Publications by authors named "Christopher S Ogilvy"

294 Publications

CTA versus DSA as a Primary Diagnostic Tool in Non-Traumatic Subarachnoid Hemorrhages: Cost-Effectiveness Analysis Study.

World Neurosurg 2021 May 29. Epub 2021 May 29.

Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, United States.

Background: Digital subtraction angiography (DSA) and computed tomographic angiography (CTA) are used to identify the cause of non-traumatic subarachnoid hemorrhage (SAH). There is no consensus on which to choose as the first diagnostic tool. We aimed to compare cost-effectiveness of CTA versus DSA as a primary tool for the cause of non-traumatic SAH.

Material And Methods: A decision analysis model was built to simulate patients undergoing DSA or CTA as a primary diagnostic tool for the cause of non-traumatic SAH. The input data for the study was extracted from literature. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the Model.

Results: In the base case calculation, it costs $1261.82 less and yields 0.0001 QALYs when DSA is used as a primary diagnostic imaging tool for non-traumatic subarachnoid. Choosing DSA as a primary tool is cost-effective in more than 65% of iterations in probabilistic sensitivity analysis. Deterministic sensitivity analyses show when the probability of employing endovascular treatment is higher than 47.2% , choosing DSA is more cost-effective, otherwise, CTA is more optimal. CTA is more cost-effective when the cost for DSA > 2.6 * CTA + $600.

Conclusion: Based on current literature and our model DSA as a primary diagnostic tool for the cause of non-traumatic SAH is more cost-effective. However, in clinical practice physicians can choose either DSA or CTA according to the scale of endovascular procedures used in their center, as well as the cost correlation between CTA and DSA which is variable between institutions.
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http://dx.doi.org/10.1016/j.wneu.2021.05.103DOI Listing
May 2021

Direct vs Indirect Revascularization in a North American Cohort of Moyamoya Disease.

Neurosurgery 2021 May 6. Epub 2021 May 6.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: In adults with ischemic moyamoya disease (MMD), the efficacy of direct vs indirect revascularization procedures remains a matter of debate.

Objective: To investigate the outcomes of ischemic MMD in a North American cohort treated by direct and indirect revascularizations.

Methods: We retrospectively reviewed medical records of adult patients with MMD with ischemic presentation from 1984 to 2018 at the Brigham and Women's Hospital and Massachusetts General Hospital who underwent either direct or indirect bypasses. Early postoperative events and outcome at more than 6 mo postoperatively were evaluated using multivariable logistic regression analyses. Multivariable Cox proportional hazards regression analyses were used to evaluate delayed ischemic and hemorrhagic events. Analyses were performed per hemisphere.

Results: A total of 95 patients with MMD and 127 hemispheres were included in this study. A total of 3.5% and 8.6% of patients had early surgical complications in the direct and indirect bypass cohorts, respectively (P = .24). Hemispheres with direct bypasses had fewer long-term ischemic and hemorrhagic events at latest follow-up (adjusted hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.058-0.63, P = .007; median follow-up 4.5 [interquartile range, IQR 1-8] yr). There was no difference between the direct and indirect bypass groups when the endpoint was limited to infarction and hemorrhage only (P = .12). There was no difference in outcome (modified Rankin Scale [mRS] ≥ 3) between the 2 cohorts (P = .92).

Conclusion: There was no difference in early postoperative events, long-term infarction or hemorrhage, or clinical outcome between direct and indirect revascularization. However, there was a significant decrease in all ischemic and hemorrhagic events combined in direct revascularizations compared to indirect revascularizations.
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http://dx.doi.org/10.1093/neuros/nyab156DOI Listing
May 2021

Tortuosity Index Predicts Early Successful Reperfusion and Impacts Functional Status After Thrombectomy for Stroke.

World Neurosurg 2021 Apr 13. Epub 2021 Apr 13.

Neurosurgical Service, Beth Israel Deaconess Medical Center. Harvard Medical School, Boston, MA, United States. Electronic address:

Objectives: Literature is scarce in studies evaluating the anatomy of cervical vessels in stroke patients. We sought to investigate the effect of the vessels' tortuosity in procedural, angiographic and functional outcomes in patients with acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT).

Materials And Methods: Patients with an emergent large vessel occlusion of the anterior circulation treated with MT between 2015 and 2020 were included. The tortuosity of the internal carotid artery was recorded as the tortuosity index (T.I.) using the following formula: [(actual/straight length - 1) X 100]. A multivariable regression was performed to assess procedural, angiographic and functional outcomes based on the T.I.

Results: A total of 212 patients were included. Median age [IQR] was 72 [62-82]; Admission NIHSS score was 17 ± 6. Median T.I. was 7.9 [3.7 - 19.7]. 127 (60%) patients had a T.I. < 10. Early reperfusion (procedure time < 60 minutes) was accomplished in 144 (67.9%) patients. A multivariable analysis showed that patients with a T.I. < 10 were more likely to achieve an early reperfusion (O.R: 2.3, 95% CI 1.11 - 4.78; p = 0.025). A T.I. < 10 was a predictor of successful reperfusion (O.R 2.0; CI 1.05 - 3.93; p = 0.035) and an early reperfusion was the sole predictor of functional independence (most recent mRS 0-2) (O.R: 4.1, 95% CI 1.62 - 10.53; adjusted p = 0.003).

Conclusion: Patients with a T.I. < 10 are significantly more likely to achieve early successful reperfusion after MT for the treatment of AIS.
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http://dx.doi.org/10.1016/j.wneu.2021.02.123DOI Listing
April 2021

Is a picture-perfect thrombectomy necessary in acute ischemic stroke?

J Neurointerv Surg 2021 Feb 16. Epub 2021 Feb 16.

Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay.

Background: The benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3.

Methods: This is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0-2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage.

Results: The unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; p=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; p=0.041).

Conclusions: Complete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.
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http://dx.doi.org/10.1136/neurintsurg-2020-017193DOI Listing
February 2021

Commentary: Safety, Efficacy, and Durability of Stent Plus Balloon-Assisted Coiling for the Treatment of Wide-Necked Intracranial Bifurcation Aneurysms.

Neurosurgery 2021 04;88(5):E417-E419

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1093/neuros/nyab008DOI Listing
April 2021

Trends of Ruptured and Unruptured Aneurysms Treatment in the United States in Post-ISAT Era: A National Inpatient Sample Analysis.

J Am Heart Assoc 2021 Feb 9;10(4):e016998. Epub 2021 Feb 9.

Neurosurgery Service Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA.

Background The ISAT (International Subarachnoid Aneurysm Trial) has generated a paradigm shift towards endovascular treatment for intracranial aneurysms but remains unclear if this has led to a true reduction in the risk for aneurysmal subarachnoid hemorrhage (aSAH). We sought to study the association between the treatment burden of unruptured and ruptured aneurysms in the post-ISAT era. Methods and Results Admissions data from the National Inpatient Sample (2004-2014) were extracted, including patients with a primary diagnosis of aSAH or unruptured intracranial aneurysms treated by clipping or coiling. Within each year, this combined group was randomly matched to non-aneurysmal control group, based on age, sex, and Elixhauser comorbidity index. Multinomial regression was performed to calculate the relative risk ratio of undergoing treatment for either ruptured or unruptured aneurysms in comparison with the reference control group, adjusted for time. After adjusting for National Inpatient Sample sampling effects, 243 754 patients with aneurysm were identified, 174 580 (71.6%) were women; mean age, 55.4±13.2 years. A total of 121 882 (50.01%) patients were treated for unruptured aneurysms, 79 627 (65.3%) endovascularly and 42 256 (34.7%) surgically. A total of 121 872 (49.99%) patients underwent procedures for aSAH, 68 921 (56.6%) endovascular, and 52 951 (43.5%) surgically. Multinomial regression revealed a significant year-to-year decrease in aSAH procedures compared with the control group of non-aneurysmal hospitalizations (relative risk ratio, 0.963 per year; <0.001), while there was no statistical significance for unruptured aneurysms procedures (relative risk ratio, 1.012 per year; =0.35). Conclusions With each passing year, there is a significant decrease in relative risk ratio of undergoing treatment for aSAH, concomitant with a stable annual risk of undergoing treatment for unruptured intracranial aneurysms.
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http://dx.doi.org/10.1161/JAHA.120.016998DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955327PMC
February 2021

Direct Transverse Sinus Cannulation for Coil Embolization of a Transverse-Sigmoid Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 03;20(4):E288-E289

Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

A 65-yr-old male presented 2 mo after an episode of acute-onset headache associated with altered mental status. Imaging workup with cerebral angiography revealed a Cognard type IV right-sided transverse-sigmoid junction dural arteriovenous fistula (dAVF). The patient was treated with endovascular embolization of several pedicles from the middle meningeal (MMA) and occipital arteries. Residual filling and cortical venous reflux were noted on follow-up imaging. Therefore, definitive treatment of the persistent fistula was offered with a combined open and endovascular embolization approach.1 This would provide direct access into the sinus followed by embolization of the fistula. In the accompanying video, we present the case in detail and provide a discussion of the rational and treatment nuances associated with this approach.  Patient consent was given prior to the procedure and consent and approval for this operative video were waived due to the retrospective nature of this manuscript and the anonymized video material.
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http://dx.doi.org/10.1093/ons/opaa455DOI Listing
March 2021

Transvenous Coil Embolization of a Transverse-Sigmoid Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 03;20(4):E290-E291

Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

This case is a 66-yr-old woman with a 2-mo history of left-sided tinnitus. Workup with magnetic resonance angiography showed early opacification of the left sigmoid sinus and internal jugular vein as well as asymmetric and abundant opacification of the left external carotid artery branches, suspicious for a dural arteriovenous fistula (dAVF). Diagnosis was confirmed with cerebral angiography, consistent with a left-sided Cognard type I dAVF.1 Initial treatment attempt was made with transarterial 6% ethylene-vinyl alcohol copolymer (Onyx 18) embolization of feeders from the occipital and middle meningeal arteries. However, embolization was not curative and there was a recurrence of a highly bothersome tinnitus 3 wk following treatment. Angiography redemonstrated the transverse sinus dAVF with new recruitment arising from several feeders, including the left external carotid artery, middle meningeal artery, and superficial temporal artery, now Cognard type IIa. Definitive treatment through a transvenous coil embolization provided permanent obliteration of the fistula without recrudescence of symptoms on follow-up. In this video, the authors discuss the nuances of treating a dAVF via a transvenous embolization. Patient consent was given prior to the procedure, and consent and approval for this operative video were waived because of the retrospective nature of this manuscript and the anonymized video material.
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http://dx.doi.org/10.1093/ons/opaa454DOI Listing
March 2021

Anesthetic management of unruptured intracranial aneurysms: a qualitative systematic review.

Neurosurg Rev 2021 Jan 7. Epub 2021 Jan 7.

Department of Anesthesiology, Critical care and pain medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Intracranial aneurysms (IA) occur in 3-5% of the general population and may require surgical or endovascular obliteration if the patient is symptomatic or has an increased risk of rupture. These procedures carry an inherent risk of neurological complications, and the outcome can be influenced by the physiological and pharmacological effects of the administered anesthetics. Despite the critical role of anesthetic agents, however, there are no current studies to systematically assess the intraoperative anesthetic risks, benefits, and outcome effects in this population. In this systematic review of the literature, we carefully examine the existing evidence on the risks and benefits of common anesthetic agents during IA obliteration, their physiological and clinical characteristics, and effects on neurological outcome. The initial search strategy captured a total of 287 published studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 28 studies were included in the final report. Our data showed that both volatile and intravenous anesthetics are commonly employed, without evidence that either is superior. Although no specific anesthetic regimens are promoted, their unique neurological, cardiovascular, and physiological properties may be critical to the outcome in vulnerable patients. In particular, patients at risk for perioperative ischemia may benefit from timely administration of anesthetic agents with neuroprotective properties and optimization of their physiological parameters. Further studies are warranted to examine if these anesthetic regimens can reduce the risk of neurological injury and improve the overall outcome in these patients.
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http://dx.doi.org/10.1007/s10143-020-01441-wDOI Listing
January 2021

Role of Surgical Intervention for Intracranial Dural Arteriovenous Fistulas With Cortical Venous Drainage in an Endovascular Era: A Case Series.

Oper Neurosurg (Hagerstown) 2021 03;20(4):364-372

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Background: Intracranial dural arteriovenous fistulae (dAVFs) with cortical venous drainage (CVD) require treatment because of their aggressive clinical presentation and natural history. Although endovascular treatment is effective for the majority of these lesions in the current endovascular era, surgical management has been required if the lesions are not amenable to or fail endovascular treatments.

Objective: To demonstrate the angioarchitecture that may necessitate surgical intervention.

Methods: A retrospective review of the patients with intracranial dAVFs with CVD treated at 2 academic institutions between January 1, 2009, and July 31, 2019 was performed. Patients who required surgical intervention were selected in this study, and angiographic findings were analyzed.

Results: A total of 81 dAVFs in 80 patients were treated during the study period. Endovascular treatments were attempted for 72 (88.9%) dAVFs, resulting in complete obliteration in 55 (76.4%). Surgical interventions were performed in 18 (22.2%) dAVFs, resulting in complete obliteration in all lesions. Overall, complete obliteration was achieved in 74 (93.7%) of 79 dAVFs with follow-up. In the surgically treated dAVFs, curative transarterial embolization was deterred by the angioarchitecture, which included dominant feeding vessels from the ophthalmic artery, meningohypophyseal trunk, posterior meningeal artery, pial artery, or ascending pharyngeal artery. Drainage through tortuous cortical vein, deep venous system, or isolated sinus made transvenous approach challenging.

Conclusion: Despite continued improvement in endovascular technology, surgical approaches to dAVFs are still of great value as initial and salvage treatment of dAVFs with angioarchitecture hampering endovascular treatment.
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http://dx.doi.org/10.1093/ons/opaa423DOI Listing
March 2021

Upfront middle meningeal artery embolization for treatment of chronic subdural hematomas in patients with or without midline shift.

Interv Neuroradiol 2020 Dec 29:1591019920982816. Epub 2020 Dec 29.

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Objectives: There is limited data on upfront middle meningeal artery (MMA) embolization in the context of significant midline shift (MLS) (greater than 5mm) for the treatment of chronic subdural hematomas (cSDH). This study reports the temporal changes following MMA embolization as an upfront treatment of cSDH in patients with or without MLS and either mild, no symptoms or mild and stable neurological deficits.

Methods: A retrospective series of patients with a cSDH from a single institution in the United States between 2018-2020 was conducted. Eligible patients were treated with upfront MMA embolization.

Results: 27 upfront MMA embolization procedures in 23 patients were included. Twelve patients had MLS of 5 millimeters or more (52%). The median maximal thickness at diagnosis was 18 mm [11-22]. The mean distance of MLS was 5 mm ±4. There were no procedural complications. The overall rescue surgery rate was 15%. A single rescue surgery secondary to an increase in hematoma thickness was required (4%). The temporal changes for both hematoma and MLS showed gradual improvement between 2 weeks and 4 weeks post-procedure. The average time-to-resolution of MLS was 46 days in patients with less than 5 mm MLS and 51 days in those with 5 mm or more.

Conclusion: Upfront MMA embolization for cSDH with a thickness up to 25 mm provides adequate symptom relief, stabilization and/or progressive resorption of the cSDH during follow-up in carefully selected asymptomatic or mildly symptomatic patients even in the presence of a MLS greater than 5 mm.
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http://dx.doi.org/10.1177/1591019920982816DOI Listing
December 2020

Transarterial Embolization of a Transverse Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 12;20(1):E41-E42

A 40-yr-old male with no significant past medical history presented with sudden onset right-sided retro-orbital headache associated with vision loss after a session of strenuous exercise. Initial assessment with noncontrast head computed tomography at the local emergency department revealed a right sided occipital intracranial hemorrhage (ICH). On arrival the patient ad a left quadrantopsia with Glasgow Coma Scale of 15 and an ICH score of 0. A computed tomographic angiography showed a high density 6 × 9 mm vascular lesion associated with 2 tortuous vessels. Cerebral angiography revealed a right sided dural arteriovenous fistula, Cognard Type IV, with arterial feeders arising from dural branches of the right vertebral artery, the posterior division of the right middle meningeal artery and meningeal branches distal to the neuromeningeal trunk of the left ascending pharyngeal artery.1 Four days after the ICH event the patient was treated with endovascular Onyx embolization of the fistula, through a transradial approach. Immediate angiographic assessment showed complete obliteration of the dAVF. The patient was discharged home and recovered his visual field deficit over 3 mo. The following operative video includes a discussion of the endovascular technique and treatment nuances associated with the transarterial management of a dural arteriovenous fistula. Patient consent was given prior to the procedure and consent and approval for this operative video was waived due to the retrospective nature of this manuscript and the anonymized video material.
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http://dx.doi.org/10.1093/ons/opaa370DOI Listing
December 2020

Current Management of Small Unruptured Intracranial Aneurysms in the United States: Results of a National Survey.

World Neurosurg 2021 Feb 2;146:e631-e638. Epub 2020 Nov 2.

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

Objective: To understand how physicians in the United States manage patients with small unruptured intracranial aneurysms and factors that influence the management.

Methods: An online survey questionnaire was designed through SurveyMonkey and distributed electronically to The Society of Interventional Surgery, American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section of Cerebrovascular Surgery, American Academy of Neurology, and Massachusetts Neurologic Association. All participations were voluntary and anonymous.

Results: Among all the participants, 53.8% of them were neurosurgeons, 33.0% were neurointerventional radiologists, and 13.2% were neurologists. For management of aneurysms 2-4 mm, 87.8% of respondents favored routine surveillance with imaging follow-up, 3.8% preferred routine treatment, and 8.5% recommended routine treatment or follow-up only for high risk patients. In total, 25.5% preferred annual follow-up, and 67.9% liked follow-up once in a year and then space out at various intervals. For aneurysms between 5 and 7 mm, 73.6% supported routine treatment, 20.8% favored surveillance with imaging follow-up, and 5.7% recommended treating or follow-up only high-risk groups. In total, 58.5% preferred annual follow-up, whereas 34.9% liked follow-up once in a year and then space out at various intervals. For routine follow-up, 64.1% of the physicians chose magnetic resonance angiography without contrast, and 40.6% preferred computed tomography angiography.

Conclusions: For aneurysms 2-4 mm, majority of the physicians preferred regular follow-up, whereas for aneurysms 5-7 mm, the majority favor treatment. There remains heterogeneity in practice among physicians in the United States regarding follow-up strategies for small unruptured aneurysms. Further studies are needed to evaluate the optimal management strategy, follow-up frequency and duration of imaging for small unruptured intracranial aneurysms.
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http://dx.doi.org/10.1016/j.wneu.2020.10.149DOI Listing
February 2021

A Novel Parameter to Predict Supraclinoid Aneurysm Persistence After Flow Diversion with the Pipeline Embolization Device.

World Neurosurg 2021 01 13;145:e216-e223. Epub 2020 Oct 13.

Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; Department of Radiology, University of Calgary, Calgary, Alberta, Canada; Department of Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada. Electronic address:

Background: Aneurysm recurrence after Pipeline Embolization Device (PED) placement can be caused by oversizing of the stent as well as poor wall apposition, both of which can lead to elongation. The objective of this study was to assess whether a novel parameter for measuring device elongation based on two-dimensional imaging could be predictive for persistent aneurysm filling after treatment with the PED.

Methods: A retrospective cohort analysis was initially completed on 41 aneurysms from institution A, examining demographic, aneurysmal, and device measurements. Device measurements, including the ratio of the measured length to the nominal length (ML/NL) of the PED, were taken by reviewers blinded to the primary end point, which was aneurysm occlusion status on 6 month catheter angiogram. Findings were then externally validated against 30 aneurysms (supraclinoid only) from institution B.

Results: Data from institution A showed 61% complete aneurysm occlusion at 6 months, and were lower for aneurysms in the supraclinoid region. For supraclinoid aneurysms alone, combined data from both institutions showed higher rates of nonocclusion with aneurysm neck size >4 mm (P = 0.008) and a trend toward significance in aneurysms with a branch vessel (P = 0.051). The mean ML/NL ratio was significantly larger in the nonoccluded group compared with the occluded group at both institution A (ratio, 1.37 versus 1.10; P < 0.001) and institution B (ratio, 1.36 vs. 1.11; P = 0.002).

Conclusions: Our data suggest that a novel parameter based on two-dimensional angiography may serve as a rapid technique to measure device elongation and predict occlusion of supraclinoid aneurysms after PED placement.
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http://dx.doi.org/10.1016/j.wneu.2020.10.013DOI Listing
January 2021

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations.

Neurosurgery 2021 01;88(2):268-277

Department of Neurological Surgery, University of Washington, Seattle, Washington.

Background: Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH).

Objective: To determine the safety and efficacy of MMA embolization.

Methods: Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes.

Results: A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities.

Conclusion: MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.
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http://dx.doi.org/10.1093/neuros/nyaa379DOI Listing
January 2021

Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases.

Neurosurg Focus 2020 10;49(4):E5

1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah.

Objective: The incidence of already common chronic subdural hematomas (CSDHs) and other nonacute subdural hematomas (NASHs) in the elderly is expected to rise as the population ages over the coming decades. Surgical management is associated with recurrence and exposes elderly patients to perioperative and operative risks. Middle meningeal artery (MMA) embolization offers the potential for a minimally invasive, less morbid treatment in this age group. The clinical and radiographic outcomes after MMA embolization treatment for NASHs have not been adequately described in elderly patients. In this paper, the authors describe the clinical and radiographic outcomes after 151 cases of MMA embolization for NASHs among 121 elderly patients.

Methods: In a retrospective review of a prospectively maintained database across 15 US academic centers, the authors identified patients aged ≥ 65 years who underwent MMA embolization for the treatment of NASHs between November 2017 and February 2020. Patient demographics, comorbidities, clinical and radiographic factors, treatment factors, and clinical outcomes were abstracted. Subgroup analysis was performed comparing elderly (age 65-79 years) and advanced elderly (age > 80 years) patients.

Results: MMA embolization was successfully performed in 98% of NASHs (in 148 of 151 cases) in 121 patients. Seventy elderly patients underwent 87 embolization procedures, and 51 advanced elderly patients underwent 64 embolization procedures. Elderly and advanced elderly patients had similar rates of embolization for upfront (46% vs 61%), recurrent (39% vs 33%), and prophylactic (i.e., with concomitant surgical intervention; 15% vs 6%) NASH treatment. Transfemoral access was used in most patients, and the procedure time was approximately 1 hour in both groups. Particle embolization with supplemental coils was most common, used in 51% (44/87) and 44% (28/64) of attempts for the elderly and advanced elderly groups, respectively. NASH thickness decreased significantly from initial thickness to 6 weeks, with additional decrease in thickness observed in both groups at 90 days. At longest follow-up, the treated NASHs had stabilized or improved in 91% and 98% of the elderly and advanced elderly groups, respectively, with > 50% improvement seen in > 60% of patients for each group. Surgical rescue was necessary in 4.6% and 7.8% of cases, and the overall mortality was 8.6% and 3.9% for elderly and advanced elderly patients, respectively.

Conclusions: MMA embolization can be used safely and effectively as an alternative or adjunctive minimally invasive treatment for NASHs in elderly and advanced elderly patients.
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http://dx.doi.org/10.3171/2020.7.FOCUS20518DOI Listing
October 2020

Cigarette smoking and risk of intracranial aneurysms in middle-aged women.

J Neurol Neurosurg Psychiatry 2020 09 28;91(9):985-990. Epub 2020 Jul 28.

Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

Background And Purpose: We previously reported a single-centre study demonstrating that smoking confers a six-fold increased risk for having an unruptured intracranial aneurysm (UIA) in women aged between 30 and 60 years and this risk was higher if the patient had chronic hypertension. There are no data with greater generalisability evaluating this association. We aimed to validate our previous findings in women from a multicentre study.

Methods: A multicentre case-control study on women aged between 30 and 60 years, that had magnetic resonance angiography (MRA) during the period 2016-2018. Cases were those with an incidental UIA, and these were matched to controls based on age and ethnicity. A multivariable conditional logistic regression was conducted to evaluate smoking status and hypertension differences between cases and controls.

Results: From 545 eligible patients, 113 aneurysm patients were matched to 113 controls. The most common reason for imaging was due to chronic headaches in 62.5% of cases and 44.3% of controls. A positive smoking history was encountered in 57.5% of cases and in 37.2% of controls. A multivariable analysis demonstrated a significant association between positive smoking history (OR 3.7, 95%CI 1.61 to 8.50), hypertension (OR 3.16, 95% CI 1.17 to 8.52) and both factors combined with a diagnosis of an incidental UIA (OR 6.9, 95% CI 2.49 to 19.24).

Conclusions: Women aged between 30 and 60 years with a positive smoking history have a four-fold increased risk for having an UIA, and a seven-fold increased risk if they have underlying chronic hypertension. These findings indicate that women aged between 30 and 60 years with a positive smoking history might benefit from a screening recommendation.
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http://dx.doi.org/10.1136/jnnp-2020-323753DOI Listing
September 2020

Corrigendum to 'Evaluation of Radiological Features of the Posterior Communicating Artery and Their Impact on Efficacy of Saccular Aneurysm Treatment with the Pipeline Embolization Device: A Case Series Study' [World Neurosurgery 125 (2019) e998-e1007].

World Neurosurg 2020 Sep 4;141:584. Epub 2020 Jul 4.

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2020.06.158DOI Listing
September 2020

Endovascular Embolization of a Paracavernous Arteriovenous Fistula Through a Cortical Venous Access: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 Jul 10. Epub 2020 Jul 10.

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

We present the case of a 62-yr-old female with a right bulging eye and intermittent headaches. A T2 weighted magnetic resonance image revealed a dilated serpiginous vessel in the right orbit and abnormal flow voids lateral to the orbital apex. The right internal carotid contrast injection demonstrated a dural arteriovenous fistula (dAVF) fed by the ophthalmic artery and drainage into the ipsilateral superficial middle cerebral veins (SMCVs) and the basal vein of Rosenthal without opacification of the cavernous sinus. A fistulous pouch was identified anterolateral to the carotid siphon. The venous phase of the left internal carotid injection demonstrated the bilateral cavernous sinuses, suggesting no involvement of the cavernous sinus with the fistula. Concerning the risk of future hemorrhagic events, endovascular treatment was recommended. Considering the robust connection of the cortical draining vein with the superior sagittal sinus (SSS), a transvenous embolization was performed. The lesion was accessed through the SSS and the right SMCV and embolized with platinum coils, resulting in complete fistula obliteration without any complications. The SMCVs can drain into paracavernous venous structure, which independently presents lateral to cavernous sinus.1,2 Because incomplete embolization of this fistula through cavernous sinus can alter the shunt flow toward cerebral veins, we did not get into the fistula site through the cavernous sinus using conventional methods. Transvenous access through a cortical bridging vein is an efficient alternative for endovascular embolization of paracavernous dAVFs. Patient approval and consent was obtained prior to the procedure and for submission of this article.
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http://dx.doi.org/10.1093/ons/opaa210DOI Listing
July 2020

Comparison of PED and FRED flow diverters for posterior circulation aneurysms: a propensity score matched cohort study.

J Neurointerv Surg 2021 Feb 1;13(2):153-158. Epub 2020 Jul 1.

Department of Neuroradiology, Friedrich Alexander University Erlangen Nuremberg Faculty of Medicine, Erlangen, Bayern, Germany.

Background: Flow diversion is a common endovascular treatment for cerebral aneurysms, but studies comparing different types of flow diverters are scarce.

Objective: To perform a propensity score matched cohort study comparing the Pipeline Embolization Device (PED) and Flow Redirection Intraluminal Device (FRED) for posterior circulation aneurysms.

Methods: Consecutive aneurysms of the posterior circulation treated at 25 neurovascular centers with either PED or FRED were collected. Propensity score matching was used to control for age, duration of follow-up imaging, adjunctive coiling, and aneurysm location, size, and morphology; previously ruptured aneurysms were excluded. The two devices were compared for the following outcomes: procedural complications, aneurysm occlusion, and functional outcome.

Results: A total of 375 aneurysms of the posterior circulation were treated in 369 patients. The PED was used in 285 (77.2%) and FRED in 84 (22.8%) procedures. Aneurysms treated with the PED were more commonly fusiform and larger than those treated with FRED. To account for these important differences, propensity score matching was performed resulting in 33 PED and FRED unruptured aneurysm pairs. No differences were found in occlusion status and neurologic thromboembolic or hemorrhagic complications between the two devices. The proportion of patients with favorable functional outcome was higher with FRED (100% vs 87.9%, p=0.04).

Conclusion: Comparative analysis of PED and FRED for the treatment of unruptured posterior circulation aneurysms did not identify significant differences in aneurysm occlusion or neurologic complications. Variations in functional outcomes warrant additional investigations.
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http://dx.doi.org/10.1136/neurintsurg-2020-016055DOI Listing
February 2021

Women With First-Hand Tobacco Smoke Exposure Have a Higher Likelihood of Having an Unruptured Intracranial Aneurysm Than Nonsmokers: A Nested Case-Control Study.

Neurosurgery 2020 Jun 10. Epub 2020 Jun 10.

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Background: The prevalence of unruptured intracranial aneurysms (UIA) in females who smoke cigarettes and the association between smoking and hypertension with purely incidental UIAs have been unexplored.

Objective: To obtain the prevalence of UIA among females and to assess the relationship between smoking and hypertension with a diagnosis of incidental UIAs.

Methods: A nested case-control study from a cohort of female patients aged between 30 and 60 yr with a brain magnetic resonance angiography (MRA) between 2016 and 2018. Incidental UIAs were compared to patients with normal MRAs. Smoking was characterized as never or former/current smokers. A logistic regression was used to evaluate the association between smoking, hypertension, or both, with a diagnosis of incidental UIAs.

Results: A total of 1977 patients had a brain MRA between 2016 and 2018. From 1572 nonsmoker patients, we encountered 30 with an UIA (prevalence: 1.9%). There were 405 patients with a positive smoking history, and 77 patients harbored an UIA (prevalence: 19%). Of 64 aneurysm patients and 130 random controls eligible for the case control, aneurysm patients were more likely to have a positive smoking history and hypertension compared with healthy controls (60% vs 18%, P ≤ .001; 44% vs 14%, P ≤ .001). A multivariable analysis demonstrated a significant association between a smoking history, hypertension, or both factors with an incidental UIA (odds ratio [OR] 5.8 CI 1.22-11.70; OR 3.8 CI 2.31-14.78; OR 12.6 CI 4.38-36.26; respectively).

Conclusion: Females who smoke cigarettes have a higher prevalence of UIAs than the general population. Smoking confers a higher risk for having a silent UIA, aggravated by hypertension. This population is an ideal target for potential screening.
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http://dx.doi.org/10.1093/neuros/nyaa227DOI Listing
June 2020

The Reproducibility of Cerebrovascular Randomized Controlled Trials.

World Neurosurg 2020 08 8;140:e46-e52. Epub 2020 May 8.

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

Background: Numerous randomized controlled trials (RCTs) relevant to the cerebrovascular field have been performed. The fragility index was recently developed to complement the P value and measure the robustness and reproducibility of clinical findings of RCTs.

Objective: In this study, we evaluate the fragility index for key surgical and endovascular cerebrovascular RCTs and propose a novel RCT classification system based on the fragility index.

Methods: Cerebrovascular RCTs reported between 2000 and 2018 were reviewed. Six key areas were specifically targeted in relation to stroke, carotid stenosis, cerebral aneurysms, and subarachnoid hemorrhage. The correlation between fragility index, number of patients lost to follow-up, and fragility quotient were evaluated to propose a classification system for the robustness of the studies.

Results: A total of 20 RCTs that reported significant differences between both study groups in terms of the primary outcome were included. The median fragility index for the trials was 5.5. An additional 30 randomly selected RCTs were added to propose a classification system with high reliability. The difference between the number of patients lost to follow-up and fragility index inversely correlated with the fragility quotient and was used to divide the robustness of the RCTs into 3 classes reflecting the reproducibility of the trial.

Conclusions: Neurosurgeons and neurointerventionalists should exercise caution with interpreting the results of cerebrovascular RCTs, especially when the sample size and events numbers are small and there is a high number of patients who were lost to follow-up, as quantitatively identified using the proposed classification system.
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http://dx.doi.org/10.1016/j.wneu.2020.04.106DOI Listing
August 2020

Transition to Radial Approach for Neurovascular Procedures is Safe and Convenient: Characterization of a Learning Experience.

Oper Neurosurg (Hagerstown) 2020 10;19(5):489-494

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Background: The transradial access for endovascular procedures has become a popular access point of preference for both patients and for many neuro-endovascular practitioners.

Objective: To describe a single-center experience on the transition to a radial-first approach for neurovascular procedures, focused on diagnostic angiographies, and to compare the differences in terms of length of procedure within the first 5 mo of its execution.

Methods: We performed a retrospective review of a prospective maintained cerebrovascular registry at an academic institution within the United States, to identify the expected adoption curve required to transition to a transradial route first approach focused mainly on diagnostic procedures. The 5 mo of experience were divided into 4 quartiles evenly distributed in time. The primary outcome was the total length of procedure. Secondary outcomes were access failure, radiation dose, the usefulness of ultrasound assistance and complications.

Results: A total of 121 transradial procedures were performed: 113 diagnostic angiographies (93%) and 8 therapeutic interventions (7%). We identified 6 access failures (5%) and 1 complication (1%). The mean length for diagnostic angiographies was 24 ± 10 min, and for therapeutic procedures was 58 ± 19 min. A multivariate regression analysis demonstrated a significant decrease in the total length of procedures after the first quartile.

Conclusion: The transradial route shows to be a safe and convenient approach. The total length of procedure starts decreasing as providers gain experience and become more confident with this route, as seen in our 5-mo experience.
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http://dx.doi.org/10.1093/ons/opaa133DOI Listing
October 2020

Flow Diversion Endovascular Treatment Improves Headaches in Patients with Unruptured Intracranial Aneurysms.

World Neurosurg 2020 08 7;140:e140-e147. Epub 2020 May 7.

Neurosurgery Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: Headache is the presenting symptom of unruptured intracranial aneurysm (UIA) in more than one-third of cases. Some patients may expect their headache to remit after aneurysm treatment. This study aims to identify factors influencing headache outcomes following endovascular treatment of UIA.

Methods: This prospective observational study was conducted in patients with UIAs treated with flow diversion. Subjects reported their headache intensity with a visual analog scale (VAS) and completed 3 surveys before treatment: Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT-6), and Patient Health Questionnaire-2 (PHQ-2). Follow-up was at 1 month, 3 months, and 6 months after treatment. Analysis was performed using generalized mixed-effects models.

Results: We identified 38 patients, 29 of whom reported headaches at baseline (76.3%). Mean patient age was 55.3 ± 12.4 years, and 79% of the cohort was female. Mean aneurysm diameter was 6.8 ± 5.3 mm, and treatment modality was Pipeline embolization in all cases. At the last follow-up, 5 aneurysms (15.1%) were incompletely occluded. The mean VAS scores for patients with headache at baseline were 4.36 ± 0.59 at baseline, 4.08 ± 0.60 at 1 month, 3.04 ± 0.62 at 3 months, and 2.76 ± 0.57 at 6 months. Controlling for occlusion status, medication, and depression, significant improvement was seen at the 3- and 6-month follow-ups. Similar patterns were observed with MIDAS and HIT-6.

Conclusions: In the present study, endovascular UIA treatment led to significantly decreased headache intensity in patients with headache at baseline, after a short delay. Our data shed light on postintervention headache patterns and can help inform patient discussions and treatment expectations.
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http://dx.doi.org/10.1016/j.wneu.2020.04.206DOI Listing
August 2020

Role of aspirin and statin therapy in patients with cerebral cavernous malformations.

J Clin Neurosci 2020 Aug 24;78:246-251. Epub 2020 Apr 24.

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States. Electronic address:

Stagnant blood flow and organizing thrombus are intralesional components of patients with cerebral cavernous malformations (CCM). Stasis and inflammation are mechanisms of growth, lesional instability and acute hemorrhages with or w/o symptoms. We evaluate the association of pre-diagnostic aspirin and/or statin use with acute hemorrhages at diagnosis. Patients with a CCM diagnosis were identified and categorized according to their medications on admission into four groups (no therapy, statin, aspirin, combined). The primary outcome was an acute hemorrhage (with or w/o symptoms) at diagnosis reported in a standardized manner from the T2 weighted magnetic resonance image. A multivariate generalized linear mixed models (GLMM) was utilized to conduct per-lesion analysis. We identified 446 patients with 635 lesions. An acute hemorrhage at diagnosis was observed in 31% of the patients. There were 328 patients without statin or aspirin therapy, 34% of whom presented with acute hemorrhage. Of patients on aspirin therapy at diagnosis, 25% presented with hemorrhage. Of patients on statin therapy, 26% had a hemorrhage at diagnosis. Combined therapy in 44 patients demonstrated a lower proportion of patients with acute hemorrhages (7 patients, 16% incidence). A GLMM showed that patients in the combined therapy group to have significantly lower odds of having an acute hemorrhage at diagnosis compared to the reference group of no therapy (OR 0.24; 95% CI 0.09-0.59; P = 0.002). Patients with a CCM receiving therapy with both aspirin and statins were less likely to present at diagnosis with acute hemorrhage.
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http://dx.doi.org/10.1016/j.jocn.2020.04.012DOI Listing
August 2020

Vertebral artery aneurysms and the risk of cord infarction following spinal artery coverage during flow diversion.

J Neurosurg 2020 Mar 27:1-10. Epub 2020 Mar 27.

10Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania; and.

Objective: Coverage of the anterior spinal artery (ASA) ostia is a source of considerable consternation regarding flow diversion (FD) in vertebral artery (VA) aneurysms due to cord supply. The authors sought to assess the association between coverage of the ASA, posterior spinal artery (PSA), or lateral spinal artery (LSA) ostia when placing flow diverters in distal VAs and clinical outcomes, with emphasis on cord infarction.

Methods: A multicenter retrospective study of 7 institutions in which VA aneurysms were treated with FD between 2011 and 2019 was performed. The authors evaluated the risk of ASA and PSA/LSA occlusion, associated thromboembolic complication, complications overall, aneurysm occlusion status, and functional outcome.

Results: Sixty patients with 63 VA and posterior inferior cerebellar artery aneurysms treated with FD were identified. The median aneurysm diameter was 7 mm and fusiform type was the commonest morphology (42.9%). During a procedure, 1 (61.7%) or 2 (33.3%) flow diverters were placed. Complete occlusion was achieved in 71.9%. Symptomatic thromboembolic complications occurred in 7.4% of cases and intracranial hemorrhage in 10.0% of cases. The ASA and PSA/LSA were identified in 51 (80.9%) and 35 (55.6%) complications and covered by the flow diverter in 29 (56.9%) and 13 (37.1%) of the procedures, respectively. Patency after flow diverter coverage on last follow-up was 89.2% for ASA and 100% for PSA/LSA, not significantly different between covered and noncovered groups (p = 0.5 and p > 0.99, respectively). No complications arose from coverage.

Conclusions: FD aneurysm treatment in the posterior circulation with coverage of ASA or PSA/LSA was not associated with higher rates of occlusion of these branches or any instances of cord infarction.
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http://dx.doi.org/10.3171/2020.1.JNS193293DOI Listing
March 2020

Pipeline Embolization Device Versus Stent-Assisted Coiling for Intracranial Aneurysm Treatment: A Retrospective Propensity Score-Matched Study.

Neurosurgery 2020 09;87(3):516-522

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Background: Pipeline embolization device (PED; Medtronic) and stent-assisted coiling (SAC) are established modalities for treatment of intracranial aneurysms.

Objective: To comparatively assess the efficacy of these techniques.

Methods: We conducted a retrospective analysis of patients with aneurysms treated at our institution with either PED from 2013 to 2017 or SAC from 2009 to 2015. All large (>10 mm), ruptured, fusiform, anterior communicating artery, posterior circulation aneurysms, and patients with no available follow-up imaging were eliminated before running the propensity score matching (PSM). Patients were matched using nearest neighbor controlling for: age, gender, smoking, exact location, maximal diameter, and presence of multiple aneurysms. Total hospital costs for equipment and implants were calculated from procedure product and hospital billing records, and compared between the propensity-matched pairs.

Results: Out of 165 patients harboring 202 aneurysms; 170 (84.2%) were treated with the PED, and 32 (15.8%) were treated using SAC. PSM resulted in 23 matched pairs; with significantly longer follow up in the SAC group (mean 29.8 vs 14.1 mo; P = .0002). Complete occlusion rates were not different (82.6 vs 87%; P = .68), with no difference between the groups for modified Rankin Scale on last clinical follow-up, procedural complications or retreatment rates. Average total costs calculated from the hospital records, including equipment and implants, were not different between propensity-score matched pairs (P = .48).

Conclusion: PED placement and SAC offer equally efficacious occlusion rates, functional outcomes, procedural complication rates, and cost profiles for small unruptured anterior circulation saccular aneurysms which do not involve the anterior communicating artery.
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http://dx.doi.org/10.1093/neuros/nyaa041DOI Listing
September 2020

Effect of Blood Pressure Variability During the Acute Period of Subarachnoid Hemorrhage on Functional Outcomes.

Neurosurgery 2020 09;87(4):779-787

Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Background: The association of blood pressure variation with poor outcomes in aneurysmal subarachnoid hemorrhage (aSAH) is unknown.

Objective: To evaluate the association of systolic blood pressure (SBP) variation and clinical outcomes in aSAH.

Methods: We conducted a retrospective chart review of all aSAH patients treated at an academic institution between 2007 and 2016. Patient demographics, aSAH characteristics, and blood pressure observations for the first 24 h of admission in 4-h intervals were obtained. SBP variability metrics assessed were mean, standard deviation, maximum, minimum, peak, trough, coefficient of variation, and successive variation. The primary outcome was a composite of the modified Rankin scale as good (0-2) or poor (3-6) at last follow-up. Comparisons between outcome groups were performed. Logistic regression models for each significant SBP metric controlling for potential confounders were constructed.

Results: The study population was 202 patients. The mean age was 57 yr; 66% were female. The median follow-up time was 18 mo; 57 (29%) patients had a poor outcome. Patients with poor outcomes had higher standard deviation (17.1 vs 14.7 mmHg, P = .01), peak (23.5 vs 20.0 mmHg, P = .02), trough (22.6 vs 19.2 mmHg, P < .01), coefficient of variation (13.9 vs 11.8 mmHg, P < .01), and lower minimum SBP (101.4 vs 108.4, P < .01). The logistic regression showed that every 1-mmHg increase in the minimum SBP increased the odds of good outcomes (odds ratio = 1.03; 95% CI = 1.001-1.064; P = .04). Models including other SBP metrics were not significant.

Conclusion: Hypotension was found to be independently associated with poor outcomes in patients with aSAH.
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http://dx.doi.org/10.1093/neuros/nyaa019DOI Listing
September 2020