Background:Carotid stenosis is associated with stroke and cognitive impairment. Whether cerebral glucose hypometabolism, a marker for neurodegeneration, mediates the association between carotid stenosis and cognitive decline remains unclear. Objectives:To investigate whether carotid stenosis is associated with reduced cerebral glucose metabolism measured by 18FDG-PET. Methods:We conducted a cross-sectional study of patients evaluated at Mayo Clinic (2010-2024) who underwent extracranial carotid imaging and brain 18F-FDG-PET within 1 year. Stenosis was classified as mild (<50%), moderate (50-69%), or severe (≥70%). Regional metabolism was quantified using standardized uptake value ratios (SUVRs) normalized to the pons across 12 cortical regions; hypometabolism was defined as SUVR <1.41. Multivariable analyses adjusted for age, sex, and vascular risk factors. Results:Among 84 patients, stenosis was mild in 86.9%, moderate in 4.8%, and severe in 8.3%; 44% underwent FDG-PET for clinical indications, mostly for suspected cognitive impairment. Increasing stenosis severity was associated with numerically lower metabolism in ipsilateral anterior circulation regions, without statistical significance. Adjusted odds of ipsilateral sensorimotor hypometabolism increased with stenosis severity (moderate: OR 2.90 [95%CI, 0.31-27.1]; severe: OR 5.56 [95% CI, 0.57-54.2]; P = 0.095), with attenuated associations in posterior circulation regions. Conclusion:FDG-PET demonstrated a numerical association between carotid stenosis severity and reduced cerebral glucose metabolism, but this did not reach statistical significance. Larger studies with greater representation of high-grade stenosis are needed.

BACKGROUND:Intraventricular hemorrhage and subarachnoid hemorrhage are associated with neuroinflammation and increased morbidity and mortality. Rapid clearance of blood from the cerebrospinal fluid space may mitigate neuroinflammatory cascades and improve clinical outcomes. This systematic review and meta-analysis aimed to compare the clinical effectiveness of active cerebrospinal fluid exchange, including neuroendoscopic lavage and IRRAflow systems, versus external ventricular drainage in patients with intraventricular hemorrhage or subarachnoid hemorrhage. METHODS:The study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and thoroughly assessed databases, including PubMed, Embase, Scopus, Cochrane, and Web of Science, up to September 18, 2025. Statistical analysis, both fixed-effect and random-effect model analyses, was performed by the Comprehensive Meta-Analysis software. In addition, the Cochran Q test was conducted to determine the statistical heterogeneity. In terms of low heterogeneity, the fixed-effect model is reported. RESULTS:This review included 7 studies with a total sample size of 834. Our analysis showed that active cerebrospinal fluid exchange was associated with significantly higher hematoma clearance (odds ratio, 2.72 [95% CI, 1.22-6.08]; P=0.015), better functional outcomes (odds ratio, 1.66 [95% CI, 1.12-2.48]; P=0.012), lower shunt dependency (odds ratio, 0.22 [95% CI, 0.10-0.50]; P<0.001), and reduced infection rates (odds ratio, 0.22 [95% CI, 0.12-0.42]; P<0.001). Subgroup analysis showed that neuroendoscopic lavage was most effective for hematoma clearance, while IRRAflow reduced infection rates. Also, younger patients had better neurological recovery. CONCLUSIONS:Active cerebrospinal fluid exchange techniques demonstrated superior outcomes over external ventricular drainage in managing intraventricular hemorrhage and subarachnoid hemorrhage, particularly in clot resolution and neurological recovery. Large-scale trials are warranted.

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

Background: The Treatment Of Brain Arteriovenous malformations Study is a pragmatic study comprising 2 randomized trials and prospective registries of patients with brain arteriovenous malformations (AVMs). We report the results of the stereotactic radiosurgery (SRS) registry. Methods: TOBAS uses an algorithm integrating clinical judgment and randomization. When SRS was selected as the preferred curative modality and randomized allocation of SRS versus observation was judged unreasonable, patients were included in the SRS registry (with/without pre-SRS embolization). The primary outcome was modified Rankin Scale > 2 at last follow-up. Secondary outcomes included serious adverse events, AVM rupture, radiation-induced changes, and magnetic resonance angiographic results at 3 years. Analyses were intent-to-treat. Results: From June 2014 to May 2021, 1010 patients were recruited; 105 (10.4%) were offered participation in the SRS registry. After exclusions, 94 patients were analyzed; most had ruptured (n = 64/94 [68%]), small AVMs (0-3 cm) (84 [89%]), within eloquent brain (57 [61%]). Pre-SRS embolization was performed in 19 (20%); 4 were cured and 3 had endovascular complications, leaving 87/94 (93%) patients who received SRS. The median SRS dose was 22 Gy (interquartile range: 20-24). During a mean follow-up of 51 months, the primary outcome (modified Rankin Scale > 2) occurred in 7/94 (7%; 95% confidence interval [CI]: 4%-15%), with serious adverse events in 16/94 (17%; 95% CI: 11%-26%), including AVM rupture in 5/94 (5%; 95% CI: 2%-12%), and symptomatic radiation-induced changes in 6/87 (7%; 95% CI: 3%-14%). Three-year imaging follow-up, available in 79/94 (84%) confirmed AVM occlusion in 51/79 (65%; 95% CI: 54%-74%) or 54% (95% CI: 44%-64%) of all patients. Conclusions: In this prospective registry, radiosurgery with or without embolization was relatively safe, but of moderate efficacy, with 3-year AVM occlusion in 54%-65% patients.

OBJECTIVE:Moyamoya disease (MMD) carries significant morbidity. While management focuses on treatment with aspirin and Extracranial-intracranial (EC-IC) bypass, the impact of pre-operative long-term aspirin use on outcomes remains unclear. Our objective was to evaluate the association of long-term aspirin use with in-hospital outcomes in patients with MMD undergoing EC-IC bypass. METHODS:We conducted a retrospective study using the National Inpatient Sample (2002-2020) to identify adult patients with MMD who underwent EC-IC bypass. Patients were stratified into 2 groups based on long-term aspirin use status at admission. Survey-weighted t-tests and Rao-Scott χ² were used to compare demographics and outcomes. Variables included complications, length of stay, total charges, and in-hospital mortality. RESULTS:A total of 1453 weighted admissions were identified (72.8% female; mean age 43 ± 13 years), including 470 patients (32.3%) with and 983 (67.7%) patients without long-term aspirin use. The frequency of ischemic stroke-coded events during the index hospitalization was lower among long-term aspirin users (18.9% vs 27.9%; p < 0.001). Hemorrhagic stroke-coded events during the index hospitalization were low and similar between the groups (1.7% vs 3.5%; p = 0.088). Long-term aspirin users had shorter hospital stays (5.7 ± 0.4 vs 7.1 ± 0.3 days; p = 0.002) and fewer pulmonary complications (1.5% vs 3.6%; p = 0.04). In-hospital mortality did not differ significantly (8.3% vs 6.1%; p = 0.14). CONCLUSION:Pre-operative long-term aspirin use in patients undergoing EC-IC bypass for MMD was associated with a lower frequency of ischemic stroke-coded events during the index hospitalization and shorter hospital stays without a significant increase in hemorrhagic complications. These findings suggest an association between long-term aspirin use and fewer ischemic stroke-coded events during the index hospitalization, although more clinically granular studies are needed before perioperative benefit can be inferred.

Abstract Background aneurysmal subarachnoid hemorrhage (aSAH) is neurological emergency associated with substantial mortality and disability. Current grading systems such as the modified Fisher Scale (mFS) and World Federation of Neurological Societies (WFNS) score, rely on semiquantitative and examination based assessments. Hence, they demonstrate limited predictive precision. The enhanced subarachnoid hemorrhage (eSAH) score is a simplified quantitative model integrating age, Glasgow Coma Scale (GCS), and cisternal subarachnoid hemorrhage volume (SAHV) to predict clinical outcomes after aSAH. Methods We performed a retrospective multicenter cohort study that included 1088 patients across three tertiary-care centers the United States. Predictive performance for unfavorable functional outcome, in-hospital mortality and delayed cerebral ischemia (DCI) was evaluated using receiver operating characteristic (ROC) analysis and area under the curve (AUC). Comparative analyses were performed and compared to the WFNS and mFS grading systems. Results the eSAH score demonstrated excellent discrimination for unfavorable functional outcome at discharge ( AUC 0.89 ) and in-hospital mortality (AUC 0.87). The DCI subscore demonstrated good discriminatory performance for predicting DCI (AUC 0.77). Compared with conventional grading systems, this was superior to both the WFNS (AUC 0.75) and the mFS ( AUC 0.70). increasing eSAH scores were additionally associated with progressively higher rates of mortality and unfavorable functional outcomes. Conclusion the eSAH score demonstrates strong external validity, reproducibility and superior predictive performance compared with conventional grading systems in a large multicenter cohort. These findings support the clinical utility of quantitative hemorrhage burden integration for early risk stratification in patients with aSAH.

Basilar apex aneurysms (BAAs) pose a challenge due to their deep location, critical neurovascular structures, and higher rupture risk compared to anterior circulation aneurysms. This case series aimed to evaluate morphological factors associated with recurrence after endovascular treatment (EVT) and explore hemodynamic factors using pulsatile computational fluid dynamics (CFD) simulations. Retrospective analysis of patients with BAAs receiving EVT at two academic centers from January 2011 to June 2024 was completed. Data collected included occlusion status (using the Raymond-Roy Occlusion Classification; RROC), recurrence (angiographic worsening in degree of occlusion), and aneurysm characteristics included wide neck (yes or no if diameter ≥ 4 mm), high aspect ratio (yes or no if ≥ 1.6), and packing density (low if < 20

Although the Woven EndoBridge (WEB) device is increasingly used for the treatment of wide-neck intracranial aneurysms, including in the acute rupture setting, comparative evidence assessing the impact of rupture status remains limited. This study compared angiographic, safety, and clinical outcomes between ruptured and unruptured intracranial aneurysms treated with WEB. We conducted a retrospective analysis of prospectively collected data from the multicenter cohort registry WorldWideWEB, including consecutive adult patients with intracranial aneurysms treated with the WEB. Patients were stratified into groups of ruptured and unruptured aneurysms. Propensity score matching was used to balance baseline characteristics between both groups. Retreatment rate was the primary outcome. Secondary outcomes included mRS, safety events (thromboembolic complications) and angiographic outcomes (periprocedurally and last follow-up). Among 1,220 patients, 342 (28.0

OBJECTIVE:The objective was to evaluate the trajectories of hematoma resolution and functional improvement after middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH), model the temporal pattern of cSDH resolution, and identify factors associated with favorable outcomes. METHODS:This real-world multicenter retrospective study included cSDH patients treated with MMAE at 24 centers between 2019 and 2024. Hematoma thickness was measured at baseline and at follow-up intervals (1-4 weeks, 1-3 months, 3-6 months, 6-12 months, and > 12 months after embolization). Resolution patterns were modeled using exponential decay functions. Modified Rankin Scale (mRS) scores assessed functional outcomes. Good functional outcome was defined as mRS score ≤ 2. Resolution patterns were modeled using exponential decay functions to estimate time to 50% and 80% reduction. Patients were categorized as complete resolution (≥ 99%) or by quartile of the remaining distribution (substantial [73%-98%], moderate [53%-73%], partial [27%-53%], minimal [< 27%]). The primary outcome was good functional status (mRS score ≤ 2). RESULTS:The authors analyzed a total of 1781 patients with 2295 cSDHs who underwent MMAE. The mean ± SD age was 72.8 ± 12.4 years and 68.1% of patients were male. The initial mean hematoma thickness was 15.31 ± 6.53 mm, decreasing to 5.24 ± 5.91 mm at final follow-up (mean reduction 64.3% ± 42.1%). Resolution followed an exponential decay pattern, with an estimated time to 50% reduction of 1.8 months and to 80% reduction of 8.9 months. Complete resolution occurred in 1031 of 2224 patients (46.4%) with complete follow-up. The median (IQR) mRS score improved from 1 (0-3) at baseline to 0 (0-2) at > 12 months. Good functional outcomes were more common in patients with complete versus minimal resolution (68.9% vs 35.0%, p < 0.001). Achieving ≥ 73% resolution within 90 days was associated with better outcomes (good outcome in 76.9% of those with ≥ 73% resolution vs 67.3% in those without, p < 0.001). Neurological deterioration was the strongest predictor of lack of good outcome (23.7% in patients with neurological deterioration vs 82.4% without, p < 0.001). CONCLUSIONS:After MMAE for cSDH, reduction in hematoma thickness follows a predictable exponential decay pattern. Greater extent (≥ 80%) and faster timing (within 90 days) of resolution are valuable prognostic indicators. Functional outcomes improve progressively through 6-12 months after the procedure. The relationship between resolution extent and functional outcomes provides quantitative benchmarks for evaluating treatment response.

BACKGROUND AND PURPOSE:Chronic subdural hematoma (cSDH) affects approximately 20 per 100,000 individuals annually, with surgical recurrence rates of 10-20%. Middle meningeal artery embolization (MMAE) has emerged as a promising minimally invasive treatment, but the optimal timing remains unclear. We evaluated the association between MMAE timing and radiological and functional outcomes in cSDH. METHODS:We conducted a retrospective multicenter international cohort study across 33 centres, including patients who underwent MMAE for cSDH between January 2018 and December 2024. Patients were stratified by timing from diagnosis: Q1 (≤1 day), Q2 (2 days), Q3 (3-6 days), and Q4 (>6 days). The primary composite endpoint required radiological success (hematoma thickness <5 mm at 1-3 months), absence of emergency surgical evacuation, and either functional improvement or good functional outcome (modified Rankin Scale 0-2). Propensity score matching compared Q1 and Q4. RESULTS:Of 1,781 patients screened, 908 met inclusion criteria. Mean age was 73.7 ± 12.2 years, and 70.9% were female. Early embolization (Q1) achieved the primary composite endpoint more frequently than delayed embolization (Q4), with concordant improvements in radiological and functional components and no difference in rescue surgery. Good functional outcome was achieved in 76.0% of Q1 patients versus 63.8% in Q4 (absolute difference, 12.2%; P=.003; number needed to treat approximately 8). Hospital length of stay was 21.0 days shorter in Q1 versus Q4 (P<.001), partly attributable to the timing definition. In 174 propensity score-matched pairs, early embolization was associated with higher odds of achieving the primary endpoint (odds ratio, 6.41; 95% confidence interval, 3.29-12.48; P<.001), with pronounced benefit among patients receiving antithrombotic therapy (odds ratio, 8.06; 95% confidence interval, 3.65-17.80). CONCLUSIONS:Early MMAE (≤1 day from diagnosis) was overall associated with better outcomes compared with delayed intervention, particularly among patients receiving antithrombotic therapy. Prospective confirmation is warranted.

BACKGROUND:The Valsalva Maneuver (VM) produces complex oscillations in arterial blood and intracranial pressure. Herein, we aim to analyze the hemodynamics of basilar tip aneurysms (BTAs) with changes in cardiovascular parameters and intracranial pressure reported during the onset of the VM. METHODS:Computational fluid dynamics (CFD) and one-way fluid-structure interaction (FSI) simulations were completed in resting conditions and hemodynamic conditions approximating phases I and IV of the VM. Time averaged wall shear stress, principal stress, Hencky strain, and wall displacement were quantified and statistically compared at the defined physiological states. RESULTS:Five unruptured (mean diameter 5.57 mm) and two ruptured (mean diameter 3.58 mm) BTAs from patients with a mean age of 60.9 ± 4.3 years were analyzed. Ruptured aneurysms had higher values of LSAR (4.5 vs. 0 %; p = 0.0445). In unruptured aneurysms, simulating cardiovascular changes during the VM increased the TAWSSan (Stage I + 41.78 %, p = 0.0008; Stage IV + 135.11 %, p = 0.0012), TAWSSpa (Stage I + 36.25 %, p = 0.0019; Stage IV + 98.73 %, p = 0.0021), and the TAWSSR (Stage I + 41.78 %, p = 0.0431; Stage IV + 135.11 %, p = 0.0431). RRT decreased from 0.42 at rest to 0.29 m2/N in Stage I (-30.93 %, p = 0.0001) and to 0.18 in Stage IV (-57.39 %, p = 0.0001), while HSAR increased from 14.3 % at baseline to 31.7 % in Stage I and 72.1 % in Stage IV (both p = 0.0431). Maximum principal stress increased by + 8.53 % (p = 0.0026) in Stage I and + 33.19 % (p = 0.0081) in Stage IV, and maximum strain rose by + 4.63 % (p = 0.0014) and + 16.27 % (p = 0.0018), respectively. Wall displacement augmented from 0.30 mm to 0.35 mm in Stage I (+6.10 %, p = 0.0422) and to 0.46 mm in Stage IV (+22.12 %, p = 0.0422). Similar trends were seen in ruptured aneurysms with significant increases in Stage I for TAWSSan (+41.2 %, p = 0.048), maximum principal strain (+4.40 %, p = 0.0425), and average strain (+5.62 %, p = 0.0317). CONCLUSION:Virtually simulating cardiovascular conditions of the VM in unruptured BTAs led to higher aneurysmal wall shear stress, increased HSAR, elevated wall stress, strain, and wall displacement, with a greater accentuation during the simulated stage IV.

BACKGROUND:Carotid revascularization prevents ipsilateral ischemic stroke in high-grade stenosis, but its effect on hemispheric white matter disease (WMD) progression is not known. METHODS:We conducted a longitudinal study of patients ≥40 years with carotid stenosis (moderate50-69%, high-grade 70-99% or occluded) seen at Mayo Clinic (Florida, Rochester, Arizona) between 2011 and 2015 with serial brain MRIs ≥1 year apart and clinical follow-up through 2020. Hemispheric WMD volumes were quantified from axial T2-FLAIR using automated segmentation. Patients were stratified by revascularization status. The primary outcome was annual change in WMD volume ipsilateral or contralateral to the index carotid. Hemispheric differences in the annual rate of WMD progression (cm3/yr) were compared between revascularized vs not revascularized using multivariable linear regression adjusted for demographic and vascular risk factors, with additional adjustment for baseline imbalances between groups. Because three outcomes were evaluated, a Bonferroni-corrected significance threshold of p < 0.0167 was applied. RESULTS:Among 150 patients (mean age 71 ± 10 years, 36.7% female), 37.3% had moderate stenosis, 42% high-grade, and 20.7% occlusion. Seventy-three (48.7%) underwent carotid revascularization; median follow-up was 5.1 years. Baseline WMD volume was 4.86 cm3 ipsilateral and 4.39 cm3 contralateral. Revascularized patients had a numerically slower ipsilateral WMD progression than non-revascularized patients (0.32 vs. 0.63 cm3/year, p = 0.34), with no contralateral difference. In fully adjusted models, revascularization was associated with attenuation of hemispheric difference in WMD progression (β = -0.46; 95% CI -0.84 to -0.08; p = 0.019). Although this association did not meet the Bonferroni-adjusted threshold, the effect estimate remained directionally consistent. CONCLUSIONS:Carotid revascularization was associated with numerically slower ipsilateral WMD progression (∼50% relative difference) and attenuation of hemispheric asymmetry over a median 5-year follow-up. Given the modest statistical signal and correction for multiple comparisons, these findings should be interpreted as observational and hypothesis-generating. Prospective studies should evaluate whether modulation of WMD progression translates into meaningful cognitive benefit.

Small Woven EndoBridge (WEB) devices (≤ 4.5 mm) for the intracranial aneurysm treatment are technically challenging to deploy, with limited efficacy and safety data. This study compared functional, angiographic, and safety outcomes of small WEBs with large (> 4.5 mm) and very large (> 7.5 mm) WEBs. The WorldWideWEB consortium is a retrospective, multicenter collaboration across 30 international institutions including adults with intracranial aneurysms treated with WEB. Patients were stratified into small (≤ 4.5 mm) and large (> 4.5 mm) groups; a subanalysis compared small with very large (> 7.5 mm) devices. Primary outcome was retreatment rate. Secondary outcomes included modified Rankin Scale (mRS), angiographic outcomes periprocedurally and last follow-up (FU), and safety events (intracranial hemorrhage (ICH) and thromboembolic complications (TECs)). Among 1473 patients, 229 (15.5

The effect of induced hypertension (iHTN) on functional outcomes in noncardioembolic acute ischemic stroke (AIS) with early neurological deterioration remains unclear. We performed a systematic review and meta-analysis evaluating the safety and efficacy of iHTN vs medical management. A literature search of PubMed/MEDLINE, Web of Science, Ovid Embase, and Scopus from inception through November 6th, 2025. The protocol was registered in PROSPERO (CRD420261282211). Studies evaluating iHTN within 72 h of AIS onset and reporting 90-day functional independence (modified Rankin Scale [mRS] 0-2) were included. Safety outcome was hemorrhagic transformation. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were estimated using random-effects model based on Restricted Maximum-Likelihood (REML) methods. Three studies were included, comprising 366 patients (iHTN, n = 180; control, n = 186). Mean age was 65.8 ± 11.8 years, 60.9% were men, and the mean initial NIHSS was 5.4 ± 3.5. Target systolic blood pressure (SBP) was a 15-25% increase from baseline SBP using phenylephrine. Functional independence at 90-days occurred more often in the iHTN group than in controls (68.8% vs 50.5%; RR = 1.37; 95% CI, 1.09-1.73; P = 0.007). Hemorrhagic transformation was uncommon and did not differ significantly between groups (3.3% vs 0.5%; RR = 2.08; 95% CI, 0.05-88.07; P = 0.70). In our study, phenylephrine-induced hypertension was associated with greater 90-day functional independence in selected AIS subtypes,without a significant increase in hemorrhagic transformation. However, the limited studies, predominance of retrospective designs, exclusively Asian cohorts, and heterogeneity in treatment protocols and populations warrant cautious interpretation and underscore the need for larger multicenter RCTs.