near-complete occlusion rate, type 2 had 75.0%, type 3 had 88.9%, and type 4 had 75%. The overall complete and near-complete occlusion rate was 83.3% (20/24). CONCLUSION: FD in the V4 VA segment is an effective way to treat proximal PICA aneurysms. Exploring the relationship between PICA origin is a helpful method in predicting occlusion rates for proximal PICA aneurysms and may lead to improved treatment considerations.

Analysis of treatment cost differences in patients undergoing femoral versus radial access in outpatient diagnostic cerebral arteriograms.

BACKGROUND: Outpatient diagnostic cerebral arteriograms are the most common procedure in neuroendovascular surgery, and the use of transradial access for these studies is growing. Although transradial access has been associated with lower hospital costs for elective diagnostic and interventional neuroendovascular procedures, no study has compared transfemoral access and transradial access costs for a homogenous population of patients undergoing outpatient diagnostic cerebral arteriogram. METHODS: In this single-center retrospective study, the Value Driven Outcomes database was used to evaluate treatment costs for patients who underwent outpatient diagnostic cerebral arteriogram from January 2019 to December 2022. Propensity-score matching was performed to reduce confounders. Costs from each encounter were subcategorized into imaging, supplies, pharmacy, procedures, labs, and facility costs. RESULTS: After matching, 337 patients each for transradial access and transfemoral access were available for analysis. A total of 118,992 cost data points were associated with all encounters. Overall, per-visit costs were 15.2% cheaper for patients who underwent transradial access versus transfemoral access (p < 0.001). Most of the cost difference was due to supplies (35.2% cost difference, p < 0.001) and procedure costs (9.3% cost difference, p < 0.001). No statistical differences were observed between the two approaches in imaging, pharmacy, labs, and facility costs (all p > 0.05). CONCLUSIONS: Costs for outpatient diagnostic cerebral arteriogram were lower in patients who underwent transradial access versus transfemoral access because of supply and procedure costs. Understanding reasons for cost differences in common procedures is important for creating strategies to reduce overall healthcare costs. Additionally, addressing the cost differences of newer techniques may increase the likelihood that they are more readily implemented by hospitals and providers.

Unusual presentation of aneurysmal subarachnoid haemorrhage.

The classic presentation of aneurysmal subarachnoid haemorrhage is sudden severe headache, associated with decreased level of consciousness. The authors present a most dramatic presentation of aneurysmal subarachnoid haemorrhage.

Neuroprotective strategies and the underlying molecular basis of cerebrovascular stroke.

Stroke is a leading cause of disability in the US. Although there has been significant progress in the area of medical and surgical thrombolytic technologies, neuroprotective agents to prevent secondary cerebral injury and to minimize disability remain limited. Only limited success has been reported in preclinical and clinical trials evaluating a variety of compounds. In this review, the authors discuss the most up-to-date information regarding the underlying molecular biology of stroke as well as strategies that aim to mitigate this complex signaling cascade. Results of historical research trials involving N-methyl-d-aspartate and α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor antagonists, clomethiazole, antioxidants, citicoline, nitric oxide, and immune regulators have laid the groundwork for current progress. In addition, more recent studies involving therapeutic hypothermia, magnesium, albumin, glyburide, uric acid, and a variety of other treatments have provided more options. The use of neuroprotective agents in combination or with existing thrombolytic treatments may be one of many exciting areas of further development. Although past trials of neuroprotective agents in ischemic stroke have been limited, significant insights into mechanisms of stroke, animal models, and trial design have incrementally improved approaches for future therapies.