Unruptured Brain Research Articles

Abstract 1122‐000030: Satellite Model for the Management of Aneurysms to Desaturate the Third Level Health System

Introduction : The Centro Medico Nacional 20 de Noviembre is the most complex centre of the Mexican public health system. The SARS COV‐2 pandemic has progressively saturated health services at all levels, impacting chronic non‐communicable diseases 1. Aneurysmal subarachnoid haemorrhage has a mortality rate of up to 35% if not treated 2. Endovascular management of aneurysms provides a therapeutic possibility that shortens the time and reduces complications if implemented in an outpatient system with high standards of patient choice and reduces the chances of complications 3. We present a case series of patients with ruptured and unruptured brain aneurysms treated in a satellite system to reduce in‐hospital days and complications. Methods : A retrospective analysis was carried out of 66 patients admitted on an outpatient basis at the Centro Medico Nacional “20 de noviembre” between May 2020 to June 2021. The patients were entered into a “satellite” system for coils’ endovascular management or flow diverter, previously diagnosed with digital subtracter angiography and computed tomography angiogram. The analysis of variables was done using the Shapiro‐Wilk test to determine the normality of the sample distribution. The correlation of variables was done using Chi‐square. Results : The mean age of the patients was 53.8 years SD 14.31 years. 71.2% of the patients were female, and 28.2% were male. There was a 59.1% left predominance regarding the aneurysm side, 37.9% on the right side, and 3.0% was a single vessel. The arterial predominance was 77.3% anterior circulation. 95.5% of the patients underwent embolization with the placement of coils, and 4.5% had a flow diverter. The mean time of admission was 23.3 hours SD 12.4 hours. Complications occurred in 13.6% of the population studied, the most frequent being vasospasm, arterial occlusion, hydrocephalus, and death from aspiration pneumonia. The modified Rankin scale at 90 days was 0.38 SD 1.13. There was a significant relationship (p = 0.05) between the left side and complications. Conclusions : The management of aneurysms with a short in‐hospital time is a feasible solution in reducing the decongestion of tertiary health systems. Endovascular management with coils results in a low rate of complications, which is why this therapeutic route can be followed to desaturate third‐level health systems and a flow diversion in high well‐selected patients. The relationship between complication rates related to the left side of aneurysms is likely due to the more significant number of aneurysms on this side, not due to anatomical vessel idiosyncrasy.

IL-6 Quotient (The Ratio of Cerebrospinal Fluid IL-6 to Serum IL-6) as a Biomarker of an Unruptured Intracranial Aneurysm.

BackgroundStudies conducted so far have focused mainly on the assessment of IL-6 levels in patients with ruptured brain aneurysms. Carrying out detailed studies in patients with un-ruptured brain aneurysms (UIA) would be extremely important, as it would answer the question of whether IL-6 plays also a role in primary aneurysm formation and growth.MethodsIL-6, S100, NSE, and albumin concentrations in 67 UIA patients and 17 individuals without vascular lesions in the brain were tested using in vitro diagnostic immunoassays according to the manufacturers’ instructions. IL-6 Quotient was calculated by dividing cerebrospinal fluid (CSF) IL-6 by serum IL-6.ResultsWe showed that IL-6 Quotient was significantly higher in UIA patients (1.78) compared to the control group (0.87; p<0.001). Multivariate logistic regression analysis demonstrated that a growth in IL-6 Quotient increases the probability of UIA diagnosis. In UIA patients CSF IL-6 concentration was significantly higher (4.55 pg/ml) compared to the serum concentration (2.39 pg/ml; p<0.001). In both the study and control group, the blood-brain barrier was intact, thus the CSF-blood gradient of the IL-6 concentration in UIA patients was likely to be the expression of local synthesis of the cytokine within the central nervous system. Patients with multiple brain aneurysms had significantly higher CSF IL-6 levels (5.08 pg/ml) compared to individuals with a single aneurysm (4.14 pg/ml; p=0.0227).ConclusionThis totality of the may suggest IL-6 as a biomarker for UIA formation; however, further studies are needed to unequivocally confirm clinical application of IL-6 concentration evaluation.

Angioarchitectural features amongst patients with unruptured brain arteriovenous malformations presenting with headache: findings from a single center retrospective review of 76 patients

BackgroundBrain arteriovenous malformations (AVMs) consist of abnormal connections between arteries and veins via an interposing nidus. While hemorrhage is the most common presentation, unruptured AVMs can present with headaches, seizures, neurological deficits, or be found incidentally. It remains unclear as to what AVM characteristics contribute to pain generation amongst unruptured AVM patients with headaches.MethodsTo assess this relationship, the current study evaluates angiographic and clinical features amongst patients with unruptured brain AVMs presenting with headache. Loyola University Medical Center medical records were queried for diagnostic codes corresponding to AVMs. In patients with unruptured AVMs, we analyzed the correlation between the presenting symptom of headache and various demographic and angiographic features.ResultsOf the 144 AVMs treated at our institution between 1980 and 2017, 76 were unruptured and had sufficient clinical data available. Twenty-three presented with headaches, while 53 patients had other presenting symptoms. Patients presenting with headache were less likely to have venous stenosis compared to those with a non-headache presentation (13 % vs. 36 %, p = 0.044).ConclusionsOur study suggests that the absence of venous stenosis may contribute to headache symptomatology. This serves as a basis for further study of correlations between AVM angioarchitecture and symptomatology to direct headache management in AVM patients.

Treatment-Associated Stroke in Patients Undergoing Endovascular Therapy in the ARUBA Trial.

Since the publication of ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations), outcomes in treated and untreated patients with unruptured arteriovenous malformation have been thoroughly compared. However, no prior analysis of ARUBA patients has sought to identify risk factors for perioperative stroke. Improved understanding of risks within the ARUBA cohort will help clinicians apply the study’s findings in a broader context. The National Institute of Neurological Disorders and Stroke database was queried for all data relating to ARUBA patients, including demographics, interventions undertaken, and timing of stroke. Retrospective cohort analysis was performed with the primary outcome of perioperative stroke in patients who underwent endovascular intervention, and stroke risk was modeled with multivariate analysis. A total of 64 ARUBA patients were included in the analysis. One hundred and fifty-ninth interventions were performed, and 26 (16%) procedures resulted in stroke within 48 hours of treatment. Posterior cerebral artery supply (adjusted odds ratio, 4.42 [95% CI, 1.23–15.9], P=0.02) and Spetzler-Martin grades 2 and 3 arteriovenous malformation (adjusted odds ratio, 7.76 [95% CI, 1.20–50.3], P=0.03; 9.64 [95% CI, 1.36–68.4], P=0.04, respectively) were associated with increased perioperative stroke risk in patients who underwent endovascular intervention. Patients treated in the United States or Germany had a significantly lower stroke risk than patients treated in other countries (adjusted odds ratio, 0.18 [95% CI, 0.04–0.82], P=0.02). Knowing patient and lesion characteristics that increase risk during endovascular treatment can better guide clinicians managing unruptured brain arteriovenous malformation. Our analysis suggests risk of perioperative stroke is dependent on Spetzler-Martin grade and posterior-circulation arterial supply. Differences in regional treatment paradigms may also affect stroke risk.

Exclusion treatment of ruptured and unruptured low-grade brain arteriovenous malformations: a systematic review.

To assess the obliteration rate, functional outcome, hemorrhagic complication, and mortality rates of exclusion treatment of low-grade brain arteriovenous malformations (BAVMs) (Spetzler and Martin grades (SMGs) 1 and 2), either ruptured or unruptured. Electronic databases-Ovid MEDLINE and PubMed-were searched for studies in which there was evidence of exclusion treatment of low-grade BAVMs treated either by endovascular, surgical, radiosurgical, or multimodality treatment. The primary outcome of interest was angiographic obliteration post-treatment and at follow-up. The secondary outcomes of interest were functional outcome (mRS), mortality rate, and hemorrhagic complication. Descriptive statistics were used to calculate rates and means. Eleven studies involving 1809 patients with low-grade BAVMs were included. Among these, 1790 patients treated by either endovascular, surgical, radiosurgical, or multimodality treatment were included in this analysis. Seventy-two percent of BAVMs were Spetzler-Martin grade II. The overall (i.e., including all exclusion treatment modalities) complete obliteration rate ranged from 36.5 to 100%. The overall symptomatic hemorrhagic complication rate ranged from 0 to 7.3%; procedure-related mortality ranged from 0 to 4.7%. Our systematic review of the literature reveals a high overall obliteration rate for low-grade BAVMs, either ruptured or unruptured, with low mortality rate and an acceptable post-treatment hemorrhagic complication rate. These results suggest that exclusion treatment of low-grade BAVMs may be safe and effective, regardless of the treatment modality chosen.

Elective intervention for unruptured cranial arteriovenous malformations in relation to ARUBA trial: a National Inpatient Sample study.

In 2014, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) concluded that medical management alone for cranial arteriovenous malformations (AVMs) had better clinical outcomes than interventional treatment. The impact of the ARUBA study on changes in the rates of intervention and outcomes is unknown. Thus, we investigated whether the conclusions from ARUBA may have influenced treatment modalities and outcomes of unruptured AVMs. The National Inpatient Sample (NIS) was queried between 2006 and 2018, for adult patients with an AVM who were admitted on an elective basis. Interventions included open, endovascular, and stereotactic surgeries. Join-point regression was used to assess differences in slopes of treatment rate for each modality before and after the time-point. Logistic regression was used to assess the odds of non-routine discharge and hemorrhage between the two time-points for each treatment modality. Linear regression was used to assess the mean length of stay (LOS) for each treatment modality between the two time-points. A total of 40,285 elective admissions for AVMs were identified between 2006 and 2018. The rate of intervention was higher pre-ARUBA (n = 15,848; 63.8%) compared to post-ARUBA (n = 6985; 45.2%; difference in slope - 8.24%, p < 0.001). The rate of open surgery decreased, while endovascular and stereotactic surgeries remained the same, after the ARUBA trial time-point (difference in slopes - 8.24%, p < 0.001; - 1.74%, p = 0.055; 0.20%, p = 0.22, respectively). For admissions involving interventions, the odds of non-routine discharge were higher post-ARUBA (OR 1.24; p = 0.043); the odds of hemorrhage were lower post-ARUBA (OR 0.69; p = 0.025). There was no statistical difference in length of stay between the two time-points (p = 0.22). The rate of intervention decreased, the rate of non-routine discharge increased, and rate of hemorrhage decreased post-ARUBA, suggesting that it may have influenced treatment practices for unruptured AVMs.

Treatments of unruptured brain arteriovenous malformations: A systematic review and meta-analysis.

Background:The best therapeutic option for unruptured brain arteriovenous malformations (bAVMs) patients is disputed.Objective:To assess the occurrence of obliteration and complications of patients with unruptured bAVMs after various treatments.Methods:A systematic literature search was performed in PubMed, EMBASE, Web of Science, and so on to identify studies fulfilling predefined inclusion criteria. Baseline, treatment, and outcomes data were extracted for statistical analysis.Results:We identified 28 eligible studies totaling 5852 patients. The obliteration rates were 98% in microsurgery group (95% confidence interval (CI): 96%–99%, I2 = 74.5%), 97% in surgery group (95%CI: 95%–99%, I2 = 18.3%), 87% in endovascular treatment group (95%CI: 80%–93%, I2 = 0.0%), and 68% in radiosurgery group (95%CI: 66%–69%, I2 = 92.0%). The stroke or death rates were 1% in microsurgery group (95%CI: 0%–2%, I2 = 0.0%), 0% in surgery group (95%CI: 0%–1%, I2 = 0.0%), 4% in endovascular treatment group (95%CI: 0%–8%, I2 = 85.8%), and 3% in radiosurgery group (95%CI: 3%–4%, I2 = 82.9%). In addition, the proportions of hemorrhage were 2% in microsurgery group (95%CI: 1%–4%, I2 = 0.0%), 23% in endovascular treatment group (95%CI: 7%–39%), and 12% in radiosurgery group (95%CI: 12%–13%, I2 = 99.2%). As to neurological deficit, the occurrence was 9% in microsurgery group (95%CI: 6%–11%, I2 = 94.1%), 20% in surgery group (95%CI: 13%–27%, I2 = 0.0%), 14% in endovascular treatment group (95%CI: 10%–18%, I2 = 64.0%), and 8% in radiosurgery group (95%CI: 7%–9%, I2 = 66.6%).Conclusions:We found that microsurgery might provide lasting clinical benefits in some unruptured bAVMs patients for its high obliteration rates and low hemorrhage. These findings are helpful to provide a reference basis for neurosurgeons to choose the treatment of patients with unruptured bAVMs.

Symptomatic Unruptured Arteriovenous Malformations: Focal Edema, Thrombosis, and Vessel Wall Enhancement: A Retrospective Cohort Study

Focal brain edema in unruptured brain arteriovenous malformations (AVMs) is rare and associated with venous outflow abnormalities and aneurysm growth. These patients have an increased rate of progressive neurologic symptoms, as well as a potentially increased risk of hemorrhage. In this study, we aim to assess in further detail the relationship between perifocal edema and enhancement of the vessel wall in symptomatic patients with an unruptured brain AVM. A single-center retrospective cohort study of all patients presenting with an unruptured AVM at Toronto Western Hospital from 2009 to 2019 was performed. Patients were included for review if they had focal edema surrounding an AVM on magnetic resonance imaging (MRI) and a contrast-enhanced MRI scan. Associated digital subtraction angiography studies were reviewed. A total of 122 patients presented with an unruptured AVM. Twelve symptomatic patients presented with focal edema surrounding the AVM. Six patients had focal edema and contrast-enhanced MRI performed. All 6 demonstrated luminal thrombosis at the level of the brain edema on MRI. Moreover, the vessel wall demonstrated enhancement at the level of the luminal thrombus in all. Vessel wall enhancement, perifocal edema, and luminal thrombosis demonstrated in all patients with unruptured AVM points towards a common mechanism. We suspect an interplay between vascular hypoxia, the innate immune system, and thrombosis formation. Current research in the field of immunothrombosis supports this theory. Unravelling the mechanisms involved is important because it might guide therapy for patients with an unruptured AVM towards noninvasive options.

Patient functional outcomes and quality of life after surgery for unruptured brain arteriovenous malformation.

Studies have questioned the effectiveness of surgery for the management of unruptured brain arteriovenous malformation (ubAVM). Few studies have examined functional outcomes and quality of life (QOL) prior and 12 months after surgical repair of ubAVM. This study examined the effectiveness of surgical management of ubAVM by measuring patients' perceived QOL and their ability to perform everyday activities. Between 2011 and 2016, patients diagnosed with an unbAVM were assessed using the Quality Metric Short Form 36 (SF36), the DriveSafe component of the off-road driver screening tool DriveSafeDriveAware (DSDA), the modified Barthel Index (mBI) and the modified Rankin Scale (mRS). Reassessments were conducted at the 6-week post-operative follow-up for surgical patients and at 12-month follow-up for surgical and conservatively managed patients. Forty-five patients enrolled in the study, of which 35 (78%) had their ubAVM surgically treated. Patients undergoing surgery had a significantly lower ubAVM Spetzler-Ponce Class (SPC). There was no significant difference 12 months after presentation in function or QOL for either the conservative or surgical group. The surgical group had significantly higher QOL of life scores from pre-surgery to 12 months post-surgery (PCS p < 0.01; MCS p = 0.02). Higher SP grade ubAVM was significantly related to poorer function in the surgical group (SP C compared with SP A; p = 0.04, mean difference - 12.4, 95%CI - 24.3 to - 0.4). Function and QOL are not diminished after surgical treatment of low Spetzler-Ponce Class unruptured brain arteriovenous malformations. QOL is higher 12 months after surgery for ubAVM than for those who do not have treatment for their ubAVM.

Unruptured Arteriovenous Malformations: Do We Have an Answer After the Final Follow-Up of ARUBA? A Bayesian Viewpoint.

Brain arteriovenous malformations (bAVMs) are vascular lesions that carry significant morbidity and mortality risk upon rupture. bAVM rupture causes either intracerebral or intraventricular hemorrhage, or both. In 2014, the first results of the ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) were published in The Lancet, causing a paradigm shift in clinical practice and suggesting the superiority of medical treatment in terms of mortality or stroke compared with any intervention designed to obliterate the AVM. In 2020, the final results of the ARUBA trial were published. In this Viewpoint, we critically review the clinical equipoise behind the trial, highlight issues regarding external validity, and place the results of the trial in the context of other results in scientific literature of bAVMs using Bayesian inference. ARUBA is a trial of decision-making, and only proper knowledge of the nuances of its interpretation within the broader context of bAVM research can lead to proper decision-making when confronted with patients with unruptured bAVMs.

Benefits of Exclusion Treatments of Unruptured Brain Arteriovenous Malformations on Epilepsy in Adults

In about 30% of the patients, brain arteriovenous malformations are revealed by seizures. Epileptic patients’ quality of life may be altered. Our objective was to evaluate the benefits of exclusion treatments (radiosurgery, embolization, and/or surgery) on post-therapeutic epilepsy in brain arteriovenous malformations-patients without prior-to-treatment intracranial hemorrhage. Our retrospective observational single-centre study included all consecutive adult patients with an unruptured brain arteriovenous malformation and epilepsy, treated at our Institution from 1995 to 2019 and who were followed for at least one year. Data on brain arteriovenous malformations’ angio-architectural characteristics, on epilepsy, and posttreatment modified Rankin score were collected. The primary endpoint was a seizure-free status (defined as Engel class IA) after exclusion treatment versus conservative management. A hundred and one consecutive adult patients with brain arteriovenous malformations, epilepsy an0 without brain arteriovenous malformation-rupture before any treatment were included, 21 (21%) in the conservative management group vs. 80 (79%) in the exclusion treatment group. After exclusion treatment, 55% patients of the group were Engel IA after treatment versus 10% of the conservative management group (OR 11·37, p < 0·001). Our results suggest that exclusion treatment in unruptured brain arteriovenous malformations with epilepsy is associated with a higher seizure-free rate in comparison with conservative management. Data from randomized controlled studies are necessary to confirm these findings. Funding Statement: The authors report no funding related to this study Declaration of Interests: The authors report no competing interest. Ethics Approval Statement: The study was approved by the local ethics committee and validated by the French National Commission of Informatics and Liberty (Commission Nationale Informatique et Libertes, CNIL).

Unruptured asymptomatic brain aneurysms: modern approaches to the choice of surgical method and treatment outcomes

In recent years, significant attention has been paid to preventive vascular neurosurgery. Treatment of unruptured asymptomatic brain aneurysms is one of the sections of this surgery. To evaluate treatment outcomes in patients with unruptured asymptomatic brain aneurysms who underwent treatment chosen on the basis of criteria adopted at the Burdenko Neurosurgery Center. There were 2814 unruptured asymptomatic brain aneurysms in 2334 patients for the period from 1995 to 2019. Microsurgical operations for unruptured asymptomatic brain aneurysms were performed in 64.9% of cases, endovascular procedures - in 35.1% of patients. Endovascular operations were usually performed for ICA aneurysms and posterior aneurysms of circle of Willis. Microsurgical operations were mainly performed in patients with aneurysms of anterior and middle cerebral arteries. Favorable outcomes (GOS grade V-IV) were obtained in most patients (98.3%). Incidence of severe complications was similar in both groups, mortality rate was 0.3% and 0.4%, respectively. Currently, there is a tendency towards annual increase in the number of surgeries for unruptured brain aneurysms. Anatomical and morphological characteristics of aneurysm should be considered to achieve favorable clinical results. At the same time, comprehensive analysis of each case and identification of individual risk factors will eliminate serious complications of surgical treatment.

Surgical Treatment of Unruptured Brain AVMs: Short- and Long-Term Results.

Unruptured brain AVMs (bAVMs) remain a controversial subject for practicing neurosurgeons, especially in the light of ARUBA and other observational studies. This retrospective study aims to analyze our experience with unruptured bAVMs to see whether it is beneficial in the long-term and how it corresponds to large literature trials. The study comprised 160 adult patients with unruptured bAVMs surgically treated in Burdenko NMC (Moscow) in 2009-2017. Mean age: 33.4±10лет. Clinical presentations were: seizures in 99 (61.9%), chronical headaches-49 (30.6%), ischemic symptoms-4 (2.5%), asymptomatic in 8 (5%) patients. Spetzler-Martin scale: I-18pt. (11.3%), II-71pt. (44.4%), III-60pt. (37.5%), IV-11pt. (6.8%). Good outcomes (mRS=0-2) at discharge were achieved in 149 (93.1%), satisfactory (mRS-3)-9 (5.6%). Follow-up was complete for 97 (60.6%) patients, mean-59.3 (13-108month). Excellent outcomes (mRS=0-1) reached in 94.8%. For epilepsy patients, Engel I outcome was found in 50 (84.8%); for chronic headaches, 43 (66.1%) patients reported improvement. Postoperative visual field defects were followed in 22 of 55 (40%), complete recovery was reported in 6 (27%) and partial recovery in 8 (36%) patients. Overall, our results support the conclusion that surgery for low-grade bAVMs (S-M I-II) is a beneficial, low-risk option.

Living with a Brain AVM: A Quality of Life Assessment.

Brain arteriovenous malformations (AVM) are uncommon vascular lesions with the risk of hemorrhage, epileptic seizures, neurological deficits, and headache. Comparing the risks of the natural history and that of preventive treatment, a recent study has found observation more beneficial than treatment for unruptured AVMs. This study, however, did not consider the long-term impact of carrying a brain AVM on everyday activities. In this study we analyzed the Quality Of Life (QOL) of patients with untreated AVMs, a measure increasingly used in clinical trials to asses this kind of impact. We enrolled 36 patients with unruptured, untreated brain AVM from our hospital database and measured their QOL retrospectively using the EQ-5D-5L questionnaire. As a control group we used the results of the Research Report, a nationwide study based on the quality of life of 5534 healthy Hungarians in 2002. Due to the low number of cases, statistical analysis could not be made. Headache proved to be the most common AVM-related sign in our cohort (40%, n=17), with a female predominance; neurological deficit was detected in 33% (n=14), while epileptic seizures occurred in 26% (n=11), more commonly affecting male subjects. Anxiety and discomfort seemed to be the most prevalent influencing factors on QOL, especially in the youngest age group (18-34years). Female subjects showed a greater dependence than men in all age groups, though males had a more significant impairment in their usual activities. Older patients were affected more significantly in their self-care and usual activities compared with the younger population. Untreated AVMs have a significant negative impact on patients carrying unruptured brain AVMs, as proved by QOL assessment. Beside neurological deficits, this impact should also be considered in the therapeutic decision.

Radiosurgery for unruptured brain arteriovenous malformations in the pre-ARUBA era: long-term obliteration rate, risk of hemorrhage and functional outcomes

The management of non-hemorrhagic arteriovenous malformations (AVMs) remains a subject of debate, even more since the ARUBA trial. Here, we report the obliteration rate, the risk of hemorrhage and the functional outcomes after Gamma Knife radiosurgery (GKRS) as first-line treatment for non-hemorrhagic AVMs treated before the ARUBA publication, in a reference university center with multimodal AVM treatments available. We retrospectively analyzed data from a continuous series of 172 patients harboring unruptured AVMs treated by GKRS as first-line treatment in our Lille University Hospital, France, between April 2004 and December 2013. The primary outcome was obliteration rate. Secondary outcomes were the hemorrhage rate, the modified Rankin Scale (mRS), morbidity and epilepsy control at last follow-up. The minimal follow-up period was of 3 years. Median age at presentation was 40 years (IQR 28; 51). Median follow-up was 8.8 years (IQR 6.8; 11.3). Median target volume was 1.9 cm3 (IQR 0.8–3.3 cm3), median Spetzler-Martin grade: 2 (IQR 1–2), median Pollock-Flickinger score: 1.07 (IQR 0.82–2.94), median Virginia score: 1 (IQR 1–2). Median treatment dose was 24 Gy at 50% isodose line. Twenty-three patients underwent a second GKRS after a median time of 58 months after first GKRS. The overall obliteration rate was of 76%, based primarily on cerebral angiography and/or rarely only upon MRI. Hemorrhage during the post-treatment follow-up was reported in 18 (10%) patients (annual risk of 1.1%). Transient post-GKRS morbidity was reported in 14 cases (8%) and persistent neurological deficit in 8 (4.6%) of patients. At last follow-up, 86% of patients had a mRS ≤ 1. Concerning patients with pretherapeutic epilepsy, 84.6% of them were seizure-free at last follow-up. GKRS as first-line therapeutic option for unruptured cerebral AVMs achieves high obliteration rates (76%) while maintaining a high-level patient’s autonomy. All hemorrhagic events occurred during the first 4 years after the initial GKRS. In cases with epilepsy, there was 84.6% seizure free at last follow-up. Permanent morbidity was reported in only 4.6%.

Differentiation between Cerebral Hemorrhage and Contrast Extravasation Using Dual Energy Computed Tomography after Intra-Arterial Neuro Interventional Procedures.

Purpose:To evaluate the value of dual-energy computed tomography (DECT) in differentiating cerebral hemorrhage from blood brain barrier (BBB) disruption after neuro-interventional procedures with intra-arterial injection of iodinated contrast material.Material and methods:This prospective study was approved by the local ethics committee, and informed consent was obtained for all patients. Thirty five patients with acute ischemic stroke or un-ruptured brain aneurysm who had received intra-arterial administration of iodinated contrast material were evaluated using DECT at 80 and 150 kV immediately after the procedure.A three-material decomposition algorithm was used to obtain virtual non-contrast (VNC) images and iodine overlay maps (IOM). A follow-up examination (brain magnetic resonance imaging MRI or conventional CT) was used as the standard of reference for hemorrhage, defined as a persistant hyperdensity on a conventional CT or T2* hypo-intensity on brain MRI. The diagnostic values of DECT in differentiating hemorrhage and iodinated contrast material were obtained.Results:Mixed images obtained with DECT showed intra-parenchymal or subarachnoid hyperattenuation in 18/35 patients. Among these, 16 were classified (according to VNC images and IOM) as contrast extravasations and two with a mixture of hemorrhage and contrast material. On follow-up imaging, there were two patients with hemorrhage. The sensitivity, specificity, and accuracy of DECT in the identifying hemorrhage was calculated as 67% (2/3), 100% (32/32) and 97% (32/33) respectively.Conclusion:DECT allows an early and accurate differentiation between cerebral hemorrhage and BBB disruption after intra-arterial neuro-interventional procedures.

Changes in Neuroendovascular Procedural Volume During the COVID-19 Pandemic: An International Multicenter Study.

ABSTRACTBACKGROUND AND PURPOSEThe effect of coronavirus disease 2019 (COVID‐19) pandemic on performance of neuroendovascular procedures has not been quantified.METHODSWe performed an audit of performance of neuroendovascular procedures at 18 institutions (seven countries) for two periods; January‐April 2019 and 2020, to identify changes in various core procedures. We divided the region where the hospital was located based on the median value of total number of COVID‐19 cases per 100,00 population‐into high and low prevalent regions.RESULTSBetween 2019 and 2020, there was a reduction in number of cerebral angiograms (30.9% reduction), mechanical thrombectomy (8% reduction), carotid artery stent placement for symptomatic (22.7% reduction) and asymptomatic (43.4% reduction) stenoses, intracranial angioplasty and/or stent placement (45% reduction), and endovascular treatment of unruptured intracranial aneurysms (44.6% reduction) and ruptured (22.9% reduction) and unruptured brain arteriovenous malformations (66.4% reduction). There was an increase in the treatment of ruptured intracranial aneurysms (10% increase) and other neuroendovascular procedures (34.9% increase). There was no relationship between procedural volume change and intuitional location in high or low COVID‐19 prevalent regions. The procedural volume reduction was mainly observed in March‐April 2020.CONCLUSIONSWe provided an international multicenter view of changes in neuroendovascular practices to better understand the gaps in provision of care and identify individual procedures, which are susceptible to change.

Verbalna memorija u bolesnika nakon operacije rupturirane i nerupturirane cerebralne aneurizme

A cerebral aneurysm is a bulge in the wall of a brain blood vessel with a risk to rupture. It occurs in about 2% of the population, somewhat more often in women. Most aneurysms are located in the anterior circulation area. Aneurysm rupture is relatively rare and accounts for 5% of all cerebrovascular brain incidents. Ruptured and asymptomatic/unruptured aneurysms are often treated surgically at the Department of Neurosurgery, Medical School University of Zagreb. The study included 134 patients after cerebral aneurysm surgery during the last 10 years, and neuropsychological testing was performed on average 77 days after surgery. The average age was 52 years and they completed an average of 12 years of education. In the group of patients included in this study, 40.3% of them were operated after ruptured, and 59.7% for unruptured cerebral aneurysm. Most aneurysms were located in the middle cerebral and anterior communicating arteries. With regard to lateralization, there was an equal number of aneurysms located in the right and left hemisphere and bilaterally (on the anterior communicating artery). As part of regular neuropsychological assessment, tests of verbal learning and memory (numerical, logical and mechanical memory) were applied. The aims of the study were to find out whether patients operated for ruptured cerebral aneurysms show greater verbal memory impairments than patients operated for unruptured cerebral aneurysms and whether there was the significant effect of lateralization of aneurysm (to check the interaction effect of both rupture and lateralization on those functions). The results obtained show that, even though there are no statistically significant differences between groups of patients that underwent surgery for ruptured and unruptured brain aneurysm, patients show a trend of somewhat better results on most of the verbal memory functions after surgery for unruptured brain aneurysm. The results show statistically significant difference between groups of patients that underwent surgery for ACoA aneurysm and those with right lateralized cerebral aneurysms on most of the trails on AVLT test. Also, patients with operated ACoA aneurysm have significantly worse scores in learning process (AVLT 3 and AVLT 4) and especially on short-term and long-term verbal memory than the patients who were operated for left or right lateralized aneurysm.

Changes in treatment strategy over time for arteriovenous malformation in a Japanese high-volume center

BackgroundDespite rapid developments in devices used to treat arteriovenous malformation (AVM), a randomised trial of Unruptured Brain Arteriovenous malformations published in 2014 recommended conservative treatment for nonhemorrhagic AVM. The purpose of the current retrospective study was to confirm how AVM treatment in Japan has changed and to assess the safety of treatment for hemorrhagic and nonhemorrhagic AVMs.MethodsWe enrolled 242 consecutive patients with AVM; each patient’s treatment was selected and performed at our hospital. The type of onset, Spetzler–Martin (S–M) grade, age, sex, selected treatment, mortality, and morbidity were compared between the first and second periods of our study.ResultsIn patients with grade I–III AVM, the selected treatment changed between the first and second periods; however, in grade IV and V patients, the selected treatment did not change. Overall, interventions by microsurgery alone decreased (p < 0.001), the proportion of total treatments including microsurgery decreased (p = 0.005), interventions using stereotactic radiosurgery (SRS) alone increased (p = 0.009), and interventions including SRS increased (p = 0.002). Morbidity associated with intervention was 0.92% in the first period and 0% in the second period, and mortality was 0.92% in the first period and 1.67% in the second.ConclusionsWith the development of new devices, the selected treatment was changed in patients with S–M grade I–III AVM, but was not changed in patients with grade IV and V. The complication rate was low and did not change throughout the periods. These findings suggest that the safety of treatment depends on a full understanding of device development and the selection of proper treatment, not on hemorrhagic onset. Further treatment innovations are expected to change the treatment for grade IV and V AVMs.

Quality of Life of Patients with Unruptured Intracranial Aneurysms Before and After Endovascular Coiling: A HEAT Trial Secondary Study and Systematic Review of the Literature

The study of quality of life (QOL) in patients with asymptomatic diseases receiving interventional treatment provides an essential metric for the assessment of procedural benefits in the surgical patient population. In this study, we analyzed QOL data collected from patients with unruptured intracranial aneurysms (UIAs) before and after endovascular coiling in the HEAT Trial, alongside a systematic review on QOL in unruptured brain aneurysms. HEAT was a randomized controlled trial comparing recurrence rates in aneurysms treated with either bare platinum coils or hydrogel coils. Patients enrolled in this trial completed a short form-36 (SF-36) QOL questionnaire before treatment and at the 3- to 12- and 18- to 24-month follow-ups. The change in QOL before and after treatment was assessed. Regression analysis evaluated the effect of select baseline characteristics on QOL change. A total of 270 patients were eligible for analysis. There was an increase in the role physical (P= 0.043), vitality (P= 0.022), and emotional well-being (P < 0.001) QOL components at the 18- to 24-month follow-up compared with baseline scores. Regression analysis showed that age younger than 60 and absence of serious adverse events were associated with improved social functioning and vitality. The literature review showed a mixed effect of intervention on QOL in patients with UIAs. Our analysis has revealed that patients with 3- to 14-mm UIAs had improvements in some physical and emotional components of QOL at 18-24 months following aneurysm coiling in the HEAT study. The literature remains indeterminate on this issue. Further studies are needed to better understand the effects of the diagnosis of UIAs and their treatment on QOL.