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Kappel AD, Nguyen HB, Frerichs KU, Patel NJ, Aziz-Sultan MA, Du R. Randomized Clinical Trials in Cerebrovascular Neurosurgery From 2018 to 2022. Cureus 2024; 16:e52397. [PMID: 38361699 PMCID: PMC10869144 DOI: 10.7759/cureus.52397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
There has been an exponential increase in randomized controlled trials (RCTs) on cerebrovascular disease within neurosurgery. The goal of this study was to review, outline the scope, and summarize all phase 2b and phase 3 RCTs impacting cerebrovascular neurosurgery practice since 2018. We searched PubMed, MEDLINE, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases for relevant RCTs published between January 1, 2018, and July 1, 2022. We searched for studies related to eight major cerebrovascular disorders relevant to neurosurgery, including acute ischemic stroke, cerebral aneurysms and subarachnoid hemorrhage, intracerebral hemorrhage, subdural hematomas, cerebral venous thrombosis, arteriovenous malformations, Moyamoya disease and extracranial-intracranial bypass, and carotid and intracranial atherosclerosis. We limited our search to phase 2b or 3 RCTs related to cerebrovascular disorders published during the study period. The titles and abstracts of all relevant studies meeting our search criteria were included. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. From an initial total of 2,797 records retrieved from the database searches, 1,641 records were screened after duplicates and studies outside of our time period were removed. After screening, 511 available reports within our time period of interest were assessed for eligibility. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. We found 80 unique phase 2b or 3 RCTs that fit our criteria, with 165 topic-relevant articles published within the study period. Numerous RCTs in cerebrovascular neurosurgery have been published since 2018. Ischemic stroke, including mechanical thrombectomy and thrombolysis, accounted for a majority of publications, but there were large trials in intracerebral hemorrhage, subdural hemorrhage, aneurysms, subarachnoid hemorrhage, and cerebral venous thrombosis, among others. This review helps define the scope of the large RCTs published in the last four years to guide future research and clinical care.
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Affiliation(s)
- Ari D Kappel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | | | - Nirav J Patel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | - Rose Du
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
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Niccum M, Gupta M, Rome JJ, O'Byrne ML. Coil Embolization of a Ruptured Mycotic Coronary Artery Aneurysm in a Pediatric Patient. JACC Case Rep 2023; 21:101967. [PMID: 37719297 PMCID: PMC10500331 DOI: 10.1016/j.jaccas.2023.101967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/12/2023] [Accepted: 07/11/2023] [Indexed: 09/19/2023]
Abstract
Mycotic coronary artery aneurysms are rare but have a high risk of mortality. Traditional management is surgical, but percutaneous intervention can be performed in patients with high surgical risk. In this report, we describe a case of mycotic coronary aneurysm in a pediatric patient successfully managed with percutaneous coil embolization. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Maria Niccum
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mudit Gupta
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan J. Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael L. O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center and Leonard Davis Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Maimaiti A, Turhon M, Cheng X, Su R, Kadeer K, Axier A, Ailaiti D, Aili Y, Abudusalamu R, Kuerban A, Wang Z, Aisha M. m6A regulator–mediated RNA methylation modification patterns and immune microenvironment infiltration characterization in patients with intracranial aneurysms. Front Neurol 2022; 13:889141. [PMID: 35989938 PMCID: PMC9389407 DOI: 10.3389/fneur.2022.889141] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/23/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe role of epigenetic modulation in immunity is receiving increased recognition—particularly in the context of RNA N6-methyladenosine (m6A) modifications. Nevertheless, it is still uncertain whether m6A methylation plays a role in the onset and progression of intracranial aneurysms (IAs). This study aimed to establish the function of m6A RNA methylation in IA, as well as its correlation with the immunological microenvironment.MethodsOur study included a total of 97 samples (64 IA, 33 normal) in the training set and 60 samples (44 IA, 16 normal) in the validation set to systematically assess the pattern of RNA modifications mediated by 22 m6A regulators. The effects of m6A modifications on immune microenvironment features, i.e., immune response gene sets, human leukocyte antigen (HLA) genes, and infiltrating immune cells were explored. We employed Lasso, machine learning, and logistic regression for the purpose of identifying an m6A regulator gene signature of IA with external data validation. For the unsupervised clustering analysis of m6A modification patterns in IA, consensus clustering methods were employed. Enrichment analysis was used to assess immune response activity along with other functional pathways. The identification of m6A methylation markers was identified based on a protein–protein interaction network and weighted gene co-expression network analysis.ResultsWe identified an m6A regulator signature of IGFBP2, IGFBP1, IGF2BP2, YTHDF3, ALKBH5, RBM15B, LRPPRC, and ELAVL1, which could easily distinguish individuals with IA from healthy individuals. Unsupervised clustering revealed three m6A modification patterns. Gene enrichment analysis illustrated that the tight junction, p53 pathway, and NOTCH signaling pathway varied significantly in m6A modifier patterns. In addition, the three m6A modification patterns showed significant differences in m6A regulator expression, immune microenvironment, and bio-functional pathways. Furthermore, macrophages, activated T cells, and other immune cells were strongly correlated with m6A regulators. Eight m6A indicators were discovered—each with a statistically significant correlation with IA—suggesting their potential as prognostic biological markers.ConclusionOur study demonstrates that m6A RNA methylation and the immunological microenvironment are both intricately correlated with the onset and progression of IA. The novel insight into patterns of m6A modification offers a foundation for the development of innovative treatment approaches for IA.
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Affiliation(s)
- Aierpati Maimaiti
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Mirzat Turhon
- Department of Neurointerventional Surgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurointerventional Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaojiang Cheng
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Riqing Su
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Kaheerman Kadeer
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Aximujiang Axier
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Dilimulati Ailaiti
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yirizhati Aili
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Rena Abudusalamu
- Department of Neurology, Neurology Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ajimu Kuerban
- Department of Neurosurgery, The First People's Hospital of Kashgar Prefecture, Kashgar, China
| | - Zengliang Wang
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Zengliang Wang
| | - Maimaitili Aisha
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- *Correspondence: Maimaitili Aisha
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EFFECTS OF THE ANEURYSM TREATMENT METHOD ON COIL PACKING DENSITY AND ITS RELATIONSHIP WITH THE OSTIUM AREA. J Vasc Interv Radiol 2022; 33:631-638. [PMID: 35283278 DOI: 10.1016/j.jvir.2021.12.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/01/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To test the following hypotheses: (1) balloon or stent assistance increases coil packing density (CPD) in the endovascular treatment of intracranial aneurysms and (2) CPD is related to the ostium area and volume of the aneurysm. MATERIALS AND METHODS This retrospective study included 60 ruptured and unruptured (54 and 6, respectively) aneurysms treated between August 2017 and December 2019 in the authors' institution with simple coiling (n=18), balloon-assisted coiling (n=7), or stent-assisted coiling (n=35). Aneurysm volume and ostium area measurements were obtained using commercial software from three-dimensional digital subtraction angiography images. Coil sizes were retrieved from patient files, and coil volume measurements were obtained using https://www.angiocalc.com/. Analysis of covariance, multivariable covariance analysis, and Pearson's correlation analyses were performed. RESULTS The median values for the aneurysm volume, coil volume, CPD, and ostium area were 63.4 (range 5.5-1771.4) mm3, 23.13 (2.03-296.95) mm3, 33.29% (13.41%-81.02%), and 10.7 (2.7-49.9) mm2, respectively. Multivariate analysis showed that the CPD values were not significantly different among the treatment groups, although the ostium area differed significantly between the simple and stent-assisted coiling groups (P<.05). Pearson's correlations showed that similar to aneurysm volume, the ostium area was negatively correlated with CPD (r=-0.321, P<.05). CONCLUSION In cerebral aneurysms treated with balloon- or stent-assisted coiling, the CPD value does not differ from that in aneurysms treated with simple coiling.
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De Leacy R, Bageac DV, Siddiqui N, Bellon RJ, Park MS, Schirmer CM, Woodward KB, Zaidat OO, Spiotta AM. Safety and Long-Term Efficacy Outcomes for Endovascular Treatment of Wide-Neck Bifurcation Aneurysms of the Middle Cerebral Artery: Insights From the SMART Registry. Front Neurol 2022; 13:830296. [PMID: 35197925 PMCID: PMC8860028 DOI: 10.3389/fneur.2022.830296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/06/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Wide-necked middle cerebral artery bifurcation aneurysms pose specific challenges to endovascular management. Surgical clipping remains the standard treatment approach for these aneurysms in many centers. While recent data suggests the endovascular treatment may be comparable, a prospective datapoint has been lacking. Materials and Methods The Penumbra SMART registry, a prospective, multi-center, single-arm outcomes registry of Penumbra coil-treated aneurysms, was queried for endovascularly treated MCA bifurcation aneurysms with wide necks (dome:neck ratio <2 or neck >4 mm). Safety and efficacy outcomes were summarized for ruptured and unruptured aneurysms, including rupture, complication rate, and 1-year occlusion outcomes. Results Seventy-two aneurysms across 31 sites were enrolled. Of these, a total of 15 presented as ruptured aneurysms. Serious adverse events were reported in 21 (29.2%) of patients, with 8 (11.1%) attributed to the device/procedure. Immediately postoperatively, 75.0% of cases achieved “adequate” Raymond Roy Class I (40.3%) or II (34.7%) occlusion outcomes. Of the 72 patients treated, 60 (83.3%) underwent follow-up angiography at 1 year, and among these, 95.0% had 1-year occlusion outcomes of Raymond Roy Class I (71.7%) or II (23.3%). A total of 6 aneurysms (10.0%) were required or were planned for retreatment at the last follow-up. Conclusion This study represents the most significant prospective sample of endovascularly treated wide-neck MCA bifurcation aneurysms conducted to date. It supports the safety and efficacy of endovascular treatment of these aneurysms.
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Affiliation(s)
- Reade De Leacy
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States
| | - Devin V Bageac
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States
| | - Neha Siddiqui
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States
| | | | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, United States
| | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System, Wilkes-Barre, PA, United States.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | | | | | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
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Spiotta AM, Park MS, Bellon RJ, Bohnstedt BN, Schirmer CM, De Leacy RA, Fiorella DJ, Yoo AJ, Dumont TM, Starke RM. Technical Success and Early Efficacy in 851 Patients with Saccular Intracranial Aneurysms: A Subset Analysis of SMART, a Prospective, Multicenter Registry Assessing the Embolization of Neurovascular Lesions using the Penumbra SMART COIL System. World Neurosurg 2021; 155:e323-e334. [PMID: 34419663 DOI: 10.1016/j.wneu.2021.08.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The Prospective, Multicenter Registry Assessing the Embolization of Neurovascular Lesions Using the Penumbra SMART COIL® System (SMART) is the largest prospective, multicenter, postmarket registry established to gather real-world experience on Penumbra (Alameda, USA) SMART COIL System, PC400, and POD embolization coils. The goal of this study is to report the technical success and efficacy of SMART COIL System coils in treating saccular intracranial aneurysms. METHODS This subgroup analysis from the SMART registry included patients with saccular intracranial aneurysms treated using ≥75% SMART COIL System or PC400 coils. Baseline and procedural data, angiographic data, and clinical outcomes were collected. Predictors of catheter kickout, packing density, and postprocedural angiographic outcome were analyzed using multivariable regression models in saccular aneurysm cases. RESULTS Between June 2016 and August 2018, the SMART registry enrolled 995 patients at 68 sites, of which 851 of 995 (85.5%) were treated for saccular aneurysms (mean age, 59.9 years). Aneurysms had a mean size of 6.8 mm, were wide neck in 63.1%, and ruptured in 31.0% of patients. Mean aneurysm packing density was 32.3%. Postprocedural Raymond-Roy Occlusion Classification (RROC) I-II was achieved in 80.3% of patients; smaller aneurysms, non-wide-neck aneurysms, and high packing density were predictive of RROC I-II. Overall, mean fluoroscopic time was 43.4 minutes, rate of reaccess attempts because of catheter kickout was 6.2%, and mean procedure time was 83.2 minutes. CONCLUSIONS SMART COIL System coils achieved good technical success and adequate occlusion in treating saccular intracranial aneurysms in a real-world setting.
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Affiliation(s)
- Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Richard J Bellon
- Radiology Imaging Associates Neurovascular Clinic, Englewood, Colorado, USA
| | | | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger and Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania, USA; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Reade A De Leacy
- Departments of Neurosurgery & Radiology, Mount Sinai Health System, New York, New York, USA
| | - David J Fiorella
- Department of Neurosurgery, Stony Brook University Medical Center, Cerebrovascular Center, New York, USA
| | - Albert J Yoo
- Interventional Neuroradiology, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Travis M Dumont
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Hospital, Miami, Florida, USA
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