Outcomes after Flow Diverter Treatment in Subarachnoid Hemorrhage: A Meta-Analysis and Development of a Clinical Prediction Model (OUTFLOW)

Neurovascular Pathology in Intracranial Mucormycosis: Treatment by Cranial Bypass and Literature Review

BACKGROUND AND IMPORTANCE

Rhino-orbital cerebral mucormycosis (ROCM) is an aggressive fungal infection involving the paranasal sinuses, orbit, and intracranial cavity, with a propensity for vascular invasion. This can lead to complications such as internal carotid artery (ICA) thrombosis and occlusion, presenting major neurosurgical challenges. Although surgical debridement and antifungal therapy are the mainstays of treatment, cases with significant neurovascular involvement require specialized intervention. We report a case of ROCM with severe flow-limiting ICA stenosis treated by direct extracranial-intracranial bypass.

CLINICAL PRESENTATION

tA 65-year-old man with diabetes presented with progressive left-sided blindness and facial numbness. Imaging revealed a left orbital mass extending into the paranasal sinuses and intracranially. Empiric antifungal therapy was started. Pathology confirmed Rhizopus species. Despite extensive surgical debridement and antifungal therapy, the patient developed progressive severe cavernous ICA stenosis, leading to watershed territory strokes. To restore cerebral perfusion, protect from distal emboli, and prepare for potential aggressive debridement, a flow-replacing direct (superficial temporal artery-middle cerebral artery (M2)) bypass was performed, and the supraclinoid carotid was trapped. Intraoperative angiography confirmed robust flow through the bypass. The patient was discharged on antifungal therapy and aspirin. At 6-month follow-up, the patient was neurologically intact with an modified Rankin Scale score of 1. Computed tomography angiography and transcranioplasty Doppler ultrasonography confirmed good flow through the bypass.

CONCLUSION

In addition to antifungal therapy and surgical debridement, superficial temporal artery-middle cerebral artery bypass can be a lifesaving intervention in the management of ROCM with severe cerebrovascular compromise. This case highlights the critical role of cranial bypass in preserving cerebral perfusion in patients with flow-limiting ROCM-associated ICA invasion.

Evaluation of flow diverter use in acutely ruptured vertebral artery dissecting Aneurysms: A focus on safety and efficacy for rapid Aneurysm obliteration

OBJECTIVE

Flow diverter device (FDD) has emerged as the reconstruction technique for treating ruptured dissecting vertebral artery Aneurysms (VADA), but data on feasibility regarding re-rupture risk and timing of Aneurysm obliteration following FDD treatment is still limited. Therefore, this study aimed to evaluate the safety and efficacy of FDD in the treatment of VADAs presenting with subarachnoid hemorrhage (SAH).

METHODS

We retrospectively reviewed patients with ruptured VADA presenting with subarachnoid hemorrhage who underwent FDD placement at our institution between 2015 and 2023. Patient demographic data, Aneurysm configuration, and occlusion status were analyzed.

RESULTS

Thirteen patients with SAH from VADA rupture underwent FDD implantation. The average size of the largest diameter of the Aneurysm was 11.2 mm (range 6.5-21 mm). Eight of 13 (61.5 %) patients had their Aneurysms completely obliterated within 2 weeks after the procedure. The small dissecting Aneurysm (d = 0.636, p = 0.002) and degree of intra-Aneurysmal contrast stasis (d = 0.524, p = 0.026) were associated with rapid Aneurysm occlusion, according to the Somer's d coefficient. There were no ischemic or hemorrhagic complications at the average clinical follow-up of 28.4 months (range 5-67 months) and average angiographic follow-up of 20.1 months (range 3-60 months). A favorable outcome (mRS 0-2) was achieved in 12 patients (92.3 %).

CONCLUSIONS

FDD is safe and effective for the reconstruction of acutely ruptured VADAs. In addition, our study emphasizes that small dissecting Aneurysms tend to be rapidly obliterated after flow diversion, which eliminates the risk of re-rupture during the acute phase of subarachnoid hemorrhage.

Management of ruptured aneurysmal subarachnoid hemorrhage with multiple basilar trunk aneurysms using a flow-diverter stent: A case report

Ruptured aneurysmal subarachnoid hemorrhage associated with multiple basilar trunk aneurysms represents a rare clinical condition. Endovascular intervention stands as the preferred therapeutic approach. We present the case of a 35-year-old patient with subarachnoid hemorrhage and three consecutive basilar trunk aneurysms. Utilizing a flow-diverter stent, we achieved simultaneous occlusion of all 3 aneurysms, performed 2 hours post dual antiplatelet therapy (comprising salicylic acid 300 mg and ticagrelor 180 mg). Sustained resistance to clopidogrel necessitated the subsequent 3 months, followed by single antiplatelet therapy. At the 1-month follow-up, the patient demonstrated a favorable clinical course, devoid of cerebral infarction, and evidenced unobstructed stent patency upon brain magnetic resonance imaging.

A novel flow diverter device (Tubridge) for the treatment of intracranial aneurysms: a systematic review and meta-analysis

The flow diverter (FD) device has become a feasible and effective option for treating intracranial aneurysms. This study aimed to evaluate the efficacy and safety of Tubridge FD (TFD) in treating intracranial aneurysms and provide evidence for further research and clinical application. Electronic databases, including PubMed, Web of Science, Embase, and the Cochrane Library from inception to July 31, 2022, were searched. The eligible studies should include TFD investigations in treating intracranial aneurysms. Pooled technical success rate, complete occlusion rate, improvement rate, stable rate, symptom elimination rate, and adverse events rate were calculated with either the fixed-effects model or the random-effects model, depending on the results of tests for heterogeneity. Egger's tests were performed to assess the potential publication bias. A total of 7 studies (145 patients) were included in this study. The pooled technical success rate was 0.98, the complete occlusion rate was 0.79, the improvement rate was 0.21, and the stable rate was 0.05. One included study reported that the surgery-related mortality rate in the Tubridge group was higher than that in the control group (3.66% vs. 1.61%), while the surgery-related morbidity rate in the Tubridge group was 2.4% and that in the control group was 0. Findings of this meta-analysis indicate that TFD manifests promising and effective performance with acceptable adverse events in the treatment of intracranial aneurysms.

The Role of MicroRNAs in Predicting the Neurological Outcome of Patients with Subarachnoid Hemorrhage: A Meta-analysis

Subarachnoid hemorrhage (SAH) is a hemorrhagic cerebrovascular disease with an extremely poor prognosis. The molecular mechanism and biomarkers involved in neurological outcome after SAH still need to be explored. This study assessed the microRNA expression characteristics of SAH patients with different neurological outcomes by meta-analysis. Public databases were searched from database inception until December 2022. The study reported that microRNA expression data in SAH patients with different neurological outcomes were included in the analysis. The differential expression of miRNAs was evaluated by meta-analysis. Overrepresentation analysis was performed for the targeted genes of significant miRNAs. The XGBoost algorithm was used to assess the predictive ability for neurological outcomes with clinical characteristics and significantly expressed miRNAs. Seven studies were finally included in the meta-analysis. The results showed that the levels of miR-152-3p (SMD: - 0.230; 95% CI - 0.389, - 0.070; padj = 0.041), miR-221-3p (SMD: - 0.286; 95% CI - 0.446, - 0.127; padj = 0.007), and miR-34a-5p (SMD: - 0.227; 95% CI - 0.386, - 0.067; padj = 0.041) were significantly lower in SAH patients with good neurological outcomes than in those with poor neurological outcomes. The PI3K-AKT signaling pathway may have an important role in neurological recovery after SAH. Based on the XGBoost algorithm, the neurological outcome could be accurately predicted with clinical characteristics plus the three miRNAs. The expression levels of miR-152-3p, miR-221-3p, and miR-34a-5p were significantly lower in patients with good neurological outcomes than in those with poor outcomes. These miRNAs can serve as potential predictive biomarkers for neurological outcomes. The molecular mechanism and biomarkers involved in neurological outcome after SAH still need to be explored. Our study analyzed microRNA expression characteristics of SAH patients with different neurological outcomes by meta-analysis. After analyze studies reporting the microRNA expression data in SAH patients with different neurological outcomes, results show that the levels of miR-152-3p, miR-221-3p, and miR-34a-5p were significantly lower in SAH patients with good neurological outcomes than in those with poor neurological outcomes. The PI3K-AKT signaling pathway may have an important role in neurological recovery after SAH. Based on the XGBoost algorithm, the neurological outcome could be accurately predicted with clinical characteristics plus the three miRNAs.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Horizontal stenting via retrograde route for recurrent ruptured posterior communicating artery aneurysm after clipping: A case report and literature review

Treatment of recurrent ruptured aneurysms incorporating a branch vessel arising from the dome is challenging. Here, we attempted horizontal stent-assisted coil embolization via a retrograde route from the contralateral internal carotid artery to treat a small ruptured posterior communicating artery aneurysm incorporating a fetal variant posterior cerebral artery after clipping.