BACKGROUND: Hemorrhagic risk in dural arteriovenous fistulas (dAVFs) is largely determined by venous anatomy, but the contribution of systemic cardiovascular factors and their medical therapy remains poorly defined. This study examined associations between cardiovascular risk factors and antithrombotic use and hemorrhagic presentation, angiographic obliteration, and early functional outcomes after treatment. METHODS: We analyzed 1350 adults with intracranial dAVFs from the international Consortium for Dural Arteriovenous Fistula Outcomes Research registry, which retrospectively accrued cases across 14 centers in 4 countries between 1990 and 2017. Demographics, cardiovascular comorbidities, antithrombotic use, angioarchitectural features, treatment strategies, and follow-up outcomes were collected from prospectively maintained databases. Primary end points were hemorrhagic presentation, angiographic obliteration, and 90-day functional status after treatment. Univariable and multivariable logistic regressions were performed with model-specific adjustments. RESULTS: Hemorrhage occurred in 375 patients (27.8%) and was most strongly associated with high-grade dAVF classification and male sex; antithrombotic therapy was associated with lower odds of hemorrhagic presentation. Other cardiovascular risk factors showed no independent relationship with bleeding. Angiographic obliteration was achieved in 621 of 845 patients (73.5%). Hemorrhagic onset, high dAVF grade, and surgical treatment were independently associated with angiographic obliteration, whereas smoking and embolization demonstrated only nonsignificant trends after adjustment. At 90 days, 934 patients (88.9%) were functionally independent. Baseline modified Rankin Scale score was the strongest factor associated with 90-day functional outcome, while neither cardiovascular comorbidities nor treatment modality independently influenced functional status. CONCLUSIONS: In this large multicenter dAVF cohort, hemorrhagic presentation was most strongly associated with venous angioarchitecture. Male sex and antithrombotic therapy were also independently associated with hemorrhagic presentation. Angiographic obliteration was common, particularly among surgically treated lesions, and 90-day functional outcome was most strongly associated with baseline functional status.

BACKGROUND:Recent trials have furthered uncertainty regarding the endovascular benefit for medium vessel occlusions (MeVO). Stent retrievers (SR) were employed in the first attempt in most interventional arm participants. We sought to compare outcomes in acute MCA M2 occlusions between frontline aspiration and SR, and to delineate procedural and anatomical covariates associated with differential treatment effect. METHODS:Retrospective analysis of a multicenter stroke thrombectomy cohort identified cases of MT for M2 occlusions. Unmatched and propensity score-matched (PSM) cohorts were generated comparing frontline aspiration to standalone and combined SR. The primary outcome was functional independence (mRS 0-2) at 90 days. Recanalization, symptomatic intracranial hemorrhage (sICH), mortality, and the effect of M2 laterality, division occlusion and procedure time were assessed. RESULTS:About 1734 patients with M2 occlusions underwent either frontline aspiration (n = 711) or SR/combined (n = 958) thrombectomy between 2013 and 2024. PSM analysis favored aspiration for functional independence (49.9% vs 44.0%, OR 1.27 (1.03-1.57)), complete recanalization (61.2% vs 48.7%, OR 1.66 (1.34-2.05)), complete first pass effect (35.0% vs 27.6%, OR 1.42 (1.13-1.78)), and sICH (3.5% vs 6.2%, OR 0.55 (0.33-0.91)), with no difference in mortality. Frontline aspiration had significantly shorter procedural times (median 28 [IQR 15-49.5] vs 51 [IQR 35-78] minutes; p < 0.001). For every minute increase in procedure time, the probability of functional independence decreased significantly (p < 0.001) less with frontline aspiration (0.35%) compared to SR/combined (1.61%). CONCLUSION:Frontline aspiration for M2 occlusions resulted in better clinical and angiographic outcomes compared to SRs. Future trials for MeVO with a focus on contact aspiration thrombectomy may succeed where recent trials have failed.

OBJECTIVE:To investigate the association between use of aspirin or statins and aneurysm wall enhancement (AWE) on 3T magnetic resonance vessel wall imaging (MR-VWI) in patients with unruptured intracranial aneurysms (UIAs). METHODS:For this cross-sectional study, we obtained individual patient data from three prospective UIA follow-up registries in which patients underwent 3.0T MR-VWI. Regular medication use was defined as aspirin ≥100 mg at least three times per week for ≥6 months, and statins at ≥20 mg daily for ≥6 months. AWE was classified as no AWE (no visible enhancement), focal AWE (enhancement limited to part of the aneurysm wall), or circumferential AWE (enhancement involving the entire wall). Multivariable ordinal logistic regression was used to assess the association between medication use and AWE in the full cohort. To isolate the effect of each drug, we conducted two separate propensity score matching analyses (PSM): statin users were excluded from the aspirin analysis, and aspirin users from the statin analysis. Logistic regression analyses were repeated within each matched group. RESULTS:We included 1351 patients with 1416 UIAs, of whom 141 (10.4%) used aspirin and 145 (10.7%) used statin. In the full cohort, multivariable ordinal logistic regression showed that aspirin use was associated with a lower likelihood of AWE (OR=0.51; 95%CI, 0.35-0.74), whereas statin use was not significantly associated with AWE (OR=1.44; 95% CI, 0.98-2.12). PSM based on age, sex, hypertension, diabetes, dyslipidemia, and aneurysm size yielded 83 matched pairs in the aspirin cohort and 97 in the statin cohort. In the matched cohorts, aspirin use remained inversely associated with AWE (OR=0.47; 95% CI, 0.26-0.85), while statin use remained unassociated (OR=1.49; 95% CI, 0.88-2.50). CONCLUSION:In this cross-sectional analysis, aspirin use was independently associated with reduced AWE in patients with UIAs, while statin use was not. However, the cross-sectional design precludes causal inference regarding a direct anti-inflammatory effect on the aneurysm wall.

Deep venous drainage (DVD) is considered a negative prognostic factor in AVM surgery, yet its effect on postoperative functional decline remains incompletely defined. This study evaluates whether DVD predicts worsened functional status after surgical resection of Spetzler-Martin Grade II-III AVMs. This retrospective multicenter study analyzed 129 patients with Spetzler-Martin Grade II-III AVMs across nine centers in North America and Europe who underwent primary surgical resection. We excluded cases with prior endovascular or stereotactic interventions. The primary outcome measured was poor functional status, defined as modified Rankin Scale (mRS) score 3–6 at last follow up. Among 129 patients with Spetzler-Martin Grade II-III AVMs, 38 (29.5

INTRODUCTION:Endovascular thrombectomy (EVT) is an effective treatment for basilar artery occlusion (BAO) stroke in select patients. While there is a growing body of literature suggesting that advanced imaging modalities such as computed tomography perfusion (CTP) and magnetic resonance (MR) may not be necessary for selecting anterior circulation large vessel occlusion stroke patients for EVT, whether advanced imaging may be superior to conventional imaging (non-contrast CT and CT angiography) in identifying good treatment candidates among BAO patients is less clear. PATIENTS AND METHODS:This was a multicenter retrospective cohort study of BAO EVT patients treated from 2013 to 2022 in the Stroke Thrombectomy and Aneurysm Registry. Patients selected for EVT by advanced imaging (CTP or MR) were matched with those selected by conventional imaging using propensity score matching (PSM) accounting for possible confounders. Primary outcome was functional independence at 90 days. Other outcomes include bedridden state or death at 90-days and symptomatic intracranial hemorrhage (sICH). RESULTS:268 patients were included. 150 patients were selected for BAO EVT by conventional imaging, 86 by CTP, and 32 by MR. Patients selected by advanced imaging were significantly older than those selected by conventional imaging (median age 71 vs 64 years, p = 0.001); patient characteristics were otherwise similar between cohorts. After PSM, 90-day outcomes were similar between the two cohorts (p = 0.56), with similar rates of functional independence (39.4% vs 35.1%, p = 0.65), bedridden state or death (40.4% vs 44.7%, p = 0.66), and sICH (3.3% vs 5.7%, p = 0.49) for conventional and advanced imaging groups, respectively. Results were similar across treatment time windows (all p > 0.05). CONCLUSIONS:Selecting patients for basilar EVT using conventional versus advanced imaging did not result in different clinical outcomes, regardless of treatment time windows. Conventional imaging appears sufficient as a first-line tool for selecting basilar EVT patients in routine clinical practice.

BACKGROUND:Preoperative embolization has been used for intracranial meningiomas for nearly 40 years with varying preferences for embolic materials and limited comparative data on their efficacy. METHODS:Consecutively treated patients from 2013 until 2023 who underwent preoperative embolization for meningioma from 12 centers across North America and Europe were included and classified by embolic material: (1) particles, (2) Onyx, and (3) coils. Primary outcomes included estimated blood loss (EBL), procedural complications, surgery duration, gross total resection (GTR), unplanned rescue surgery, modified Rankin Scale (mRS), and mortality. After unmatched analysis. Propensity score matching (PSM) subgroup analyses compared each pair of embolic materials, controlling for age, sex, body mass index, smoking, comorbidities, prior surgery, pre-treatment antithrombotics, WHO grade, tumor location, maximal diameter, and baseline mRS. RESULTS:A total of 275 patients (median age 47 years, 62.9% female) underwent preoperative embolization for meningioma. The mean maximum tumor diameter was 32.9±10.1 mm, with 61.1% classified as WHO I. Onyx was most frequently used 117 (42.5%), followed by particles 107 (38.9%), and coils (18.5%). Unmatched analysis revealed that Onyx was significantly associated with reduced EBL, surgery duration, and increased GTR, while decreasing unplanned rescue surgeries compared to particles and coils. PSM produced 89, 48, and 44 matched pairs for Onyx vs. Particles, Particles vs. Coils, and Onyx vs. Coils, respectively. Onyx demonstrated significant reductions against Particles in EBL (250 mL vs. 350 mL, P = 0.011) and surgical time (291 min vs. 403 min, P < 0.001), and against Coils in EBL (250 mL vs. 400 mL, P = 0.012) and surgical time (255 min vs. 347 min, P = 0.002). Onyx also showed higher rates of gross total resection compared to Particles (80.9% vs. 56.2%, P = 0.021) and Coils (88.6% vs. 56.8%, P = 0.002). No significant differences were observed in blood transfusion requirements, embolization-related complications mRS, or mortality rates across all comparisons. CONCLUSIONS:Onyx, a liquid embolic agent, reduces EBL which may explain the shorter surgery duration, higher GTR rates, and lower retreatment rates. Procedural risks and patient selection require further investigation.

OBJECTIVE:Endovascular thrombectomy (EVT) for acute large-vessel occlusion stroke is well established, yet its role in patients presenting with minor stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score < 6) remains unclear. Prior studies have not accounted for intraprocedural factors that may influence outcomes in this subgroup. METHODS:The authors analyzed 5693 patients from the STAR (Stroke and Thrombectomy and Aneurysm Registry), including 398 with low NIHSS scores, to evaluate the association between procedure time (PT) and outcomes. Among patients with low NIHSS scores, propensity score matching was used to compare outcomes between those with PT ≤ 35 versus > 35 minutes, a cutoff defined using receiver operating characteristic curve analysis. The authors performed a meta-analysis of studies reporting best medical management (BMM) outcomes in patients with low NIHSS scores. To compare these with EVT-treated patients, a matched BMM comparator cohort using stratification on pooled baseline characteristics was constructed. Outcomes included 90-day functional independence (modified Rankin Scale [mRS] scores 0-2), intracranial hemorrhage, and mortality. RESULTS:PT had a stronger negative effect on outcomes in patients with low NIHSS scores compared with those with high scores, with a steeper decline in functional independence per minute of PT (slope: -0.45% vs -0.21%; p = 0.03 for interaction). Among patients with low scores, PT ≤ 35 minutes was associated with higher 90-day functional independence compared with the propensity score-matching cohort with PT > 35 minutes (82.6% vs 59.0%, p < 0.001). When benchmarked against BMM (75.2% mRS scores 0-2), patients undergoing EVT within 35 minutes had superior outcomes (85.1%, p = 0.047). In contrast, EVT with PT > 35 minutes resulted in worse outcomes than BMM (mRS scores 0-2: 59.8%, p = 0.008). The number needed to treat for PT ≤ 35 minutes was 10, whereas PT > 35 minutes yielded a number needed to harm of 6. CONCLUSIONS:PT critically modulates the benefit of EVT in minor stroke. While efficient EVT yields better outcomes than BMM, prolonged procedures are associated with harm. These findings may explain prior inconsistent evidence on EVT in patients with low NIHSS scores and underscore the need to individualize procedural thresholds in this population.

Middle meningeal artery embolization (MMAE) plus surgical evacuation is increasingly used for chronic subdural hematoma (cSDH), but predictors of length of stay (LOS) and outcomes associated with early discharge remain unclear. We performed a multicenter MESH Registry study (2019–2024) of patients undergoing MMAE and surgical evacuation for symptomatic cSDH. Short-stay discharge was defined as LOS ≤4 days. Predictors were identified using multivariable logistic regression. The 90-day composite adverse event was defined as cSDH recurrence requiring intervention, reintervention (repeat MMAE or surgical evacuation), or 30-day all-cause readmission. Safety was assessed using adjusted logistic regression, generalized estimating equations (GEE), inverse probability of treatment weighting (IPTW), and multiple imputation by chained equations (MICE). Among 647 patients (mean age 72.6 years; 74.0

BackgroundArtificial intelligence can help to identify irregular shapes and sizes, crucial for managing unruptured intracranial aneurysms (UIAs). However, existing artificial intelligence tools lack reliable classification of UIA shape irregularity and validation against gold-standard three-dimensional rotational angiography (3DRA). This study aimed to develop and validate a deep-learning model using computed tomography angiography (CTA) for classifying irregular shapes and measuring UIA size.MethodsCTA and 3DRA of UIA patients from a referral hospital were included as a derivation set, with images from multiple medical centers as an external test set. Senior investigators manually measured irregular shape and aneurysm size on 3DRA as the ground truth. Convolutional neural network (CNN) models were employed to develop the CTA-based model for irregular shape classification and size measurement. Model performance for UIA size and irregular shape classification was evaluated by intraclass correlation coefficient (ICC) and area under the curve (AUC), respectively. Junior clinicians’ performance in irregular shape classification was compared before and after using the model.ResultsThe derivation set included CTA images from 307 patients with 365 UIAs. The test set included 305 patients with 350 UIAs. The AUC for irregular shape classification of this model in the test set was 0.87, and the ICC of aneurysm size measurement was 0.92, compared with 3DRA. With the model’s help, junior clinicians’ performance for irregular shape classification was significantly improved (AUC 0.86 before vs 0.97 after, P<0.001).ConclusionThis study provided a deep-learning model based on CTA for irregular shape classification and size measurement of UIAs with high accuracy and external validity. The model can be used to improve reader performance.

INTRODUCTION:Infectious intracranial aneurysms (IIAs) are rare but serious complications of systemic infections, particularly infective endocarditis. These aneurysms are prone to rupture, leading to significant morbidity and mortality. Management strategies lack consensus due to the rarity of the condition and reliance on small case series. This study examines the clinical management of IIAs using data from a large multicenter cohort. METHODS:A retrospective registry-based cohort study was conducted across 11 tertiary care centers in the USA between 2018 and 2023. Patients with IIAs were identified based on clinical and radiographic criteria. The primary outcome was treatment failure defined as persistence, growth, or rupture of the aneurysm. Secondary outcomes were mortality and the modified Rankin Scale (mRS) score at 90 days and 1 year. Multivariate logistic regressions were used to identify outcome predictors. RESULTS:A total of 104 patients with 166 aneurysms were included, with a median age of 43 years. Medical management was successful in 56% of cases, with failure often within 18 days of initiation. Predictors of failure included younger age, larger aneurysm size, and rupture at presentation. Surgical and endovascular interventions achieved higher success rates with better outcomes. At 90 days, 57% of patients achieved functional independence (mRS 0-2), while the mortality rate was 24%. CONCLUSION:This study highlights the limitations of medical management for IIAs and underscores the need for early surgical or endovascular intervention in high-risk patients. Outcome predictors aid clinical decision-making, optimizing patient management. Further research is needed to standardize management guidelines for IIAs.

Middle meningeal artery embolization (MMAE) has emerged as a treatment for chronic subdural hematoma (cSDH), but comprehensive real-world safety data remain limited. We performed a multicenter retrospective analysis of 1781 consecutive patients undergoing MMAE for cSDH (2019–2025). The primary outcome was any procedure-related complication within 30 days. Inverse probability of treatment weighting (IPTW) assessed the association between technical success and complications, adjusting for demographic, clinical, and procedural confounders. Mean age was 72.8 ± 12.4 years; 68.1

Aneurysm wall enhancement (AWE) on 3T magnetic resonance aneurysm wall imaging (MR-AWI) predicts aneurysm growth and rupture during follow-up. However, its association with hypertension and the impact of blood pressure (BP) control remain unclear. This study aims to evaluate the association between hypertension, BP control, and AWE in patients with unruptured intracranial aneurysms (UIAs). We retrospectively analyzed patients with UIAs from three prospective cohorts (IARP-CP, 100-Project, 100-Project II) who had 3.0 T MR-AWI. AWE was categorized into three patterns: no enhancement, focal enhancement, and circumferential enhancement. Hypertension was defined as a history of hypertension and/or use of antihypertensive drugs. Hypertensive patients were categorized as well-controlled (systolic BP [SBP] < 140 mmHg and diastolic BP [DBP] < 90 mmHg) or poorly controlled (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg). Propensity score matching (PSM) (1:1) balanced confounders (age, sex, BMI, comorbidities, aneurysm characteristics). Ordinal logistic regression assessed associations between hypertension, BP control, and AWE. From a cohort of 1351 patients with 1416 UIAs who had MR-AWI, we matched 427 hypertensive patients with 427 normotensive patients. Hypertension was associated with higher AWE prevalence in both the total cohort (odds ratio (OR) 1.98, 95

Flow diverters (FDs) are increasingly used for cerebral aneurysms, including distal anterior cerebral artery (DACA) aneurysms, but comparative data between devices in this challenging location are limited. To compare the safety and efficacy of Pipeline, Silk Vista Baby (SVB), and FRED Jr. FDs for unruptured DACA aneurysms and identify predictors of complete occlusion. We retrospectively analyzed 166 patients treated with FDs at 39 centers in 14 countries (2018–2022) from the CRETA registry. Outcomes included aneurysm occlusion (O’Kelly–Marotta [OKM] scale), complications, retreatment, modified Rankin Scale (mRS) scores, and independent predictors of complete occlusion using multivariable Cox regression. Aneurysms were predominantly saccular and located on the pericallosal artery. Complete occlusion (OKM D) was achieved in 73

Endovascular treatment of unruptured intracranial aneurysms (UIAs) becomes particularly challenging when they are associated with moderate to severe parent artery stenosis. This study aimed to summarize and analyze a proposed treatment strategy to provide a valuable reference for clinical practice. Patients with UIAs and moderate to severe parent artery stenosis who underwent endovascular treatment were retrospectively enrolled. An interventional protocol focusing on this proposed treatment strategy was implemented. A comprehensive summary and analysis of the patient characteristics, imaging data, outcomes, and complications were conducted. A total of 96 patients were included. Among these, 93 patients underwent single-stage treatment, whereas the remaining 3 underwent staged treatment. Primary endovascular techniques included coiling, stent-assisted coiling, and flow diverter placement. Adjunctive balloon angioplasty, performed either before or after embolization, was utilized in specific cases. The results demonstrated that the proposed strategies could be effectively and rationally customized according to aneurysm characteristics and the severity of parent artery stenosis. At the 6-month follow-up, in-stent restenosis was observed in 11 patients (11.5

OBJECTIVE:Cognard type V dural arteriovenous fistulas (dAVFs), defined by spinal perimedullary venous drainage, represent a rare and aggressive neurovascular pathology. Comprehensive multicenter data remain scarce. The authors present the largest multicenter analysis to date, characterizing presentation, radiology, treatment, complications, and functional outcomes of Cognard type V dAVFs. METHODS:The authors retrospectively analyzed patients with angiographically confirmed Cognard type V dAVFs from the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR), spanning 16 academic centers. Patient demographics, imaging features, treatment strategies, procedural complications, and modified Rankin Scale (mRS) scores were recorded. RESULTS:Among 1077 patients with dAVFs, 37 (3%) had Cognard type V lesions. The mean patient age was 57 years, and 59.5% of patients were male. Most presented with nonhemorrhagic neurological deficits (68%), while 14% had hemorrhage. The most common location was the foramen magnum (32%). Embolization was the primary treatment in 67% of cases, complete obliteration was achieved in 71% of cases. Upfront microsurgery was performed in 22% of patients (obliteration rate 88%), and radiosurgery in 14% (success rate 40%). Salvage treatment further improved obliteration outcomes. Temporary complications occurred in 8% of patients (3/37): 2 with transient neurological deficits postembolization and 1 with transient hydrocephalus after surgery. Permanent complications were observed in 3% (1/37) due to treatment-related hemorrhage. At the last follow-up (mean 2.4 years), 69% (24/35) of patients maintained or improved to an mRS score ≤ 2. No deaths occurred. Functional improvement was seen in 29% (10/35), while mRS decline was in 40% of patients (14/35), all unrelated to the dAVF itself. CONCLUSIONS:Cognard type V dAVFs carry a high risk of neurological morbidity. However, favorable functional outcomes are achievable with timely, multimodal intervention. Complication rates remain low, with most being transient. These data support aggressive but tailored management to prevent permanent disability in this high-risk population.

Introduction: Dural arteriovenous fistulas (dAVFs) with cortical venous drainage (CVD) are arteriovenous shunts with significant risk of intracranial hemorrhage. Endovascular treatment is considered first-line treatment, yet it can be associated with lower complete obliteration and higher recurrence rates when compared to surgery. This study aims to identify predictors of failed endovascular-only treatment for dAVFs with CVD using the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database. Methods: The CONDOR registry was queried for patients with dAVFs with presence of angiographically-confirmed CVD who underwent endovascular embolization as first-line therapy. Successful endovascular treatment was defined as durable complete obliteration of the fistula or disconnection of the CVD (regardless of the number of embolization sessions) without the need for additional treatment modalities. Patients who required surgery or radiosurgery following embolization due to persistent CVD, or demonstrated recurrence after initially successful embolization requiring additional treatment, were considered as failure of primary endovascular treatment. Results: A total of 507 patients with dAVFs with CVD that underwent first-line endovascular treatment were included. Of these, 332 (65.5%) had successful initial endovascular embolization and 175 (34.5%) had unsuccessful embolization failing to achieve either complete obliteration or CVD disconnection. Of the 332 initially successful embolizations, 5 had a recurrence of their dAVF requiring surgery or radiosurgery. Endovascular treatment success was thereby achieved in 327 (64.5%) patients, while treatment failure was observed in 180 (35.5%). On multivariable logistic regression, embolization of the middle meningeal artery lowered the odds of failed endovascular treatment (OR: 0.558, p=0.010). The presence of intracranial feeders (p=1.868, p=0.007) and venous drainage into the deep venous system (OR 1.859, p=0.013) increased the odds of failed endovascular treatment. Conclusions: Intracranial feeders and deep venous drainage to straight sinus and vein of Galen were predictors of failed primary endovascular treatment in patients with dAVFs with CVD, while arterial supply by the MMA was predictive of successful endovascular treatment. Predicting which dAVFs are more likely to fail first-line endovascular treatment may help improve patient selection for endovascular-only versus multimodal therapy.

Background: Depression is a common and functionally limiting complication of aneurysmal subarachnoid hemorrhage (aSAH). Patients with comorbid coronary artery disease (CAD) may be particularly vulnerable due to overlapping neuroendocrine and inflammatory mechanisms. As part of an ongoing biomarker study investigating HPA axis dysregulation, GR signaling, IL-33/ST2 imbalance, and miR-124-3p expression, we used a large electronic health record (EHR) database to conduct a preliminary screening analysis to identify high-risk phenotypes. Objective: To evaluate whether comorbid CAD is associated with increased risk of post-aSAH depression, using structured EHR data as a retrospective phenotyping tool to inform prospective translational biomarker research. Methods: We used MIMIC-IV v3.1, an openly available EHR dataset that includes ICU and emergency department admissions to Beth Israel Deaconess Medical Center from 2008 to 2022. A total of 1,576 admissions with aSAH were identified via ICD-9/10 codes (430, I60.x). CAD was defined using standard ICD codes (ICD-9 411.1/412/414.x; ICD-10 I25.x). Depression was defined by in-hospital SSRI administration or a diagnosis of depression (ICD-9 2962/2963/3004/311; ICD-10 F32.x/F33.x). To focus on new-onset depression, patients with prior SSRI exposure were excluded. Logistic regression adjusted for age and sex was used to assess associations between CAD and depression proxies. A secondary analysis evaluated incident SSRI use, defined as ≥48 hours after admission. Results: After exclusion of pre-SSRI users, 1,463 unique aSAH admissions were included, of which 192 (13.1%) had comorbid CAD. Depression proxies occurred in 21.4% of CAD patients versus 16.6% of those without CAD. CAD was associated with increased odds of depression proxy during the index stay (OR 1.66; 95% CI 1.11–2.48). In the subset with incident SSRI initiation (n = 62), rates were similar (4.3% vs. 3.6%), though numbers were underpowered for stratified inference. Conclusions: Preliminary EHR analysis suggests an association between CAD and increased risk of post-aSAH depression. This supports the biologic rationale for our ongoing prospective biomarker study focused on GR signaling and neuroimmune-cardiac pathways. Publicly available EHR datasets like MIMIC-IV can serve as powerful tools for hypothesis generation and early phenotype stratification in translational cerebrovascular research.

BACKGROUND:Flow-diverter stents (FDS) have become the standard of care for a wide range of intracranial aneurysms, but their efficacy/safety in the context of recurrent/recanalized aneurysms following stent-assisted coiling (SAC) is not well established. We evaluate the outcomes of FDS retreatment in a large multicenter cohort. METHODS:We retrospectively analyzed data from 118 patients across 22 institutions who underwent FDS retreatment for recurrent/persistent aneurysms after SAC (2008-22). The primary outcome was angiographic occlusion status at last follow-up, categorized as complete (100%), near-complete (90-99%), or incomplete (<90%) occlusion. Secondary outcomes included procedural complications and clinical outcomes measured by the modified Rankin Scale (mRS). RESULTS:A total of 118 patients (median age 57, 74.6% female) with median follow-up of 15.3 months were identified. Complete occlusion was achieved in 62.5% and near-complete occlusion in 25%. FDS deployment within the pre-existing stent was successful in 98.3% of cases. Major complications occurred in 3.4% of cases, including postoperative aneurysmal rupture with resultant mortality (1.6%) and thromboembolic events with long-term disability (1.6%). Favorable clinical outcomes (mRS 0-2) were observed in 95.1% of patients. Wider aneurysm neck diameter was a significant predictor of incomplete occlusion (adjusted OR (aOR) 1.23 per mm, P=0.044), with male sex trending towards association with non-occlusion (aOR 3.2, P=0.07), while baseline hypertension was associated with complete occlusion (aOR 0.32, P=0.048). CONCLUSIONS:FDS treatment for recurrent/residual aneurysms after SAC represents a viable treatment option for these challenging cases with acceptable safety and reasonable occlusion rates, although lower than de novo FDS occlusion rates.

BACKGROUND:The EMBOLISE trial (The Embolization of the Middle Meningeal Artery With Onyx Liquid Embolic System in the Treatment of Subacute and Chronic Subdural Hematoma) demonstrated that middle meningeal artery embolization as an adjunct to surgical drainage reduces recurrence of symptomatic subacute and chronic subdural hematomas. We performed a subgroup analysis of the EMBOLISE surgical cohort to determine how the timing of embolization relative to surgery impacted various outcomes. METHODS:We performed a post hoc subgroup analysis to examine the association of the timing of embolization relative to surgery with the primary end point (hematoma reoperation within 90 days), secondary end points (clinical and radiographic outcomes), and safety end points (serious adverse events, neurological death, all-cause death, and stroke). RESULTS:Middle meningeal artery embolization before surgery (embolization-first group) and middle meningeal artery embolization after surgery (surgery-first group) were performed in 107 and 78 patients, respectively. Demographics and baseline clinical characteristics of the 2 groups were similar. The core laboratory confirmed the procedure to be successful in all patients with similar rates of distal penetration of Onyx into middle meningeal artery branches at the end of the embolization procedure in both groups (49.5% and 48.7%, respectively, P>0.99). Six of 103 patients in the embolization-first group (5.8%) and none in the surgery-first group needed reoperation within 90 days (analysis with observed data, P=0.08). Hematoma volumes at 90 and 180 days were similar except for lower hematoma thickness in the surgery-first group (2.3±3.0 mm versus 4.4±5.6 mm, P=0.03) at 180 days. Clinical and safety outcomes at 30, 90, and 180 days were similar. CONCLUSIONS:Performing surgical drainage before embolization in patients with subacute and chronic subdural hematomas may help minimize treatment failures and enhance hematoma resolution. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04402632.