BACKGROUND:Venous sinus stenting (VSS) is an established treatment for patients with idiopathic intracranial hypertension (IIH). However, the associated effect of VSS on skull base remodeling has not been described. METHODS:We performed a single center retrospective study of adults with symptomatic venous sinus stenosis who underwent VSS. Tegmen (tympani and mastoideum) volume was measured on thin cut cranial CT using semi-automated 3D Slicer segmentation. The primary outcome was the within patient change in tegmen volume before and after VSS. Paired analyses were performed for the overall cohort and right-sided stent subgroups. Multivariable linear regression was used to identify factors associated with bilateral tegmen volume change. RESULTS:Of 65 patients treated with VSS from 2022 to 2026, 25 met the inclusion criteria. Mean age was 40.4 years, 92.0% were women, and median imaging follow-up was 295 days. Inter-rater reproducibility was excellent for the volumetric analysis on predefined anatomical segmentation boundaries. Four surgically repaired right-sided skull base patients were excluded from the ipsilateral analysis. Significant post-stenting mean tegmen growth was observed: right 146 mm³ (95% CI 118 to 174; n=21; P<0.001), left 145 mm³ (95% CI 114 to 170; n=25; P<0.001), and bilateral total 299 mm³ (95% CI 250 to 348; n=21; P<0.001). In the right-sided stent cohort, both ipsilateral and contralateral tegmen volumes increased significantly. Longer follow-up duration and pulsatile tinnitus were independently associated with bilateral tegmen volume gain. CONCLUSIONS:VSS was associated with a significant bilateral increase in tegmen volume in patients with IIH.

BACKGROUND AND IMPORTANCE:Ruptured neoplastic cerebral aneurysms (NCAs) due to choriocarcinoma are rare. They are found most commonly in distal middle cerebral artery (MCA) and carry a high risk of rerupture, morbidity and mortality. We present a case of choriocarcinoma-associated NCA managed by a combination of microsurgical-trapping, flow diversion, and low-dose induction chemotherapy initiated in the early postoperative period. CLINICAL PRESENTATION:This 3-month postpartum young woman developed subarachnoid hemorrhage in the left sylvian fissure due to an irregular left MCA trifurcation fusosaccular aneurysm. Serum and cerebrospinal fluid beta human chorionic gonadotrophin (β-hCG) levels were elevated. While undergoing a systemic workup, she reruptured and was taken for emergent craniectomy, with microsurgical trapping and excisional biopsy of the ruptured vessel segment. Rest of the unruptured diseased segment in inferior MCA trunk was flow diverted 5 days later using a Pipeline Vantage device (Medtronic) designed for smaller and more distal vessels. In an attempt to halt disease progression and prevent rerupture, 2 low-dose induction chemotherapy cycles (etoposide and cisplatin) were administered immediately over the following 2 weeks. She was later transitioned to etoposide, methotrexate, actinomycin-D + cyclophosphamide, vincristine chemotherapy. She gradually improved and serum β-hCG levels normalized over 4 weeks after surgery. At 6-month follow-up, she had slight disability (modified Rankin Scale 2), and angiogram revealed resolution of inferior MCA aneurysmal dilatation. CONCLUSION:This case highlights a strategic synergistic application of microsurgical and endovascular modalities with chemotherapy while balancing the risks of aneurysm rerupture, stent thrombosis, and intracranial hemorrhage. It is also the first reported case of a ruptured NCA treated with flow diversion.

BACKGROUND:Venous congestion is associated with tissue swelling in multiple organ systems. In idiopathic intracranial hypertension (IIH), its effects on brain parenchyma are less well defined, but may contribute to slit ventricles through increased parenchymal volume. We therefore analyzed ventricular volumes before and after venous sinus stenting (VSS). METHODS:Semi-automated ventricular segmentation was performed using 3D Slicer (image analysis and scientific visualization software) on pre- and post-VSS volumetric MRI or CT scans from patients with IIH at a single center (2022-2025). The primary objective was to quantify change in total ventricular volume. Secondary objectives were to assess compartmental changes, predictors of ventricular volume change, and associations between volumetric data and clinical outcomes. RESULTS:25 patients were included. Median time to post-stent imaging was 6.7 months (IQR 4.7-7.0). Median total ventricular volume increased from 10.96 mL (IQR 8.91-19.21) to 12.8 mL (IQR 9.72-20.32) (+16.8%, P=0.024), driven predominantly by increased lateral ventricular volume (+12.3%, P=0.021). Third and fourth ventricular volumes did not change significantly. No predictors of volume change were identified. Lower baseline ventricular volume was associated with higher odds of a favorable clinical outcome following VSS (OR 1.14, 95% CI 1.01 to 1.32, P=0.047). CONCLUSION:There is a small but consistent increase in ventricular volume following VSS, driven by expansion of the lateral ventricles. Greater benefit from stenting was observed in patients with lower baseline ventricular volumes. These findings suggest cerebral venous congestion may contribute to slit ventricles in IIH, and that improved venous drainage may permit re-expansion of cerebrospinal fluid spaces.

Establishing parent artery access for stent placement across large wide-necked aneurysms can be challenging. ‘Around-the-world’ technique, forming an intra-aneurysm loop with some form of distal anchoring, has been described in several reports. This comprehensive educational review summarizes the different variations of this technique, with their relative advantages and disadvantages. The review is supported with a technical case description of balloon-anchoring technique, one of the already described techniques in a patient with proximal posterior cerebral artery aneurysm. A comprehensive literature search was conducted to identify studies describing intra-aneurysmal looping with different distal anchoring techniques. A narrative synthesis of the data obtained from the identified studies was performed. Thirteen retrospective studies with 51 patients and the patient in the current report were included in the review. Different techniques described include balloon anchoring, stent anchoring, coil anchoring, vacuum anchoring, rapid pull-back and wire anchor loop traction techniques. Largest dimension of the aneurysms ranged from 12.3 mm to 29 mm with a mean of 19.9 mm (8 studies, 44 aneurysms). Neck size ranged from 5.2 mm to 15 mm with a mean of 10.4 mm (5 studies, 10 aneurysms). Aneurysms were unruptured in all 6 studies reporting the rupture status. Majority of the studies reported good outcomes with only two patients (3.9

Endovascular transarterial or retrograde transvenous occlusion is the preferred modality for treatment of dural arteriovenous fistulas at most intracranial locations. However, transvenous navigation to the segment of interest might not be possible due to occlusion or stenosis of an extracranial or intracranial major venous channel. Direct transcranial access to a major venous sinus proximal to the occlusion is a useful strategy in such situations. This video demonstrates successful endovascular coil embolization of an external carotid artery-internal jugular vein fistula below the jugular foramen through direct transcranial access to the transverse-sigmoid sinus in a patient with bilateral internal jugular vein occlusion. The video can be found here: https://stream.cadmore.media/r10.3171/2025.7.FOCVID2537.

BackgroundIdiopathic intracranial hypertension (IIH) is strongly associated with spontaneous skull-base cerebrospinal fluid (CSF) leaks. Venous sinus stenting (VSS) has proven effective for the treatment of IIH. Hence, its role in spontaneous skull-base CSF leaks is being explored actively.MethodsWe performed a systematic literature search across EMBASE, MEDLINE, Scopus, The Cochrane Library, and Google Scholar to identify studies reporting the use of VSS for spontaneous skull-base CSF leaks. Studies with pediatric patients, non-English articles, and nonspontaneous leaks were excluded. Failure of treatment (persistence / recurrence of CSF leak) was regarded as the primary outcome.ResultsEight studies with 62 patients undergoing VSS for spontaneous skull-base CSF leaks were included. Mean age of the patients was 51.9 years; 87.5% were females. Obesity was highly prevalent, with a mean body mass index of 33.9 kg/m2 (4 studies). IIH was noted in 74.6% patients (7 studies). Twenty-six patients (41.9%) underwent VSS alone whereas 36 patients (58.1%) underwent surgical repair + VSS. Seven patients (11.3%) had a failure of treatment. Three failures from one study could not be definitively ascribed to either of the groups. Hence, the estimated failure rate for VSS alone ranged from 18.6% (95% CI [0.02 - 0.46]) to 26.4% (95% CI [0.11 - 0.46]), whereas that for surgical repair + VSS ranged from 5.5% (95% CI [0.00 - 0.16]) to 12.2% (95% CI [0.01 - 0.32]). Furthermore, the estimated rate for resolution of concomitant IIH-related symptoms was 88.7% (95% CI [0.75 - 0.98%]). Majority of the studies did not report any serious complications or mortality related to VSS.ConclusionVSS has a potential role in the management of spontaneous skull-base CSF leaks. Its exact indications as a standalone treatment versus as an adjuvant to surgical repair, and the predictors for successful treatment remain to be defined.

Background:Pseudoaneurysm arising from the distal segment of an intracranial artery is a rare cause of subdural hematoma (SDH). We report a patient diagnosed with a pseudoaneurysm of a cortical branch of the distal anterior cerebral artery (ACA) during planned middle meningeal artery embolization for SDH and present a systematic review to summarize the present literature. Methods:A systematic literature search was conducted across EMBASE, MEDLINE, CINAHL, the Cochrane Library, and Scopus to identify studies reporting SDH due to pseudoaneurysms in the terminal intracranial artery segments. Details regarding clinical presentation, management, and outcomes were extracted. Results:Twenty patients from the 18 retrospective studies and the patient from the present report were included in the review. The mean age of the patients was 49.4 years; 80.9% of the patients were males. A history of nonpenetrating head trauma was present in 11 (52.4%) patients. The most common presenting symptoms were hemiparesis and altered mental status. Catheter angiography established the diagnosis in the majority of the patients (85.7%). Angiography was performed due to a clinical/radiological suspicion for a pseudoaneurysm in 6 (28.5%) patients. In the majority of the patients (66.7%), angiography was performed for a different indication. Middle cerebral artery (15 patients, 71.4%) was the most common location of the pseudoaneurysm, followed by ACA, posterior cerebral artery, and posterior inferior cerebellar artery. Pseudoaneurysm was treated surgically in 14 patients (66.7%) and by endovascular modalities in 5 patients (23.8%). One patient undergoing endovascular treatment required surgical evacuation of SDH. The majority of the patients in both treatment groups (surgical - 72.7%, endovascular - 80%) recovered without severe disability (modified Rankin Scale ≤ 4). Conclusion:Pseudoaneurysms of distal segments of intracranial arteries are a very rare cause of SDH. A high index of suspicion is required for their identification. While a definitive diagnosis requires catheter angiography, indications to perform angiography in SDH are unclear. Pseudoaneurysms with SDH can be treated safely with both microsurgical and endovascular modalities. Microsurgery has the advantage of draining SDH at the same time. The relative efficacy of different treatment approaches and the indications for each are not yet defined.

Use of animal models in preclinical transplant research is essential to the optimization of human allografts for clinical transplantation. Animal models of organ donation and preservation help to advance and improve technical elements of solid organ recovery and facilitate research of ischemia-reperfusion injury, organ preservation strategies, and future donor-based interventions. Important considerations include cost, public opinion regarding the conduct of animal research, translational value, and relevance of the animal model for clinical practice. We present an overview of two porcine models of organ donation: donation following brain death (DBD) and donation following circulatory death (DCD). The cardiovascular anatomy and physiology of pigs closely resembles those of humans, making this species the most appropriate for pre-clinical research. Pigs are also considered a potential source of organs for human heart and kidney xenotransplantation. It is imperative to minimize animal loss during procedures that are surgically complex. We present our experience with these models and describe in detail the use cases, procedural approach, challenges, alternatives, and limitations of each model.

Neurosurgeries complicated by infection are associated with prolonged treatment and significant morbidity. Craniotomy is a common neurosurgical procedure; however, the cellular and molecular signatures associated with craniotomy infection in human subjects are unknown. A retrospective study of over 2,500 craniotomies reveals diverse patient demographics, pathogen identity, and surgical landscapes associated with infection. Leukocyte profiling in patient tissues from craniotomy infection characterizes a predominance of granulocytic myeloid-derived suppressor cells that may arise from transmigrated blood neutrophils, based on single-cell RNA sequencing (scRNA-seq) trajectory analysis. Single-cell transcriptomic analysis identifies metabolic shifts in tissue leukocytes, including a conserved hypoxia-inducible factor (HIF) signature. The importance of HIF signaling was validated using a mouse model of Staphylococcus aureus craniotomy infection, where HIF inhibition increases chemokine production and leukocyte recruitment, exacerbating tissue pathology. These findings establish conserved metabolic and transcriptional signatures that may represent promising future therapeutic targets for human craniotomy infection in the face of increasing antimicrobial resistance.

Intradural exposure in the extended middle fossa anterior transpetrosal approach is traditionally limited to the inferior petrosal sinus inferomedially. Expanding bone removal of the petrous apex around the petrous internal carotid artery (ICA), underneath the trigeminal ganglion/mandibular nerve, and into the lateral component of the clivus can significantly expand the limits of this approach beyond the inferior petrosal sinus and allows for exposure of the midline structures, aspects of the contralateral inferior clival region, and, when high riding, the vertebrobasilar junction. To date, no descriptive techniques for drilling into the lateral clivus in this approach have been published. The authors provide a detailed stepwise description of their complete anterior petrosectomy, in use at their institution, that involves skeletonization of the posteromedial petrous ICA, gentle elevation of the trigeminal ganglion/mandibular nerve, removal of the infratrigeminal petrous apex, and two techniques for drilling into the lateral clivus along the petroclival fissure. These techniques provide a direct and unobstructed corridor to the midpetroclival region and ventral brainstem with greater maneuverability and enhanced control of the midline structures, which is especially useful for resection of petroclival meningiomas, chondrosarcomas, and giant vascular lesions of the mid- and upper basilar artery and its proximal branches.

Introduction: Mission: Lifeline Stroke Nebraska was a 4-year program to enhance stroke systems of care in Nebraska. With 68% of hospitals in Nebraska participating in GWTG-Stroke, analysis of stroke treatment data can be accomplished on disparities across the state. Methods: De-identified data was accessed through AHA GWTG-Stroke registry to assess stroke outcomes of patients at 49 participating NE hospitals in 2020. Data were analyzed based on AHA specified Mission: Lifeline reporting, achievement, and pre-hospital measures. The purpose of analysis was to describe patient characteristics and determine differences in IV thrombolytic treatment and mean patient NIH stroke score (NIHSS) upon admission. Percentages and counts were reported for categorical variables. The mean, standard deviation (SD) and median were reported for continuous variables. The Kruskal-Wallis rank sum, Wilcoxon sign rank, T-tests, chi-square and one-way ANOVA tests were used, where appropriate, to assess differences in stroke outcomes by age, gender, and race/ethnicity. Results: Of the 3,952 patient encounters registered in GWTG-Stroke from 01/01/2020 to 12/31/20, 2670 (67.5 %) were patients 18+ at time of admission with clinical diagnosis of ischemic stroke. Statistically significant differences in age, NIHSS at admission, and treatment with thrombolytics by gender were observed. Compared to males, females were older (72.7 vs. 68.1 years), had a lower mean NIHSS at admission (5.8 vs. 6.0), and a smaller proportion of females received thrombolytic treatment (42% vs. 58%). Conclusions: Overall, females were less likely to receive IV thrombolytic treatment compared to males. Women in the study were older with lower NIHSS than males. Results from this analysis align with those from the study “The Impact of Sex and Gender on Stroke” (Rexrode, et al.,2022) indicating that females may present different signs of a stroke than males. Our data showed the NIHSS scores to be lower for females possibly leading to lower frequency of treatment. As a part of the Mission: Lifeline initiative, this information was shared with hospitals and providers across the state. These results led to public awareness and education targeted to women, including a local podcast and social media.

Introduction Mechanical thrombectomy (MT) is the gold standard for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Although >70% of patients in the randomized clinical trials (RCTs) assessing the efficacy of MT for AIS‐LVO had successful recanalization, only up to 27% were free of disability according to the 90‐day modified Rankin scale (mRS) score. It is suggested that microcirculation disruption distal to the LVO might contribute to futile recanalization. Hence, combining intra‐arterial (IA) tissue plasminogen activator (tPA) with MT was investigated in a few studies in an attempt to reduce the burden of distal microthrombi and microcirculation disruption. We conducted this meta‐analysis to provide collective evidence in this regard. Methods We performed this meta‐analysis following the Preferred Reporting Items for Systematic Review and Meta‐Analyses statement recommendations. We aimed to include all original studies investigating the benefits of IA tPA in AIS patients undergoing MT.All screening and extraction stages were conducted by two authors, with a third author resolving any conflicts. Using R software, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI). A fixed‐effect model was adopted to pool all data due to the absence of significant heterogeneity among the included studies. Heterogeneity was assessed using Q statistics and the I2test, where I2> 50% or P‐value < 0.05 were considered significant. Results Following the database search, a manual search of references, and different screening phases, we included 5 studies (2,686 patients) satisfying the predefined inclusion criteria. Successful recanalization rates were comparable between both groups. The 90‐day functional independence was reported in 4 studies (2,474 patients), with comparable rates between both groups (OR = 1.25; 95%CI = 0.92‐1.70; P‐value = 0.154). Mortality was reported in 3 studies (368 patients), with comparable rates between both groups (OR = 0.73; 95%CI = 0.44‐1.23; P‐value = 0.240). Symptomatic intracranial hemorrhage (sICH) was reported in 5 studies (2,678 patients) with no significant difference between the two groups (OR = 0.66; 95%CI = 0.34‐1.26; P‐value = 0.304). Conclusions The current evidence does not show any significant differences between MT alone versus MT plus IA tPA in terms of 90‐day functional independence, mortality, and sICH. With the limited number of studies and included patients, more studies are needed to investigate the benefits and safety of the combined MT and IA tPA.

Introduction: Mission: Lifeline Stroke Nebraska (NE) is a four-year project which aims to improve stroke systems of care within the state through various interventions, including education of healthcare providers. Timely in-hospital treatment of stroke patients is key to reducing death and disability in stroke patients. Methods: An anonymous survey was administered to physicians and advanced practice providers that work in the ED at NE hospitals to assess the comfort/confidence level in administering IV thrombolytics and to learn more about the reasons for giving (and not giving) IV thrombolytics in various scenarios, including when an ischemic stroke is mild (NIHSS <4). A total of 110 providers completed the survey between February and April of 2021. Results: Critical Access Hospital (CAH) providers represented 70% of respondents. Only 50% of providers at certified centers and 29% at CAHs feel comfortable/confident in giving IV thrombolytics to ischemic stroke patients before consulting another provider. After consulting another clinician, this percentage increases to 89.7% in CAH providers but does not change in certified center providers. Overall, only 26.5% of certified center providers and 21.8% of CAH providers stated they are likely to give IV thrombolytic to a mild ischemic stroke patient. Certified center providers indicated that improved feedback on patient outcomes post IV thrombolytic therapy (41.2%) is the top item that would increase their comfort/confidence with administering IV thrombolytic. Qualitative feedback from certified center providers also shows there is hesitancy in administering IV thrombolytics to stroke patients and a desire to see more research showing the benefits. CAH providers identified access to telestroke (78.2%) and annual stroke education including updated guidelines on IV thrombolytic administration (66.7%) as the top items that would increase their comfort/confidence. Conclusions: These results indicate there is hesitancy to use IV thrombolytics to treat mild ischemic stroke patients and a need for more telestroke/neurology consultation options for providers in CAHs. From these conclusions, Mission: Lifeline is catering educational opportunities to the needs of rural and urban providers in NE

Objective: There are few objective measures for evaluating individual performance throughout surgical residency. Two commonly used objective measures are the case log numbers and written board examination scores. The objective of this study was to investigate possible correlations between these measures. Methods: We conducted a retrospective review of the American Board of Neurological Surgery (ABNS) written board scores and the Accreditation Council for Graduate Medical Education case logs of 27 recent alumni from neurologic surgery residency training programs at The Ohio State Wexner Medical Center and the University of Nebraska Medical Center. Results: The number of spine cases logged was significantly correlated with the ABNS written examination performance in univariate linear regression (r(2) = 0.0182, P = 0.0265). However, case numbers from all other neurosurgical subspecialties did not significantly correlate with ABNS written board performance (P > 0.1). Conclusions: Identifying which objective measures correlate most closely with resident education could help optimize the structure of residency training programs. We believe that early exposure to focused aspects of neurosurgery helps the young resident learn quickly and efficiently and ultimately score highly on standardized examinations. Therefore program directors may want to ensure focused exposure during the early years of residency, with particular attention to worthwhile rotations in spine neurosurgery.

OBJECTIVE The Accreditation Council for Graduate Medical Education (ACGME) has pushed for more frequent and comprehensive feedback for residents during their training, but there is scant evidence for how neurosurgery residents view the current feedback system as it applies to providing information for self-improvement and goal formation. The authors sought to assess neurosurgery resident and staff perceptions of the current resident feedback system in providing specific, meaningful, achievable, realistic, and timely (SMART) goals. The authors then created a pilot project to improve the most unfavorably viewed aspect of the feedback system. METHODS The authors conducted an anonymous survey of neurosurgery residents and staff at an academic medical institution to assess SMART goals for resident feedback and used the results to create a pilot intervention to address the most unfavorably viewed aspect of the feedback system. The authors then conducted a postintervention survey to see if perceptions had improved for the target of the intervention. RESULTS Neurosurgery residents and staff completed an anonymous online survey, for which the results indicated that resident feedback was not occurring in a timely manner. The authors created a simple anonymous feedback form. The form was distributed monthly to neurosurgery residents, neurosurgical staff, and nurses, and the results were reported monthly to each resident for 6 months. A postintervention survey was then administered, and the results indicated that the opinions of the neurosurgery residents and staff on the timeliness of resident feedback had changed from a negative to a nonnegative opinion (p = 0.01). CONCLUSIONS The required ACGME feedback methods may not be providing adequate feedback for goal formation for self-improvement for neurosurgery residents. Simple interventions, such as anonymous feedback questionnaires, can improve neurosurgery resident and staff perception of feedback to residents for self-improvement and goal formation.

ImportancePatients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood.ObjectiveTo assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study.Design, Setting, and ParticipantsThis retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress.ExposuresFrailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score.Main Outcomes and MeasuresPostoperative mortality at 30, 90, and 180 days.ResultsOf 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures.Conclusions and RelevanceWe developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.

Schmidt, Kyle; Price, Michael; Gard, Andrew P MD; Surdell, Daniel L MD; Sisson, Joseph MD; Thorell, William E MD Author Information

Passive drainage systems are commonly used after subdural hematoma evacuation but there is a dearth of published data regarding the suction forces created. We set out to quantify the suction forces generated by a passive drainage system.

Direct oral anticoagulants are becoming more commonplace for the treatment of nonvalvular atrial fibrillation and deep vein thrombosis. Unfortunately, effective reversal agents are not widely available limiting options for neurosurgical intervention during active anticoagulation. We report a case series of 3 patients treated for aneurysmal subarachnoid hemorrhage while taking direct oral anticoagulants. All three underwent open surgical clipping after adequate time was allowed for drug metabolism. Decision-making must take into account timing of intervention, drug half-life, and currently available reversal agents.

The use of antiplatelet or anticoagulants has previously been shown to increase hemorrhagic complications of ventricular catheterization. Although heparin use 24 h after ventriculostomy appears safe, the safety of heparin immediately (within 4 h) after ventriculostomy is unknown. The objective of this study was to assess the safety of heparin immediately (within 4 h) after ventriculostomy in subarachnoid hemorrhage (SAH) patients undergoing endovascular treatment.