BACKGROUND AND PURPOSE:There is an imperfect correlation between morphologic MRI findings and radiating low back pain (LBP). Nerve irritation, visualized as glucose hypermetabolism on [18F]FDG-PET/MRI, has the potential to identify symptomatic segments. This study aimed to investigate the association of foraminal [18F]FDG uptake on PET/MRI, radiologic abnormalities, and patient outcomes. MATERIALS AND METHODS:Prospectively recruited patients with radiating LBP underwent [18F]FDG-PET/MRI of the lumbar spine in this observational study. Back pain and leg/buttock pain were assessed by using the visual analog scale (0-10). Foraminal stenosis, facet joint arthropathy, and annular fissures of the disc were graded by radiologists. As part of the standard clinical care, a subset of patients received image-guided nerve root blocks, by using a steroid/anesthetic mixture, and pain on visual analog scale was noted before and after injection. Standardized tracer uptake was quantitatively assessed in all neural foramina, facet joints, and discs. Generalized estimating equations were used to investigate associations between the maximum standardized uptake value of [18F]FDG in the neural foramina, degree of stenosis (none, mild, moderate, severe), and pain, additionally adjusted for tracer uptake in the adjacent tissues, age, sex, and body mass index. RESULTS:A total of 110 lumbar neural foramina in 11 patients were included in the analysis. Generalized estimating equations revealed significant associations between foraminal [18F]FDG uptake and degree of foraminal stenosis (β = 0.18; 95% CI, 0.03-0.33; P = .02). In patients with unilateral radicular symptoms but bilateral stenoses on MRI, [18F]FDG uptake was significantly higher on the symptomatic side (1.64 versus 1.88; P = .002). In segments treated with image-guided nerve root block, change in pain was positively associated with foraminal [18F]FDG uptake before injection (β = 2.24; 95% CI, 0.03-4.45; P = .05) but negatively associated with degree of stenosis (β = -1.27; 95%CI -2.24 to -0.31; P = .01). CONCLUSIONS:Foraminal [18F]FDG uptake on PET/MRI as a surrogate marker of nerve irritation may improve differentiation between painful versus nonpainful foraminal stenosis.

OBJECTIVE:Labral tears are common in young adults participating in high-impact physical activity. No longitudinal studies have investigated whether labral tears expedite cartilage loss. This longitudinal study investigated the association between labral tears and cartilage loss in young adults participating in high-impact physical activity. METHODS:Study participants were high-impact athletes (soccer or Australian football) with and without hip and/or groin pain from the femoroacetabular impingement and hip osteoarthritis cohort study who underwent unenhanced 3T MRI at baseline and after 2-3 years. Labral tears and cartilage defects were scored semi-quantitatively. At baseline, labral tear presence (grade ≥2), subregion, number of subregions affected by labral tear, maximal labral score, labral sum score and presence of paralabral cysts were determined. A cartilage sum change score (difference between baseline and follow-up) was calculated for each hip (0-20). Negative binomial regression models were used to estimate if baseline labral tears were associated with cartilage loss, adjusting for sex, age, body mass index, alpha angle and baseline cartilage sum score. RESULTS:173 (343 hips) participants (82% with hip and/or groin pain; 22% women) with a median age of 26 years were included. The median International Hip Outcome Tool-33 total score was 69 at baseline. Follow-up MRIs were collected at a median of 2.1 years after baseline. 150 (87%) participants were still participating in high-impact physical activity at follow-up. Weak-to-moderate strength associations were identified between cartilage sum change score and baseline anterior labral tears (adjusted incidence rate ratio (a)IRR 1.46; 95% CI 1.01 to 2.09), paralabral cysts (aIRR 1.38; 95% CI 1.02 to 1.86) and labral sum score (aIRR 1.05; 95% CI 1.00 to 1.09). CONCLUSION:Our findings suggest that acetabular labral tears contribute to cartilage loss in young adult athletes; however, the associations observed were modest, suggesting that additional factors contribute to cartilage loss in this population. Further research is required to inform preventative strategies aimed at reducing cartilage loss in athletes with labral tears.

PURPOSE:Lesions of the vertebral endplates (Modic changes) are associated with low back pain (LBP), and different pathological processes, including inflammation, have been proposed as causative. This study aimed to explore the relationship between [18F]FDG uptake (inflammation) and [18F]NaF uptake (bone remodeling) and patient-reported back pain as well as conventional MRI detected endplate changes. METHODS:Participants were selected from an IRB-approved study, creating 2 arms: [18F]NaF (n = 11) and [18F]FDG (n = 11). Scans were performed on a 3.0 T PET-MRI scanner. An MSK radiologist rated endplates changes using Modic classification and a relative scale: None; only edema; edema > fat; edema=fat; edema< fat; only fat. Radiotracer uptake (SUVmax) in endplate-adjacent bone was measured using ROIs. VAS scores (0-10) for back pain were recorded before imaging. Generalized estimating equations assessed associations between pain and radiotracer uptake as outcomes and radiologic findings as predictors, adjusted for age, sex, and body mass index (BMI). RESULTS:The study included 220 endplates from 22 patients (110 per arm). Overall, pain was positively associated with edematous lesions (beta 0.21, P = .024) but not with fatty changes (beta 0.10, P = .567). In the [18F]NaF arm, tracer uptake was associated with edematous lesions (beta 1.79, P = .001) and with pain (beta 0.18, P = .007). In the [18F]FDG arm, tracer uptake was negatively associated with edematous lesions (beta -0.11, P = .013) and showed no significant association with pain (beta -1.50, P = .064). CONCLUSION:Our study shows that [18F]NaF-PET-MRI detected bone-remodeling is more closely linked to painful vertebral end-plate degeneration than inflammatory [18F]FDG signal.

BACKGROUND:Anterior cruciate ligament (ACL) injury often leads to posttraumatic osteoarthritis (PTOA), despite ACL reconstruction (ACLR). Medial meniscal extrusion (MME) is implicated in PTOA progression but remains understudied after ACL injury and ACLR. HYPOTHESIS/PURPOSE:It was hypothesized that MME would increase longitudinally after ACL injury and ACLR, with greater changes in the ipsilateral knee compared with the contralateral knee, leading to cartilage degeneration. The study aimed to assess MME 3 years after ACLR and its relationship with magnetic resonance imaging (MRI) T1ρ and T2 as cartilage degeneration markers. STUDY DESIGN:Cohort study; Level of evidence, 2. METHODS:MME and relative percentage of extrusion (RPE) were measured on 3 coronal slices of 3-dimensional fast spin-echo images and the mean values were used. T1ρ and T2 sequences were obtained and cartilage compositional measurements were performed using in-house developed software with MATLAB. Mixed models were used to assess the longitudinal changes and linear regression was used to assess the relationships between RPE and T1ρ and T2 values. RESULTS:A total of 54 participants with unilateral ACL injuries underwent preoperative bilateral knee MRI. A total of 36 participants completed MR scans at 6 months and 3 years after ACLR. MME and RPE measurements demonstrated high reliability (ICC > 0.88 and > 0.91, respectively). The predicted values of MME and RPE from the mixed models showed that the ipsilateral side had significantly greater MME and RPE than the contralateral side at all 3 time points (P = .023 for MME; P = .013 for RPE at baseline; and P < .001 at 6 months and P < .001 at 3 years for both MME and RPE). The rate of change of MME and RPE on the ipsilateral side was significantly greater than that on the contralateral side (P < .001). Postoperative RPE was associated with T1ρ and T2 values in the posterior medial femoral condyle. CONCLUSION:MME and RPE obtained pre- and postoperatively after ACLR on the ipsilateral side were significantly greater than those on the contralateral side, and the longitudinal increases on the ipsilateral side were greater than those on the contralateral side. Postoperative RPE was significantly associated with cartilage degeneration in the posterior medial femoral condyle.

Objectives:Modic changes (MC) are vertebral endplate bone marrow lesions frequently observed in patients with chronic low back pain (CLBP), but their immunogenetic underpinnings remain unknown. We investigated HLA allele associations to uncover immune-mediated mechanisms and potential biomarkers for patient stratification. Methods:We analysed the blood transcriptome from 257 patients with CLBP aged ≥40 years, consisting of 187 patients with MC (types 1-3) and 70 without MC. Bootstrapped LASSO regression identified candidate HLA alleles, which were correlated with MC status using multivariate logistic regression adjusted for demographic covariates. Key findings were validated against US population allele frequencies from 8830 subjects stratified by race and ethnicity. Results:HLA-A*26:01 was strongly associated with MC in CLBP patients (OR = 18.9; FDR = 0.041), and enrichment was independently confirmed by comparison with external population data (OR = 2.15; FDR = 0.008). HLA-DQA1*03:03 was associated with reduced risk of MC (OR = 0.09; FDR = 0.0038). A trend toward positive association was noted for HLA-DRB1*11:01 (OR = 6.0; FDR = 0.069). Conclusions:This is the first study to identify significant associations between HLA and MC. The link to HLA-A*26:01 highlights the significance of CD8 + T-cell-mediated immune responses in MC pathobiology. These findings suggest HLA typing may enable personalised treatment strategies in chronic low back pain patients with MC. Key messages:What is already known: MC are inflammatory spinal lesions common in CLBP, but their immunogenetic basis is undefined.What this study adds: We identify HLA-A*26:01 as a novel risk allele for MC, validated across external population datasets.How this may affect research, practice or policy: HLA typing may help stratify patients with MC for targeted therapy or inclusion in immunomodulatory trials.

OBJECTIVE:Knee-adjacent subcutaneous fat (kaSCF) has emerged as a potential biomarker and risk factor for osteoarthritis (OA) progression. This study aims to develop an artificial intelligence-based tool for the automatic segmentation of kaSCF thickness and evaluate the cross-sectional associations between kaSCF, cartilage thickness, magnetic resonance imaging-based cartilage T2 relaxation time, knee pain, and muscle strength independent of body mass index (BMI). DESIGN:Baseline 3.0T MR images of the right knee from the entire Osteoarthritis Initiative cohort (n=4796) were used to quantify average values of kaSCF, cartilage thickness, and T2 using deep learning algorithms. Regression models (adjusted for age, gender, BMI, and race) were used to evaluate the associations between standardized kaSCF and outcomes of cartilage thickness, T2, pain, and knee extension strength. RESULTS:Model prediction CVs for kaSCF thickness ranged from 3.57% to 9.87% across femoral and tibial regions. Greater average kaSCF was associated with thinner cartilage in men (std. β= -0.029, 95% CI: -0.050 to -0.007, p=0.010) and higher T2 in women (std. β=0.169, 95% CI: 0.072 to 0.265, p=0.001). Greater kaSCF was also associated with lower knee extension force (std. β= -15.36, 95% CI: -20.39 to -10.33, p<0.001) and higher odds of frequent knee pain (std. odds ratio=1.156, 95% CI: 1.046 to 1.278, p=0.005) across all participants. CONCLUSIONS:Greater kaSCF was associated with thinner cartilage in men, higher T2 in women, reduced knee strength, and greater knee pain, independent of BMI. These findings suggest a potential role of kaSCF as a predictor for knee osteoarthrits-related structural, functional, and clinical outcomes independent of the effects of BMI.

OBJECTIVE:To compare the diagnostic performance of non-contrast MRI versus MRI with contrast for differentiating atypical lipomatous tumors (ALT) from lipomas. MATERIALS AND METHODS:This multicenter retrospective study included subjects with a histopathologic diagnosis of lipoma or ALT and a preoperative MRI study with contrast. An experienced musculoskeletal radiologist reviewed the images in two sessions, the first session with non-contrast only, and the second session, including postcontrast sequences. In each session, the radiologist assigned a binary classification (lipoma or ALT) and a 5-point diagnostic score to reflect clinical reporting. Pathology reports served as the reference standard. McNemar's test was used to evaluate the statistical significance of the differences in sensitivity and specificity, while intraclass correlation coefficients (ICC) compared ordinal diagnostic scores. RESULTS:Four-hundred and forty-one patients (219 ALT, 222 lipoma) were eligible for analysis. In the first session, 76.1% of the lesions were classified as true negative and 76.3% as true positive. In the second session, 74.8% of lesions were assessed as true negative and 77.2% as true positive. There were no significant differences between the two readings in terms of sensitivity or specificity. The agreement in assigning the exact score between the two sessions, as measured by ICC, was 0.878 (95%CI: 0.855-0.898). CONCLUSION:Our study found no significant difference between the radiological readings of MRIs that used only precontrast sequences were used for the evaluation of lipoma and ALT, and those that included both pre- and postcontrast-enhanced sequences.

Large-scale bone defects require complex surgical procedures to repair, but full restoration of the bone is not guaranteed due to the significant tissue loss involved. In contrast, fractures can frequently be treated with conservative techniques. Particularly, ribs have a remarkable ability to spontaneously regenerate large-scale bone defects. However, we show here that skeletal maturity and age are associated with a decrease in the regenerative potential of human ribs. To investigate skeletal maturity and age-related cellular and transcriptional changes during large-scale bone regeneration, we used a mouse model that mimics the regenerative clinical features of human ribs. Unlike immature mice, mature mice lose the ability to regenerate after rib resection, and instead of bone, the resected rib space is repaired with abundant fibronectin cells. In addition, bone repair in mature mice presents reduced immune cell infiltration, which coincides with decreased levels of circulatory pro-inflammatory factors. To address the role of cell-cell communication and test whether skeletal maturity and age-related changes in immune cells and circulatory factors influence bone regeneration, we used immunodeficient mouse strains and performed heterochronic parabiosis. In immature mice, defective immune cell function altered callus composition rather than inhibiting bone regeneration. Remarkably, under parabiosis, a systemic pro-regenerative response is triggered exclusively in resected immature mice and is capable of partially rescuing bone regeneration in mature mice otherwise unable to regenerate spontaneously. Collectively, these findings suggest that therapeutic strategies focused on identifying pro-regenerative immune factors are promising for supporting the regeneration of large bone defects.

Background/Objectives: This study aimed to create a pipeline for standardized data extraction from lumbar-spine MRI radiology reports using a large language model (LLM) and assess the agreement of the extracted data with research-grade semi-quantitative scoring. Methods: We included a subset of data from a multi-site NIH-funded cohort study of chronic low back pain (cLBP) participants. After initial prompt development, a secure application programming interface (API) deployment of OpenAIs GPT-4 was used to extract different classes of pathology from the clinical radiology report. Unsupervised UMAP and agglomerative clustering of the pathology terms’ embeddings provided insight into model comprehension for optimized prompt design. Model extraction was benchmarked against human extraction (gold standard) with F1 scores and false-positive and false-negative rates (FPR/FNR). Then, an expert MSK radiologist provided comprehensive research-grade scores of the images, and agreement with report-extracted data was calculated using Cohen’s kappa. Results: Data from 230 patients with cLBP were included (mean age 53.2 years, 54% women). The overall model performance for extracting data from clinical reports was excellent, with a mean F1 score of 0.96 across pathologies. The mean FPR was marginally higher than the FNR (5.1% vs. 3.0%). Agreement with comprehensive scoring was moderate (kappa 0.424), and the underreporting of lateral recess stenosis (FNR 63.6%) and overreporting of disc pathology (FPR 42.7%) were noted. Conclusions: LLMs can accurately extract highly detailed information on lumbar spine imaging pathologies from radiology reports. Moderate agreement between the LLM and comprehensive scores underscores the need for less subjective, machine-based data extraction from imaging.

Corticosteroid injections were associated with higher progression of knee osteoarthritis compared with hyaluronic acid injections and controls, as determined by Whole-Organ MRI Score.

We investigated whether cartilage composition and thickness and its change over time were associated with future intermittent and constant knee pain. Osteoarthritis Initiative participants with 3T MRI scans from baseline to 36-month visits were selected. Outcomes were Intermittent and Constant Osteoarthritis Pain (ICOAP) scores in the right knee at the 48-month visit (0 to 100 = highest pain). We measured T2 values and cartilage thickness in 5 regions in the right knee from baseline to 36-months using deep-learning-based segmentation. Associations between baseline and change in cartilage biomarkers with pain scores were tested using adjusted logistic and linear regression models. Of 3780 included participants, 1042(28

OBJECTIVE:Entheses have been discussed as potential sources of pain in osteoarthritis (OA). Entheseal bone remodeling quantified by [18F]NaF-PET could be a surrogate marker for tensile forces causing a painful tissue response. This study aimed to investigate the relationship between [18 F]NaF-uptake, MRI findings and knee-related symptoms. METHOD:Patients and healthy controls in this prospective observational study on patello-femoral OA (PFJOA) underwent simultaneous MR (at 3.0 T) and [18F]NaF PET imaging of both knees. Cartilage damage, subchondral marrow lesions, synovitis, and enthesophytes were semi-quantitatively assessed on MRI and entheseal tracer uptake was quantified in the anterior patella and tibial tuberosity. Symptoms were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS). Generalized estimating equations were used to investigate associations between tracer uptake and symptoms; analyses were additionally adjusted for MRI-detected changes (as alternative symptom drivers), age, sex and body mass index. RESULTS:A total of 135 knees from 68 subjects were investigated (mean age 48.8 ± 10.4 years; 58.8% women). Higher [18F]NaF-uptake was significantly associated with worse outcomes for KOOS subscales sports (beta -2.7; p<0.001), quality of live (beta 3.0; p<0.001) and PFJ (beta 2.3; p=0.001), but not pain (beta -0.8; p=0.18), symptoms (beta -0.6; p=0.30) or activities of daily living (beta -1.1; p=0.06). CONCLUSION:Entheseal bone remodeling quantified by [18F]NaF-PET-MRI is associated with patient-reported clinical knee outcomes. These findings underscore the potential of entheseal biology to inform the understanding of symptom generation in degenerative disease of the musculoskeletal system.

Machine learning (ML), increasingly used for predictive modeling, has seen rapid growth in osteoarthritis (OA) research over the past decade. This review highlights recent advances in ML model development across four OA outcome domains: clinical, structural (radiographic and MRI-based), and surgical endpoints, each addressing different but interrelated aspects of the disease.For clinical outcomes, ML studies have focused on predicting changes in patient-reported clinical measures (e.g., pain and function). Radiographic OA has been characterized using deep learning (DL) models, and ML approaches have also been used to predict progression of Kellgren Lawrence grades and joint space narrowing. For MRI-based features, DL-based tools have been developed for automatic quantification of cartilage, bone marrow lesions, and subcutaneous fat; they have improved scalability and supported development of ML prediction models with cartilage loss outcomes. For total knee replacement outcomes, ML models have demonstrated strong performance, offering the potential for both early intervention and surgical planning.This review also discusses emerging directions for ML in OA research, including the integration of multimodal data sources, the development of interpretable and explainable ML models, and the use of automated ML to streamline model development. Future approaches may include OA subtype-specific prediction models, alignment of ML approaches with clinical workflows, and enhanced external validation to ensure generalizability. These evolving strategies underscore the growing potential of ML to improve the detection of early OA, individualized risk stratification, and personalized interventions in OA clinical care.

BACKGROUND:Quantitative magnetic resonance imaging (qMRI), such as T1ρ and T2 mapping, allows for the characterization of the biochemical composition of cartilage and the detection of early degeneration within 1 year after anterior cruciate ligament reconstruction (ACLR). It remains unclear if early imaging biomarkers are associated with the long-term development of posttraumatic osteoarthritis (PTOA). HYPOTHESIS/PURPOSE:The study aimed to investigate the relationship between qMRI-based evaluation of the medial compartment at baseline and 1 year after ACLR and the knee joint morphological status using 3-dimensional (3D) MRI at a 10-year follow-up. It was hypothesized that elevated T1p and T2 values at 1 year after ACLR would correlate with increased degenerative joint disease at 10 years after ACLR. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:Patients with ACLR between 2011 and 2014 who had preoperative bilateral qMRI were included. Thirteen patients completed the 10-year follow-up and were evaluated. The mean T1ρ and T2 values at baseline and 1 year were obtained using in-house-developed software with MATLAB. The MRI scans at the 10-year follow-up were acquired using a 3-T MRI scanner, including bilateral 3D proton-density fat-saturated fast-spin-echo sequence. Two radiologists used the modified Whole-Organ Magnetic Resonance Imaging Score (WORMS) to grade the images. The correlations between baseline, 1-year, and delta (1 year - baseline) T1ρ/T2 values and the WORMS at 10 years postoperatively were analyzed using the Spearman correlation coefficient. Significance was defined as a P value <.05. RESULTS:The baseline, 1-year, and delta medial tibia (MT) T1ρ values were significantly associated with the 10-year WORMS Total Score (r = 0.604, P = .031; r = 0.604, P = .031; and r = 0.582, P = .039, respectively). The MT T2 value at 1 year postoperatively was significantly associated (r = 0.566; P = .046) with the 10-year WORMS Total Score. CONCLUSION:The T1ρ/T2 values 1 year postoperatively and the increase from baseline to 1 year in the MT cartilage after ACLR were associated with the deterioration of the comprehensive evaluation of the knee at 10 years postoperatively. These findings help establish qMRI as a valuable biomarker for detecting early signs of PTOA progression.

Objective:Weight loss can modify the progression of osteoarthritis (OA), and this may, in part, be achieved by decreased synovitis, a known accelerator of cartilage degeneration. The purpose of this study was to investigate whether change in synovitis mediates the beneficial effect of weight loss on longitudinal cartilage outcomes. Method:We analyzed right knees with baseline Kellgren & Lawrence grades 1-3 of 1153 obese and overweight participants of the Osteoarthritis Initiative (OAI) cohort with Whole Organ MRI Scores (WORMS) and semi-quantitative assessment of effusion synovitis and synovial proliferation scores form 3T MRIs at baseline and 48 months. There were 295 participants with weight-loss >5 ​% and 858 stable weight controls. Ordered logistic regression was used to assess the association of weight-loss status with concurrent changes in synovitis as well as cartilage WORMS scores; models were adjusted for age, gender, race, presence of radiographic OA, and abdominal circumference at baseline. A mediation analysis was used to determine whether change in overall cartilage degeneration was mediated by change in synovitis scores. Results:Individuals who lost weight had significantly lower odds for a higher grade on the scale assessing change in overall synovitis (OR 0.72; 95%CI 0.54, 0.95; p ​= ​0.018). Mediation analysis showed that slowing synovitis during weight loss had a small mediating effect on longitudinal cartilage outcomes. Conclusion:Decreased cartilage degeneration during weight loss was partially mediated by concurrent deceleration in synovitis, showing that decreasing systemic inflammation during weight-loss may not be mirrored in imaging markers of joint inflammation.

INTRODUCTION: Subdural hematoma (SDH) is quickly becoming the most common neurosurgical pathology due to the aging population. Middle meningeal artery embolization (MMAE) has recently emerged as an effective adjunct to surgical SDH evacuation by decreasing recurrence risk. MMAE has also shown promise as a standalone SDH intervention, but clinical and radiographic predictors of successful MMAE remain ill-defined. METHODS: Retrospective review from 2020–2023 at a high-volume center identified all MMAE cases performed as primary SDH treatment. Subacute, chronic, or mixed density collections with less than a 50% acute component and minimal associated neurological symptoms were eligible. Cases were classified by hematoma internal architecture as homogeneous, separated, laminar, or trabecular (using the Nakaguchi classification). SDH maximal thickness was assessed on all follow-up imaging, and any SDH recurrences or expansions requiring surgical evacuation were denoted as treatment failures. RESULTS: 164 upfront MMAE cases were reviewed with a mean follow-up of 7.1 months. Most cases were in male patients (75.0%), and mean age was 73.2 years. The cases with laminar and trabecular collections were slightly larger than those with homogeneous and separated collections (16.2mm vs. 14.2mm, p=0.008*), but other baseline characteristics were similar. The overall MMAE failure rate was 6.7% with a 4.9% periprocedural complication rate. The MMAE failure rate was significantly lower in the laminar and trabecular subgroup (1.2%) compared to the homogeneous and separated subgroup (12.4%) (p=0.005*). Homogeneous and separated internal hematoma architecture was the only predictor of MMAE failure in multivariate analysis (OR 11.6, p=0.021*) and was also associated with delayed SDH resorption (Two-way ANOVA: F=4.8, p=0.0025*). CONCLUSIONS: Upfront MMAE is an effective, safe, and durable treatment for non-acute SDH, and is especially effective for hematomas with more membranous internal architecture.

BackgroundEndovascular coil embolization is a common treatment for intracranial aneurysms, but aneurysm recanalization remains a significant problem that may necessitate retreatment. This study aimed to identify patient, aneurysm, and procedural factors associated with recanalization in aneurysms treated exclusively with coil embolization.MethodsThis single center retrospective study assessed intracranial aneurysms treated with coiling-only between 2017 and 2022. Follow-up imaging was reviewed for recanalization with occlusion status graded via a modified Raymond-Roy classification. Univariate analysis assessed the association of clinical, morphological, and procedural factors with clinical complication, aneurysm occlusion, and recanalization status. Stepwise multivariable logistic regression was performed to identify independent predictors of aneurysm recanalization.ResultsOf 163 initially treated aneurysms, 142 were analyzed in complete case analysis for clinical outcomes. Complications occurred in 8 patients and were associated with larger aneurysm neck sizes (3.83 mm vs. 2.92 mm, p = 0.024), increased incidence of coil herniation (63% vs. 10%, p = 0.001), and greater number of coils used per aneurysm (7.13 coils vs. 4.64 coils, p = 0.028). Follow-up angiography in 122 aneurysms showed adequate occlusion in 116 (95.1%) and recanalization in 11.5%. Recanalization was more frequent in aneurysms that had larger initial volumes and in those without balloon inflation during coil deployment (both p < 0.05). On multivariable analysis, balloon inflation during coil deployment was the only independent predictor of aneurysm recanalization (OR 0.18; 95% CI 0.05-0.69; p = 0.009).DiscussionIn this single-center cohort of coiling-only treated aneurysms, the use of the balloon remodeling technique was strongly associated with durable aneurysm occlusion, reducing the odds of aneurysm recanalization. These findings support the routine use of balloon assistance in wide-neck and large aneurysms to achieve complete, stable occlusion and reduce the need for retreatment.