BACKGROUND AND OBJECTIVES:Dual antiplatelet therapy (DAPT) is an essential component of medical management after flow diversion. To our knowledge, no studies have compared DAPT regimens using ticagrelor vs clopidogrel in patients undergoing flow diversion with newer generation surface-modified stents. Our study compares outcomes of flow diversion between ticagrelor- and clopidogrel-based DAPT. METHODS:This was a retrospective analysis of patients who underwent flow diversion with surface-modified stents at 6 participating institutions in North America. Patients were dichotomized based on DAPT regimen into acetyl salicylic acid (ASA) + ticagrelor vs ASA + clopidogrel. Outcomes of interest were in-stent stenosis (ISS), stroke or transient ischemic attack (TIA), and hemorrhagic complications on follow-up. RESULTS:Of 171 patients, 48.5% (n = 83) received ticagrelor and 51.4% (n = 88) received clopidogrel. A total of 13.4% patients (n = 23) developed ISS, 6.4% (n = 11) developed stroke/TIA, and 3.5% (n = 6) developed hemorrhagic complications After propensity-score weighting, patients who received clopidogrel did not have higher odds for ISS (odds ratio [OR]: 0.63, 95% CI: 0.25-1.59, P = .333), stroke/TIA (OR: 0.68, 95% CI: 0.19-2.43, P = .555), or hemorrhagic complications (OR: 0.17, 95% CI: 0.02-1.51, P = .113), compared with those receiving ticagrelor. CONCLUSION:DAPT with ASA and ticagrelor demonstrated comparable safety and efficacy to ASA and clopidogrel. Clopidogrel-based DAPT regimens should be considered as first line in preventing ischemic complications. However, in case of clopidogrel resistance, the use of ticagrelor does not confer increased risk of hemorrhagic complications.

Introduction The Flow Re-direction Endoluminal Device (FRED) is a novel flow diverter with a unique double stent design, with an inner stent composed of 48 nitinol wires, and an outer stent with 16 nitinol wires. It is designed for endovascular cerebral aneurysm treatment, although, limited data exist regarding in-stent stenosis (ISS) rates associated with FRED devices. Methods A registry encompassing two North American comprehensive stroke centers was the base of this study. We longitudinally assessed patients implanted with FRED devices, emphasizing baseline demographics, aneurysmal characteristics, procedural data, aneurysmal occlusion, and the incidence of ISS. Results In our cohort of 87 patients receiving 88 FRED devices, ISS occurred in 10.4% (9) of cases. Mild ISS (<50%) was noted in 8.0% (7) of patients, moderate ISS (50-75%) in 1.1% (1), and severe ISS (>75%) in 1.1% (1). Analysis indicated ISS in 17.0% (8) of patients with the FRED device and 5.7% (2) with the FRED-X device; all ISS cases in the FRED-X group were mild. Differences in ISS rates between device types were not significant (p = 0.122). Delayed thrombotic events were documented in 6.9% (6) of patients. Aneurysm occlusion rates, measured via the Raymond-Roy Scale (RRS), showed adequate occlusion (RRS 1 or 2) in 68.8% at 3 months, 74.6% at 6 months, and 89.3% at 12 months. Conclusions The study elucidates the efficacy and safety profile of FRED devices, presenting favorable aneurysm occlusion rates and low retreatment needs while underscoring the manageability of ISS.

Background and objectivesMiddle meningeal artery embolization (MMAE) has become a pivotal intervention in managing chronic subdural hematomas (cSDHs). This systematic review synthesizes past, recent, and ongoing clinical trials to assess MMAE's role in cSDH treatment.MethodsA systematic review was conducted using PRISMA guidelines, incorporating PubMed, ClinicalTrials.gov, and reverse bibliography searches to identify clinical trials evaluating MMAE for cSDH. Inclusion criteria included randomized and nonrandomized trials reporting outcomes, such as recurrence rates and procedural safety. Case reports, retrospective reviews, and opinion pieces were excluded.ResultsSeven published and 15 ongoing trials were identified. Landmark randomized controlled trials (RCTs), including EMBOLISE, STEM, and MAGIC-MT, demonstrated reductions in hematoma recurrence and surgical rescues with MMAE, establishing its role as both an adjunctive and standalone therapy. Ongoing trials, such as EMPROTECT and CHESS, investigate diverse embolic agents, procedural strategies, and patient populations to optimize MMAE outcomes. However, challenges remain, including variability in patient selection criteria, embolic materials, and endpoints.ConclusionMMAE is an innovative and minimally invasive approach that has reshaped cSDH management. Evidence supports its efficacy and safety as an adjunct to surgery and a potential standalone therapy for select patients. Future research should focus on long-term outcomes, subgroup analyses, and standardization of protocols to further refine its application and integration into clinical practice.

Introduction: Artificial intelligence (AI) has gained significant attention in medicine, particularly in neurosurgery, where its potential is frequently discussed and occasionally feared. Large language models (LLMs), such as ChatGPT-4.0 (OpenAI) and Gemini (Google DeepMind), have shown promise in text-based tasks but remain underexplored in image-based domains, which are essential for neurosurgery. This study evaluates the performance of ChatGPT-4.0 and Gemini on image-based neurosurgery board practice questions, focusing on their ability to interpret visual data, a critical aspect of neurosurgical decision-making. Methods: A total of 250 image-based questions selected from two neurosurgical review textbooks were obtained. Each question was presented to both ChatGPT-4.0 and Gemini in its original format, including images such as MRI scans, pathology slides, and surgical visuals. The models were tasked with answering the questions, and their accuracy was determined based on the number of correct responses. Results: ChatGPT-4.0 correctly answered 84 questions (33.6 %), significantly outperforming Gemini, which answered only 1 question correctly (0.4 %) (p < 0.0001). ChatGPT-4.0 provided correct answers for 17.7 % of questions from The Comprehensive Neurosurgery Board Preparation Book and 50.0 % from Neurosurgery Board Review. Gemini exhibited a 17.8 % "inability response" rate, explicitly stating it could not interpret images. The performance gap between the two models was significant (p < 0.0001), highlighting their limitations in handling complex visual data. Conclusions: While ChatGPT-4.0 demonstrated some capacity to interpret image-based neurosurgery board questions, both models exhibited significant limitations, particularly in processing and analyzing complex visual data. These findings emphasize the need for targeted advancements in AI to improve visual interpretation in neurosurgical education and practice.

BACKGROUND:The Flow Re-direction Endoluminal Device (FRED) X is a next generation flow-diverting stent for treating intracranial aneurysms. Its surface modification (X technology) aims to minimize device thrombogenicity. Early post-market multicenter data from the US are lacking. METHODS:We conducted a retrospective multicenter analysis of consecutive FRED X procedures performed to treat unruptured intracranial aneurysms at four US centers (March 2022 to January 2024). Cases with ruptured aneurysms or extracranial aneurysm location were excluded (n=10). We assessed patient and aneurysm characteristics, antithrombotic management, safety events, and both clinical and angiographic (effectiveness) outcomes. RESULTS:In this cohort, 101 patients underwent FRED X stenting for 117 aneurysms. Most aneurysms were saccular in shape (95.7%) and located at the C6-C7 segments of the internal carotid artery (72.6%). Thromboembolic events occurred in 5.9% of the cases, leading to one instance of permanent procedure related morbidity (1.0%). No procedure related mortality (0%) was observed. Device related issues were recorded in 2.0% of cases. At the 6 month follow-up, complete aneurysm occlusion was achieved in 58% of aneurysms. At the last available follow-up (6-12 months), 74.8% of aneurysms were adequately occluded. CONCLUSIONS:FRED X stenting for unruptured intracranial aneurysms demonstrated low rates of neurological morbidity and periprocedural complications. Early aneurysm occlusion rates were appropriate, but further mid-term and long term follow-up is required. These findings support the early safety and effectiveness of the FRED X device for intracranial aneurysm treatment.

OBJECTIVE:The Flow-Redirection Endoluminal Device X (FRED X) is a newer generation flow diverter with surface modifications aimed at minimizing thrombogenicity. At present, data on its long-term efficacy are limited. This multicenter study presents the largest series within the United States describing the device's efficacy, safety, and long-term outcomes in treating cerebral aneurysms of varying morphology. METHODS:Patients treated with the FRED X for a cerebral aneurysm between February 2022 and February 2024 at 6 high-volume centers across the United States were included. Data were collected regarding demographics, clinical presentation, and procedural efficacy. Angiographic and clinical follow-up outcomes were assessed at 6 and 12 months. RESULTS:A total of 154 patients with 162 aneurysms were treated with 164 FRED X devices over the study period. Overall, 81.8% of the cohort was female with a mean age of 56.8 years. The authors observed satisfactory rates (≥ 99.3%) of device deployment and good wall apposition and neck coverage. One hundred forty-seven (95.5%) patients were functionally independent at discharge (modified Rankin Scale scores 0-2). Rates of adequate occlusion (Raymond-Roy Occlusion Scale score I or II) increased from 84.2% at 6 months to 83.5% at the 12-month follow-up, while rates of in-stent stenosis decreased. All patients (100%) who underwent follow-up were functionally independent at 6 months, and 95.9% were functionally independent at 12 months. CONCLUSIONS:This multicenter cohort study demonstrates the ease of FRED X deployment with an adequate safety profile, with low rates of procedural complications and favorable outcomes on follow-up. Rates of aneurysm occlusion increased over time, with a subsequent decrease in stent-associated complications.

BACKGROUND AND OBJECTIVES:X (formerly known as Twitter) is a social media platform gaining popularity in neurosurgery. Other disciplines have demonstrated a positive correlation between Twitter activity and traditional citation metrics. This study aims to determine if X activity is a greater predictor of citation rates than a journal's 5-year impact factor (IF) among major neurosurgical journals. METHODS:Using a mixed linear model, we compared the predictive value between alternative metrics (such as mentions on X and Altmetric attention score, a weighted aggregate of the attention an article receives on various platforms) and traditional citation metrics (5-year journal IF) on the number of citations an article received by analyzing 7592 articles published from January 2022 to December 2023 in 18 neurosurgical journals. It was necessary to also account for the confounding variable time since publication in the model to determine the true effect of altmetrics. The relative importance (RI) of each predictor variable was determined through permutation testing. RESULTS:X mentions, time since publication, 5-year journal IF, and Altmetric attention score all significantly predict citation rates (P < .001). RI of X mentions on citation rates indicate that X (RI = 0.13) is approximately 8.7x times greater of a predictor of citations than 5-year IF (RI = 0.015) and 5.4x times greater of a predictor than the Altmetric attention score (RI = 0.024). Time of publication remains the strongest predictor (RI = 0.83). CONCLUSION:Our study shows that in neurosurgical research, while social media mentions (X mentions) are significant, they are weaker predictors of citation rates than time since publication. Traditional journal IF and Altmetric attention scores have weaker predictive value. These findings indicate that altmetrics, especially X mentions, can complement traditional citation metrics.

IntroductionThe ARUBA trial has influenced a shift towards more conservative management of small, unruptured cerebral arteriovenous malformations (AVMs), leading to less aggressive treatment approaches among neurointerventionalists. However, with evolving endovascular techniques, it is important to assess whether national practice changes have impacted rupture rates and outcomes.MethodsData from the Nationwide Inpatient Sample (NIS) for 2016-2022 regarding clinical characteristics, cost, morbidity, and mortality endovascularly treated AVMs was analyzed. Trends were evaluated using multivariable regression modeling, controlling for patient and hospital characteristics.ResultsA total of 8,935 patients underwent endovascular treatment for cerebral AVMs (6,500 unruptured and 2,435 ruptured). Endovascular treatment for unruptured AVMs declined significantly from 1195 cases in 2016 to 780 in 2022 (-34.7%, p = 0.020). Over the same period, the proportion of AVMs presenting ruptured increased from 15.7% to 25.7%, a 63.7% relative increase (p = 0.015). Multivariable analysis confirmed rising odds of rupture over time among endovascularly treated patients (OR = 1.12, 95% CI 1.00-1.25, p = 0.042). Among 11,205 ruptured AVM patients, the in-hospital mortality rate of thosewho did not undergo surgery rose 67.2% over time (6.7% in 2016 to 11.2% in 2022, p = 0.006).ConclusionThe study reveals an increase in the probability of patients presenting with ruptured AVMs and being observed with a consequent increase in in-hospital mortality. This may be an unintended consequence of less aggressive strategies following the ARUBA trial, prompting a need to reevaluate current management techniques amidst rising costs, morbidity, and mortality.

BACKGROUND AND OBJECTIVES:In-stent stenosis (ISS) occurs in approximately 0% to 55.3% of cases after flow diversion. The Flow Redirection Endoluminal Device-X (FRED-X) is a newer generation flow diverter with surface modifications. Our study identifies predictors of ISS after flow diversion using the FRED-X. METHODS:This was a multicenter retrospective study of patients who underwent flow diversion of an intracranial aneurysm using the FRED-X device between February 2022 and February 2024. Multivariate logistic regression was used to analyze for predictors of ISS at 6-month or 12-month follow-up. RESULTS:One fifty-four patients with 161 aneurysms underwent flow diversion with 164 FRED-X devices. At 6 months, 15.1% of cases (n = 21) developed ISS. Overall, 61.9% of patients (n = 13) developed mild ISS, 33.3% (n = 7) patients had moderate ISS, and 4.7% (n = 1) patients had severe ISS. On multivariate regression, cardiovascular disease and FRED-X stent length were associated with 6.25-fold (95% CI: 1.19-32.86) and 1.09-fold (95% CI: 1.00-1.20) higher odds of developing ISS at 6 months, whereas aneurysm width was associated with decreased odds of developing ISS (odds ratio: 0.61, 95% CI: 0.38-0.88). At 12 months, 12.0% of cases (n = 10) developed ISS. Overall 80% of this cohort (n = 8) developed mild ISS, whereas 1 patient each developed moderate and severe ISS. CONCLUSION:Our study identified cardiovascular disease, smaller aneurysm width, and stent length as independent predictors of ISS after flow diversion using the FRED-X. Patients with ISS were asymptomatic and did not require retreatment. Further prospective studies are necessary to validate these findings.

Stent development has focused recently on low-profile, self-expandable stents compatible with 0.0165-inch microcatheters. The LVIS EVO is the second generation version of the Low-Profile Visualized Intraluminal Support (LVIS) with improved visibility as a result of drawn filled tube (DFT) wires consisting of an inner platinum wire and an outer nitinol wire. The LVIS EVO underwent a limited premarket release (PMR) in December 2023. This is a multicenter retrospective observational study evaluating patients who underwent treatment of an intracranial aneurysm with an LVIS EVO stent after the limited PMR. All physicians who had placed an LVIS EVO stent were asked to input their cases after IRB approval was obtained. The data was then sent to a single center for analysis. 53 patients with 55 aneurysms underwent treatment with the LVIS EVO stent at 15 institutions. 100% of cases had successful deployment. Coils were placed in 48 cases (87.2%) and a microcatheter was jailed in 98% of those cases. The EVO was used as a standalone flow diverter in 5 cases and as an adjunct to a WEB device in 1 case. There were no delayed thromboembolic or hemorrhagic complications. The LVIS EVO is a braided, self-expanding, retrievable stent with enhanced visibility and smaller cell size. The DFT technology results in improved visibility of the stent allowing for more controlled stent positioning and visualization of vessel wall apposition. All cases in our series had complete neck coverage and good wall apposition. There were no thromboembolic or hemorrhagic complications.

Introduction Large vessel occlusion (LVO) strokes are a significant cause of disability and death globally. Endovascular mechanical thrombectomy (EVT) has improved outcomes for LVO patients. However, the impact of pre-existing frailty on outcomes for patients undergoing EVT remains understudied. Methods This study utilized the National Inpatient Sample (NIS) database to identify patients aged 18 and older who underwent EVT for LVO of the internal carotid artery (ICA) or middle cerebral artery (MCA) from 2016 to 2021. Frailty was assessed using the modified Frailty Index-5 (mFI-5), mFI-11, Charlson Comorbidity Index (CCI), and Risk Analysis Index (RAI). Outcomes analyzed included mortality, complications, length of stay (LOS), discharge disposition, and cost of care. Results We analyzed 57,260 EVT admissions. Patients classified as highly frail by the CCI had the highest in-hospital mortality (odds ratio (OR) 1.13, p < 0.0001). High frailty identified by mFI-5 was associated with a higher likelihood of postoperative complications (OR 1.41, p < 0.0001) and extended LOS (OR 1.23, p < 0.0001). High frailty by the administrative RAI was linked to nonhome discharge (OR 1.31, p < 0.0001), with mFI-5 showing similar predictive value (OR 1.30, p < 0.0001). High frailty, as determined by the CCI, incurred the highest estimated cost of care (p < 0.0001). Conclusions Frailty assessment using mFI-5 is a practical predictor of patient outcomes in LVO thrombectomy, including complication rates, extended LOS, and discharge disposition. The CCI remains the most predictive for mortality, though it is more complex to calculate. We emphasize that frailty, as measured by the mFI-5, is one of many factors to consider when deciding on EVT for LVO.

The modified brain injury guidelines (mBIG) were developed to improve care of traumatic brain injury (TBI) patients and resource utilization. This represents a retrospective cohort study at one level one trauma center. Utilization of the mBIG began in November 2021. Patient related outcome and safety measures for patients 18 years and older meeting mBIG 1 criteria treated 18 months prior to (pre-mBIG) and after implementation (post-mBIG) were compared. Patients meeting criteria for mBIG 2 or mBIG 3 classification were excluded. In contrast to the mBIG, neurosurgery was involved in the care of all TBI patients. 170 patients meeting mBIG 1 criteria were included (77 pre-mBIG, 93 post-mBIG). 53 patients (57%) post-mBIG were discharged from the emergency department after a period of observation, compared to 3 (4%) pre-mBIG (p=<0.01). Patients not discharged post-mBIG were most often admitted for care of unrelated traumatic injuries (85%). Repeat neuroimaging was less frequent post-mBIG (15% vs. 62%, p=<0.01). 0 patients in either cohort needed operative neurosurgical interventions, medical therapy for intracranial hypertension, or suffered neurologic deterioration. 8 (10%) pre-mBIG patients and 4 (4%) post-mBIG patients re-presented to the emergency department within 30 days (p=0.14), of which 2 pre-mBIG and 1 post-mBIG were for a TBI related complaint (p=0.59). At re-presentation, 0 patients had radiographic injury progression, needed operative neurosurgical interventions, medical therapy for intracranial hypertension, or suffered neurologic deterioration. Identification of TBI patients that may be safe for a short period of observation and discharge utilizing the mBIG 1 criteria with neurosurgery oversight appears to be safe and effective. Neurosurgery involvement may help to ensure safety and promote adoption by the neurosurgical community.

BACKGROUND AND OBJECTIVES:Flow diversion induces progressive aneurysm occlusion by reducing blood flow across the aneurysm neck over time. Various factors, including comorbid conditions, aneurysm characteristics, and stent design, have been shown to affect occlusion rates after flow diversion. Our study analyzed predictors of angiographic occlusion after flow diversion of intracranial aneurysms using the Flow Redirection Endoluminal Device with X-technology (FRED-X). METHODS:This was a multicenter study of ruptured and unruptured aneurysms treated at 6 participating institutions across the United States. Data were collected on patient-specific factors and aneurysm characteristics. Angiographic occlusion was assessed using the Raymond Roy Occlusion Classification. Multivariate logistic regression was used to analyze predictors of complete angiographic occlusion at either the 6- or 12-month follow-up. RESULTS:One hundred forty-four patients with 152 aneurysms met criteria for inclusion. A total of 69.4% of patients (n = 100) achieved complete occlusion. The average age of the cohort that achieved complete occlusion was 56.2 years, and 84% (n = 84) was female. On univariate analysis, aneurysm laterality, partial thrombosis of the aneurysm sac, proximal and distal diameters of the parent artery, and procedure time were significantly associated with complete angiographic occlusion. On multivariate analysis, parent artery diameter distal to the aneurysm was associated with 0.46-fold decreased odds of complete occlusion (95% CI: 0.26-0.78, P < .002). One patient in the incompletely occluded cohort underwent retreatment using the Pipeline Shield at 7 months after the initial flow diversion procedure using the FRED-X. CONCLUSION:Our study identified that parent artery diameter distal to the aneurysm was associated with decreased odds of aneurysm occlusion after flow diversion using the FRED-X. This adds to the literature on the importance of device sizing during flow diversion. Further prospective studies could help validate these findings.

OBJECTIVE: The modified Brain Injury Guidelines (mBIG) were developed to improve care of patients with traumatic brain injury (TBI). This study aimed to assess if utilization of mBIG by neurosurgeons would improve TBI patient throughput at a Level I trauma center, particularly for patients meeting mBIG 1 criteria. METHODS: This was a retrospective observational study at a Level I trauma center. The mBIG were adopted in November 2021. Outcome and safety data for patients >= 18 years old meeting mBIG 1 criteria treated 18 months before (pre-mBIG cohort) or after (post-mBIG cohort) implementation were compared. Patients meeting criteria for mBIG 2 or mBIG 3 classification were excluded. In contrast to mBIG, neurosurgery was involved in the care of all patients. RESULTS: The study included 170 patients with traumatic brain injury (77 pre-mBIG, 93 post-mBIG). In the post-mBIG cohort, 53 patients (57%) were discharged from the emergency department after a period of observation versus 3 patients (4%) in the pre-mBIG cohort (P <= 0.01). Post-mBIG patients who were not discharged were most often admitted for care of other injuries (85%). Repeat neuroimaging was less frequent in post-mBIG patients (15% vs. 62%, P <= 0.01). No patients in either cohort needed operative neurosurgical interventions or medical therapy for intracranial hypertension or experienced neurological deterioration. No post-mBIG patients had radiographic injury progression. The rate of repeat emergency department presentation within 30 days was not different between cohorts (P = 0.14). CONCLUSIONS: The mBIG 1 criteria were safe and improved low-risk TBI patient throughput at a Level I trauma center. Neurosurgical involvement may be beneficial to the mBIG while still facilitating significant resource savings.

BackgroundRecent literature highlights the adverse effects of recreational marijuana on cerebrovascular pathologies and outcomes. However, its impact on arteriovenous malformation (AVM) outcomes is unknown.ObjectiveTo investigate the differences in AVM outcomes between marijuana users and non-users, focusing primarily on the likelihood of presenting with rupture and secondly, on the effects of other drugs on in-hospital mortality and complications.MethodsAdult patients diagnosed with cerebral AVMs from the National Inpatient Sample were included. Use of recreational drugs, including marijuana, alcohol, opioids, hallucinogens, stimulants, and tobacco, was documented. Univariate and multivariate logistic regression analyses identified associations between drug use and AVM outcomes.ResultsA total of 46 480 patients were analyzed, with 11 580 (24.9%) presenting with rupture. Smoking was the most prevalent substance used (18 010, 38.7%), followed by alcohol (3 065, 6.6%), and cannabis (745, 1.6%). Smoking tobacco (OR=0.801; P=0.0002) and cannabis use (OR=0.613; P=0.0523) showed trends towards a protective effect against presentation with AVM rupture. Tobacco use was associated with reduced likelihood of extended length of stay (OR=0.837; P=0.0013), any complications (OR=0.860; P=0.0082), and in-hospital mortality (OR=0.590; P=0.0003). Alcohol use was linked to increased extended length of stay (OR=1.363; P=0.0033) and complications (OR=1.442; P=0.0007).ConclusionsStimulant use increases the likelihood of presenting with ruptured AVMs and is associated with higher mortality. Tobacco and cannabis use appear to reduce the possibility of extended hospital stays and complications.

Introduction As we emerge from the current pandemic, hospitals, staff, and resources will need to continue to adjust to meet ongoing healthcare demands. Lessons learned during past shortages can be used to optimize peri-procedural protocols to safely improve the utilization of hospital resources. Methods Retrospective review of patients who underwent elective endovascular intracranial aneurysm treatment was performed. Multivariable logistic regression was used to identify factors associated with patients who were able to be discharged within 24 h of elective procedures. Rates of complications (particularly readmission) were determined. Results 330 patients underwent elective endovascular aneurysm treatment with 86 (26.1%) discharged within 24 h. Factors associated with earlier discharge included procedure years (2019–2021) and male sex. Patients were more likely to be discharged later (after 24 h) if they underwent stent-coil embolization or flow-diversion. There was no association between discharge timing and likelihood of readmission. Discussion Our review highlights the safety of earlier discharge and allowed us to prepare a fast-track protocol for same-day discharge in these patients. This protocol will be studied prospectively in the next phase of this study. As we gain more comfort with emerging, minimally invasive endovascular therapies, we hope to safely achieve same-day discharge on a protocolized and routine basis, reducing the demand of elective aneurysm treatments on our healthcare system. Conclusion We retrospectively demonstrate that early discharge following elective aneurysm treatment is safe in our cohort and provide a fast-track pathway based on these findings for other centers developing similar protocols.

Introduction Artificial intelligence (AI) has significant potential in medicine, especially in diagnostics and education. ChatGPT has achieved levels comparable to medical students on text-based USMLE questions, yet there's a gap in its evaluation on image-based questions. Methods This study evaluated ChatGPT-4's performance on image-based questions from USMLE Step 1, Step 2, and Step 3. A total of 376 questions, including 54 image-based, were tested using an image-captioning system to generate descriptions for the images. Results The overall performance of ChatGPT-4 on USMLE Steps 1, 2, and 3 was evaluated using 376 questions, including 54 with images. The accuracy was 85.7% for Step 1, 92.5% for Step 2, and 86.9% for Step 3. For image-based questions, the accuracy was 70.8% for Step 1, 92.9% for Step 2, and 62.5% for Step 3. In contrast, text-based questions showed higher accuracy: 89.5% for Step 1, 92.5% for Step 2, and 90.1% for Step 3. Performance dropped significantly for difficult image-based questions in Steps 1 and 3 (p=0.0196 and p=0.0020 respectively), but not in Step 2 (p=0.9574). Despite these challenges, the AI's accuracy on image-based questions exceeded the passing rate for all three exams. Conclusions ChatGPT-4 can handle image-based USMLE questions above the passing rate, showing promise for its use in medical education and diagnostics. Further development is needed to improve its direct image processing capabilities and overall performance.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThis study did not receive any funding### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesI confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesAll data produced in the present study are available upon reasonable request to the authors

BackgroundThe Enterprise stent (Codman Neuro, Massachusetts, USA) received Food and Drug Administration (FDA) approval in 2007 for stent-assisted coiling (SAC). Since its introduction, newer stents and devices for aneurysm treatment have been developed resulting in a shift in the utilization of this stent from SAC to other off-label indications.ObjectiveTo describe our experience with the Enterprise stent being used for SAC and other off-label indications.MethodsThis is a multi-center retrospective review of the use of the Enterprise stent between 2018 and 2023. All patients in which the Enterprise stent was successfully deployed were included in the study.ResultsOur study cohort comprised of 194 patients, mostly females (n = 112, 57.7%), with a mean age of 63.2 years ± 14.3. The Enterprise stent was used for SAC in only 24 (12.4%) patients and was used for rescue stenting in stroke in 101 patients (52.1%), treatment of intracranial stenosis in 53 patients (27.3%), treatment of in-stent stenosis in 1 patient (0.5%), and for treatment of dissections in 15 patients (7.7%). From 2018 to 2023, the use of Enterprise stents for SAC significantly decreased (p < 0.0001) while the use of Enterprise stents for non-SAC purposes was insignificantly variable (p = 0.05).ConclusionOur study shows that the Enterprise stent remains a reliable tool in neuroendovascular procedures, even if its original intended use has been supplanted by other devices.