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The climate crisis has been dubbed a "super wicked problem"—one where there is a sense of urgency, complicity in the problem by those who wish to solve it, and difficulty in sacrificing the short term for the long term. To respond to the difficulty of long-term thinking in addressing super wicked problems as part of SDG 13 (Climate Action), there is a need to pay attention to the narratives, norms, and values at work, and how we employ these categories in climate action. This paper discusses how Catholic social thought and the concept of the normativity of the future can be an approach to understanding the SDGs and the alternative future they offer in order to energize communities toward responding to the climate crisis, especially in response to current dominant narratives that make climate action difficult, as well as a way to make sense of the tensions found within the SDGs themselves. [ABSTRACT FROM AUTHOR]

Background Tools predicting intracranial dural arteriovenous fistulas (dAVFs) treatment outcomes remain scarce. This study aimed to use a multicenter database comprising more than 1000 dAVFs to develop a practical scoring system that predicts treatment outcomes. Methods Patients with angiographically confirmed dAVFs who underwent treatment within the Consortium for Dural Arteriovenous Fistula Outcomes Research-participating institutions were retrospectively reviewed. A subset comprising 80% of patients was randomly selected as training dataset, and the remaining 20% was used for validation. Univariable predictors of complete dAVF obliteration were entered into a stepwise multivariable regression model. The components of the proposed score (VEBAS) were weighted based on their ORs. Model performance was assessed using receiver operating curves (ROC) and areas under the ROC. Results A total of 880 dAVF patients were included. Venous stenosis (presence vs absence), elderly age (<75 vs ≥75 years), Borden classification (I vs II-III), arterial feeders (single vs multiple), and past cranial surgery (presence vs absence) were independent predictors of obliteration and used to derive the VEBAS score. A significant increase in the likelihood of complete obliteration (OR=1.37 (1.27-1.48)) with each additional point in the overall patient score (range 0-12) was demonstrated. Within the validation dataset, the predicted probability of complete dAVF obliteration increased from 0% with a 0-3 score to 72-89% for patients scoring ≥8. Conclusion The VEBAS score is a practical grading system that can guide patient counseling when considering dAVF intervention by predicting the likelihood of treatment success, with higher scores portending a greater likelihood of complete obliteration. [ABSTRACT FROM AUTHOR]

This article, published in the Journal of Neurological Surgery, discusses the incidence, risk factors, management, and outcomes of internal carotid artery (ICA) injuries during endoscopic transsphenoidal surgery (ETSS) for pituitary adenomas. The study, conducted at the University of Washington Medical Center, included 910 ETSS cases, of which 5 (0.5%) resulted in intraoperative carotid injury. The article highlights the importance of prevention and immediate management, such as hemodynamic support, visualization of the injury, and transport to the angiography suite. The study also discusses different treatment options, including endovascular flow diversion and coil sacrifice, depending on the patient's collaterals and injury. [Extracted from the article]

Background Reducing intracranial hemorrhage (ICH) can improve patient outcome in acute ischemic stroke (AIS) intervention. We sought to identify ICH risk factors after AIS thrombectomy. Methods This is a retrospective review of the Stroke Thrombectomy and Aneurysm Registry (STAR) database. All patients who underwent AIS thrombectomy with available ICH data were included. Multivariable regression models were developed to identify predictors of ICH after thrombectomy. Subgroup analyses were performed stratified by symptom status and European Cooperative Acute Stroke Study (ECASS) grade. Results The study cohort comprised 6860 patients. Any ICH and symptomatic ICH (sICH) occurred in 25% and 7% of patients, respectively. Hemorrhagic infarction 1 (HI1) occurred in 36%, HI2 in 24%, parenchymal hemorrhage 1 (PH1) in 22%, and PH2 in 17% of patients classified by ECASS grade. Intraprocedural complications independently predicted any ICH (OR 3.8083, P<0.0001), PH1 (OR 1.9053, P=0.0195), and PH2 (OR 2.7347, P=0.0004). Race also independently predicted any ICH (black: OR 0.5180, P=0.0017; Hispanic: OR 0.4615, P=0.0148), sICH (non- white: OR 0.4349, P=0.0107), PH1 (non-white: OR 3.1668, P<0.0001), and PH2 (non- white: OR 1.8689, P=0.0176), with white as the reference. Primary mechanical thrombectomy technique also independently predicted ICH. ADAPT (A Direct Aspiration First Pass Technique) was a negative predictor of sICH (OR 0.2501, P<0.0001), with stent retriever as the reference. Conclusions This study identified ICH risk factors after AIS thrombectomy using real-world data. There was a propensity towards a reduced sICH risk with direct aspiration. Procedural complications and ethnicity were predictors congruent between categories of any ICH, sICH, PH1, and PH2. Further investigation of technique and ethnicity effects on ICH and outcomes after AIS thrombectomy is warranted. [ABSTRACT FROM AUTHOR]

Background Anterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs. Methods The CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990-2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed. Results 60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs. Conclusion Most ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation. [ABSTRACT FROM AUTHOR]

Background Irregular pulsation of aneurysmal wall detected by four-dimensional CT angiography (4D-CTA) has been described as a novel imaging feature of aneurysm vulnerability. Our study aimed to investigate whether irregular pulsation is associated with symptomatic and ruptured intracranial aneurysms (IAs). Methods This retrospective study included consecutive patients with IAs who underwent 4D-CTA from January 2018 to July 2021. IAs were categorized as asymptomatic, symptomatic or ruptured. The presence of irregular pulsation (defined as a temporary focal protuberance ≥1 mm on more than three successive frames) was identified on 4D-CTA movies. Univariate and multivariate analyses were used to identify the parameters associated with aneurysm symptomatic or ruptured status. Results Overall, 305 patients with 328 aneurysms (37 ruptured, 60 symptomatic, 231 asymptomatic) were included. Ruptured and symptomatic IAs were significantly larger in size compared with asymptomatic IAs (median (IQR) 6.5 (5.1-8.3) mm, 7.0 (5.5-9.7) mm vs 4.7 (3.8-6.3) mm, p=0.001 and p<0.001, respectively) and had more irregular pulsations (70.3%, 78.3% vs 28.1%, p<0.05). Irregular pulsation (OR 5.03, 95% CI 2.83 to 8.92; p<0.001) was independently associated with aneurysm symptomatic/ruptured status in the whole population. With unruptured IAs, both irregular pulsation (OR 6.31, 95% CI 3.02 to 13.20; p<0.001) and size (OR 1.17, 95% CI 1.03 to 1.32; p=0.015) were independently associated with the symptoms. The combination of irregular pulsation and size increased the accuracy over size alone in identifying symptomatic aneurysms (AUC 0.81 vs 0.77, p=0.007) in unruptured IAs. Conclusion In a large cohort of patients with IAs detected by 4D-CTA, the presence of irregular pulsation was independently associated with aneurysm symptomatic and ruptured status. [ABSTRACT FROM AUTHOR]

Chronic subdural haematoma (CSDH) is an encapsulated collection of old blood between the dura mater and arachnoid caused by tear of bridging veins. Chronic subdural haematoma is considered when the blood is more than three weeks old. It is fairly common disease, especially in the elderly with incidence ranging 1.72 to 7. 35 per 100,000 population with male predominance.1,2,3. Elderly population is associated co-morbidities that can impact on immediate postoperative outcome and overall survival. Although history of trivial trauma is present in majority of cases but some cases may be secondary to coagulation defect, intracranial hypotension, and use of anticoagulant and antiplatelet agents. It commonly presents with headaches, confusion, drowsiness, vomiting, and seizures. On examination, patient have various neurological deficits including a low Glasgow coma scale, hemiparesis/hemiplegia, ocular palsy, and other deficits are seen. Diagnosis is usually confirmed by NCCT scan head however MRI are indicated for better visualisation of, multiloculated, intrahaematoma membranes. Management of this condition is mostly surgery but some patients have also been managed conservative with steroids. Steroids have been used in patient who have minor headache and also used in patients who are unfit for surgery 4. [ABSTRACT FROM AUTHOR]

Objective To evaluate the safety and effectiveness of the Flow Redirection Endoluminal Device (FRED) flow diverter in support of an application for Food and Drug Administration approval in the USA. Methods 145 patients were enrolled in a prospective, single-arm multicenter trial. Patients with aneurysms of unfavorable morphology for traditional endovascular therapies (large, wide-necked, fusiform, etc) were included. The trial was designed to demonstrate noninferiority in both safety and effectiveness, comparing trial results with performance goals (PGs) established from peer-reviewed published literature. The primary safety endpoint was death or major stroke (National Institutes of Health Stroke Scale score ≥4 points) within 30 days of the procedure, or any major ipsilateral stroke or neurological death within the first year. The primary effectiveness endpoint was complete occlusion of the target aneurysm with ≤50% stenosis of the parent artery at 12 months after treatment, and in which an alternative treatment of the target intracranial aneurysm had not been performed. Results 145 patients underwent attempted placement of a FRED device, and one or more devices were placed in all 145 patients. 135/145 (93%) had a single device placed. Core laboratory adjudication deemed 106 (73.1%) of the aneurysms large or giant. A safety endpoint was experienced by 9/145 (6.2%) patients, successfully achieving the safety PG of <15%. The effectiveness PG of >46% aneurysm occlusion was also achieved, with the effectiveness endpoint being met in 80/139 (57.6%) Conclusion As compared with historically derived performance benchmarks, the FRED flow diverter is both safe and effective for the treatment of appropriately selected intracranial aneurysms. [ABSTRACT FROM AUTHOR]

Background Although the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance. Objective To carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs. Methods From the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models. Results A total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0-129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last followup, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes. Conclusions In this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse- sigmoid sinus junction are associated with fewer complications. [ABSTRACT FROM AUTHOR]

Vascular malformations of the bone most often involve the cranio-facial area. Even in relevant peer reviewed journals, venous malformations are often misdiagnosed as "hemangiomas" or "angiomas" of the bone. By reviewing literature from the past 5 years (2013–2018), we found many reports of vascular malformations of the bone where the diagnosis was incorrect. Unfortunately, there is still much confusion in understanding and/or diagnosing vascular malformations, despite the fact that in recent years many papers tried to clarify this topic. The purpose of this article is to make a review of the scientific literature concerning vascular malformations of the bone which have been reported as angioma, hemangioma, or hemangioendothelioma, and have been published between January 2013 to October 2018. Clinical features, imaging and histologic reports contained in the papers were reviewed. Subsequently, after reviewing every single paper we reclassified the diagnosis according to the 2018 ISSVA classification. Almost all of the vascular anomalies presented in the reviewed papers as angiomas, hemangiomas, or hemangioendotheliomas were venous (mostly) or arteriovenous malformations. Therefore, only 8 out of 58 papers (14.7%) had an accurate diagnosis. Interestingly, all of the papers reporting cavernous or capillary hemangiomas were actually presenting venous malformations. Making a correct diagnosis is of primary importance because depending on the type of vascular anomaly, the treatment and the prognosis for the patient are very different. Everyone who approaches or describes a vascular anomaly of the bone should know and should adopt a correct and updated nosography. [ABSTRACT FROM AUTHOR]

Background The transcirculation approach (TCA) for stent-assisted coiling (SAC) of intracranial aneurysms may be useful for certain wide-neck bifurcation aneurysms as well as those with acute-angle efferent branches. Objective To describe a multicenter experience using the TCA for SAC. Methods A multicenter, retrospective study (2016-2020) of aneurysm treatment using SAC via the TCA. Angiographic outcome was scored using the Raymond Scale (adequate occlusion 1 and 2), and clinical outcome was scored using a modified Rankin Scale (good outcome 0-2) Results Twenty-nine patients with 29 aneurysms were included (62.1% female; average age 61; 89.7% unruptured; 13.8% previously treated; average dome size 6.4 mm; average neck 4.4 mm). Aneurysm locations included internal carotid artery-fetal posterior cerebral artery (n=4), internal carotid artery terminus (n=4), anterior communicating artery (n=8), vertebral artery-posterior inferior cerebellar artery (n=2), and basilar tip (n=11). The TCA used communicating arteries (93.1%; average 1.6 mm), intermediate catheters (51.7%), jailing technique (62.1%), and staged procedures (10.3%). The most common stent was the Neuroform Atlas (Stryker; 69%). Immediate adequate occlusion was obtained in 75.9%, and five patients with inadequate occlusion progressed to adequate occlusion at follow-up. One (3.4%) procedural complication occurred: a watershed stroke in the setting of baseline four-vessel extracranial disease. Two patients had a poor outcome unrelated to the TCA. The majority of patients (86.4%) had a good clinical outcome. One case of in-stent stenosis due to non-compliance with medication was seen, which resolved with medication resumption. Conclusions The TCA for SAC can be performed for a variety of aneurysms with a low complication rate and good clinical outcomes. [ABSTRACT FROM AUTHOR]

The flow in a spherical cavity on a curved round pipe is a canonical flow that describes well the flow inside a sidewall aneurysm on an intracranial artery. Intracranial aneurysms are often treated with a flow-diverting stent (FDS), a low-porosity metal mesh that covers the entrance to the cavity, to reduce blood flow into the aneurysm sac and exclude it from mechanical stresses imposed by the blood flow. Successful treatment is highly dependent on the degree of reduction of flow inside the cavity, and the resulting altered fluid mechanics inside the aneurysm following treatment. Using stereoscopic particle image velocimetry, we characterize the fluid mechanics in a canonical configuration representative of an intracranial aneurysm treated with a FDS: a spherical cavity on the side of a curved round pipe covered with a metal mesh formed by an actual medical FDS. This porous mesh coverage is the focus of Part 2 of the paper, characterizing the effects of parent vessel Re, De and pulsatility, Wo, on the fluid dynamics, compared with the canonical configuration with no impediments to flow into the cavity that is described in Part 1 (Chassagne et al., J. Fluid Mech., vol. 915, 2021, A123). Coverage with a FDS markedly reduces the flow Re in the aneurysmal cavity, creating a viscous-dominated flow environment despite the parent vessel Re > 100. Under steady flow conditions, the topology that forms inside the cavity is shown to be a function of the parent vessel De. At low values of De, flow enters the cavity at the leading edge and remains attached to the wall before exiting at the trailing edge, a novel behaviour that was not found under any conditions of the high-Re, unimpeded cavity flow described in Part 1. Under these conditions, flow in the cavity co-rotates with the direction of the free-stream flow, similar to Stokes flow in a cavity. As De increases, the flow along the leading edge begins to separate, and the recirculation zone grows with increasing De, until, above De ≈ 180, the flow inside the cavity is fully recirculating, counter-rotating with respect to the free-stream flow. Under pulsatile flow conditions, the vortex inside the cavity progresses through the same cycle - switching from attached and co-rotating with the free-stream flow at the beginning of the cycle (low velocity and positive acceleration) to separated and counter-rotating as De reaches a critical value. The location of separation within the harmonic cycle is shown to be a function of both De and Wo. The values of aneurysmal cavity Re based on both the average velocity and the circulation inside the cavity are shown to increase with increasing values of De, while Wo is shown to have little influence on the time-averaged metrics. As De increases, the strength of the secondary flow in the parent vessel grows, due to the inertial instability in the curved pipe, and the flow rate entering the cavity increases. Thus, the effectiveness of FDS treatment to exclude the aneurysmal cavity from the haemodynamic stresses is compromised for aneurysms located on high-curvature arteries, i.e. vessels with high De, and this can be a fluid mechanics criterion to guide treatment selection. [ABSTRACT FROM AUTHOR]

Flow in sidewall cerebral aneurysms can be ideally modelled as the combination of flow over a spherical cavity and flow in a curved circular pipe, two canonical flows. Flow in a curved pipe is known to depend on the Dean number De, combining the effects of Reynolds number Re and of the curvature along the pipe centreline, κ. Pulsatility in the flow introduces a dependence on the Womersley number Wo. Using stereo particle image velocimetry measurements, this study investigated the effect of these three key non-dimensional parameters, by modifying pipe curvature (De), flow rate (Re) and pulsatility frequency (Wo), on the flow patterns in a spherical cavity. A single counter-rotating vortex was observed in the cavity for all values of pipe curvature κ and Reynolds number Re, for both steady and pulsatile inflow conditions. Increasing the pipe curvature impacted the flow patterns in both the pipe and the cavity, by shifting the velocity profile towards the cavity opening and increasing the flow rate in to the cavity. The circulation in the cavity was found to collapse well with only the Dean number, for both steady and pulsatile inflows. For pulsatile inflow, the counter-rotating vortex was unstable and the location of its centre over time was impacted by the curvature of the pipe, as well as Re and Wo in the free stream. The circulation in the cavity was higher for steady inflow than for the equivalent average Reynolds number and Dean number pulsatile inflow, with very limited impact of the Womersley number in the range studied. A second part of this study, that focuses on the changes in fluid dynamics when the intracranial aneurysm is treated with a flow-diverting stent, can be found in this issue (Barbour et al., J. Fluid Mech., vol. 915, 2021, A124). [ABSTRACT FROM AUTHOR]

Background Infection from the SARS-CoV-2 virus has led to the COVID-19 pandemic. Given the large number of patients affected, healthcare personnel and facility resources are stretched to the limit; however, the need for urgent and emergent neurosurgical care continues. This article describes best practices when performing neurosurgical procedures on patients with COVID-19 based on multi-institutional experiences. Methods We assembled neurosurgical practitioners from 13 different health systems from across the USA, including those in hot spots, to describe their practices in managing neurosurgical emergencies within the COVID-19 environment. Results Patients presenting with neurosurgical emergencies should be considered as persons under investigation (PUI) and thus maximal personal protective equipment (PPE) should be donned during interaction and transfer. Intubations and extubations should be done with only anesthesia staff donning maximal PPE in a negative pressure environment. Operating room (OR) staff should enter the room once the air has been cleared of particulate matter. Certain OR suites should be designated as covid ORs, thus allowing for all neurosurgical cases on covid/PUI patients to be performed in these rooms, which will require a terminal clean post procedure. Each COVID OR suite should be attached to an anteroom which is a negative pressure room with a HEPA filter, thus allowing for donning and doffing of PPE without risking contamination of clean areas. Conclusion Based on a multi-institutional collaborative effort, we describe best practices when providing neurosurgical treatment for patients with COVID-19 in order to optimize clinical care and minimize the exposure of patients and staff. This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. [ABSTRACT FROM AUTHOR]

Introduction Endovascular embolization of intracranial meningiomas is commonly used as an adjunct to surgical resection. We sought to describe the anatomic locations and vascular supplies of meningiomas to identify characteristics predictive of successful preoperative endovascular embolization. Methods We conducted a retrospective review of 139 meningioma cases receiving cerebral angiograms for possible preoperative endovascular embolization at our institution between December 2000 and March 2017. The extent of embolization, arterial supply, anatomic location, and procedural complications were recorded for each case. Univariate and multivariate analyses were performed to identify tumor characteristics that predicted successful embolization. results Of the total meningioma patients undergoing preoperative angiography, 78% (108/139) were successfully embolized, with a 2.8% periprocedural complication rate (3/108). Within the subset of patients with successful embolization, 31% (33/108) achieved complete angiographic embolization. Significant multivariate predictors of embolization (either partial or complete) were convexity/parasagittal locations (OR 5.15, 95% CI 0.93 to 28.54, p=0.060), meningohypophyseal trunk (MHT, OR 4.65, 95% CI 1.63 to 13.23, p=0.004), middle meningeal artery (MMA, OR 10.89, 95% CI 3.43 to 34.64, p<0.001), and ascending pharyngeal artery supply (APA, OR 9.96, 95% CI 1.88 to 52.73, p=0.007). Significant predictors for complete embolization were convexity/parasagittal locations (OR 4.79, 95% CI 1.66 to 13.84, p=0.004) and embolized APA supply (OR 6.94, 95% CI 1.90 to 25.39, p=0.003). Multiple arterial supply was a negative predictor of complete embolization (OR 0.38, 95% CI 0.15 to 0.98, p=0.05). Conclusions Tumor characteristics can be used to predict the likelihood of preoperative meningioma embolization. Parasagittal and convexity meningiomas, and those with APA supply, are most likely to achieve complete angiographic embolization. [ABSTRACT FROM AUTHOR]

Background Use of the radial artery as an access site for neurointerventional procedures is gaining popularity after several studies in interventional cardiology have demonstrated superior patient safety, decreased length of stay, and patient preference compared with femoral artery access. The transradial approach has yet to be characterized for intraoperative cerebral angiography. Objective To report a multicenter experience on the use of radial artery access in intraoperative cerebral angiography, including case series and discussion of technical nuances. Methods 27 patients underwent attempted transradial cerebral angiography between May 2017 and May 2019. Data were collected regarding technique, patient positioning, vessels selected, technical success rate, and access site complications. Results 24 of the 27 patients (88.8%) underwent successful transradial intraoperative cerebral angiography. 18 patients (66.7%) were positioned supine, 6 patients (22.2%) were positioned prone, 1 patient (3.7%) was positioned lateral, and 2 patients (7.4%) were positioned three-quarters prone. A total of 31 vessels were selected including 13 right carotid arteries (8 common, 1 external, 4 internal), 11 left carotid arteries (9 common and 2 internal), and 6 vertebral arteries (5 right and 1 left). Two patients (7.4%) required conversion to femoral access in order to complete the intraoperative angiogram (1 due to arterial vasospasm and 1 due to inadvertent venous catheterization). One procedure (3.7%) was aborted because of inability to obtain the appropriate fluoroscopic views due to patient positioning. No patient experienced stroke, arterial dissection, or access site complication. Conclusions Transradial intraoperative cerebral angiography is safe and feasible with potential for improved operating room workflow ergonomics, faster patient mobility in the postoperative period, and reduced costs. [ABSTRACT FROM AUTHOR]

Flow-diverting stents (FDS) are used to treat cerebral aneurysms. They promote the formation of a stable thrombus within the aneurysmal sac and, if successful, isolate the aneurysmal dome from mechanical stresses to prevent rupture. Platelet activation, a mechanism necessary for thrombus formation, is known to respond to biomechanical stimuli, particularly to the platelets' residence time and shear stress exposure. Currently, there is no reliable method for predicting FDS treatment outcomes, either a priori or after the procedure. Eulerian computational fluid dynamic (CFD) studies of aneurysmal flow have searched for predictors of endovascular treatment outcome; however, the hemodynamics of thrombus formation cannot be fully understood without considering the platelets' trajectories and their mechanics-triggered activation. Lagrangian analysis of the fluid mechanics in the aneurysmal vasculature provides novel metrics by tracking the platelets' residence time (RT) and shear history (SH). Eulerian and Lagrangian parameters are compared for 19 patient-specific cases, both pre- and post-treatment, to assess the degree of change caused by the FDS and subsequent treatment efficacy. [ABSTRACT FROM AUTHOR]

Background Endovascular treatment of basilar tip aneurysms is less invasive than microsurgical clipping, but requires closer follow-up. Objective To characterize the additional costs associated with endovascular treatment of basilar tip aneurysms rather than microsurgical clipping. Materials and methods We obtained clinical records and billing information for 141 basilar tip aneurysms treated with clip ligation (n=48) or endovascular embolization (n=93). Costs included direct and indirect costs associated with index hospitalization, as well as re-treatments, follow-up visits, imaging studies, rehabilitation, and disability. Effectiveness of treatment was quantified by converting functional outcomes (modified Rankin Scale (mRS) score) into quality-adjusted life-years (QALYs). Cost-effectiveness was performed using cost/QALY ratios. Results Average index hospitalization costs were significantly higher for patients with unruptured aneurysms treated with clip ligation ($71 400 ± $47 100) compared with coil embolization ($33 500 ± $22 600), balloon-assisted coiling ($26 200 ± $11 600), and stent-assisted coiling ($38 500 ± $20 900). Multivariate predictors for higher index hospitalization cost included vasospasm requiring endovascular intervention, placement of a ventriculoperitoneal shunt, longer length of stay, larger aneurysm neck and width, higher Hunt-Hess grade, and treatment-associated complications. At 1 year, endovascular treatment was associated with lower cost/QALY than clip ligation in unruptured aneurysms ($52 000/QALY vs $137 000/QALY, respectively, p=0.006), but comparable rates in ruptured aneurysms ($193 000/QALY vs $233 000/QALY, p=0.277). Multivariate predictors for higher cost/QALY included worse mRS score at discharge, procedural complications, and larger aneurysm width. Conclusions Coil embolization of basilar tip aneurysms is associated with a lower cost/QALY. This effect is sustained during follow-up. Clinical condition at discharge is the most significant predictor of overall cost/QALY at 1 year. [ABSTRACT FROM AUTHOR]

Background pediatric acute ischemic stroke with underlying large vessel occlusion is a rare disease with significant morbidity and mortality. there is a paucity of data about the safety and outcomes of endovascular thrombectomy in these cases, especially with modern devices. Methods We conducted a retrospective review of all pediatric stroke patients who underwent endovascular thrombectomy in nine US tertiary centers between 2008 and 2017. Tesults Nineteen patients (63.2% male) with a mean (SD) age of 10.9(6) years and weight 44.6 (30.8) kg were included. Mean (SD) NIH stroke scale (NIHSS) score at presentation was 13.9 (5.7). CT-based assessment was obtained in 88.2% of the patients and 58.8% of the patients had perfusionbased assessment. All procedures were performed via the transfemoral approach. The first-pass device was stentriever in 52.6% of cases and aspiration in 36.8%. successful revascularization was achieved in 89.5% of the patients after a mean (SD) of 2.2 (1.5) passes, with a mean (SD) groin puncture to recanalization time of 48.7 (37.3) min (median 41.5). The mean (SD) reduction in NIHss from admission to discharge was 10.2 (6.2). A good neurological outcome was achieved in 89.5% of the patients. one patient had post-revascularization seizure, but no other procedural complications or mortality occurred. Conclusions endovascular thrombectomy is safe and feasible in selected pediatric patients. Technical and neurological outcomes were comparable to adult literature with no safety concerns with the use of standard adult devices in patients as young as 18 months. This large series adds to the growing literature but further studies are warranted. [ABSTRACT FROM AUTHOR]

Background Cavernous carotid artery aneurysms (CCAs) represent a unique subset of intracranial aneurysms due to their distinct natural history and the anatomy of the cavernous sinus. enlarging CCAs can cause elastic compression of the parent internal carotid artery (ICA). We suggest defining aneurysms that cause luminal stenosis of their parent vessels as 'matricidal aneurysms.' Though many patients are asymptomatic, presenting symptoms of CCAs include ophthalmoplegia with resulting diplopia, vision changes, pain, ptosis, facial numbness, and cavernous-carotid fistula. Less commonly, patients with CCAs can present with epistaxis, subarachnoid hemorrhage, and--in cases of matricidal aneurysms--ischemia due to stenosis. The proper management of stenosis caused by a matricidal CCA is not well established and may not be intuitive. Methods We present a multicenter retrospective case series of patients with matricidal CCAs. Results Forty patients with matricidal aneurysms presented with both asymptomatic and symptomatic stenosis. These patients were either treated with conservative medical management, coiling, flow diversion, or endovascular sacrifice of the parent artery. Planned treatment modalities were not executed in 11 cases (28% treatment failure rate). Presenting symptoms, patient outcomes, and follow-up data are presented for all cases. Conclusion Matricidal aneurysms require careful consideration and planning. The restricted anatomy of the cavernous sinus can make successful execution of endovascular interventions more difficult. Direct elastic compression of the parent artery does not respond to angioplasty and stenting in the same way atherosclerotic stenosis does. Because of this, planning for the possibility of parent vessel sacrifice is important. [ABSTRACT FROM AUTHOR]

Introduction: Transition to comfort measures only (CMO) is common in the neurocritical care unit, and close communication between interdisciplinary health-care teams is vital to a smooth transition. We developed and implemented a CMO huddle in an effort to reduce inconsistencies during the process of CMO transition. Methods: The CMO huddle was a multiphase quality improvement project in a neurocritical care unit of a level-1 trauma and comprehensive stroke center. Interdisciplinary critical care clinicians engaged in a huddle during CMO processes and participated in a pre- and postimplementation survey to examine the impact of CMO huddle on communication, missed opportunities, and improvement in knowledge. Results: Since the CMO implementation, a total of 131 patients underwent CMO transitions. After implementation of an interdisciplinary CMO huddle, 64.3% of neurocritical care nurses reported that they felt included and involved in CMO process compared to 28% before implementation (P = .003); 87.9% of all neurocritical care clinicians reported that they felt comfortable participating in CMO discussions compared to 69.8% before (P < .001); 57.4% of all neurocritical care clinicians reported that the CMO huddle improved communication among neurocritical care clinicians, 51.9% reported reduction in missed opportunities during CMO process, and 21.7% reported witnessing less-than-ideal CMO process compared to 80% before (P < .001). Conclusions: Implementation of a multidisciplinary huddle in the neuro–intensive care unit before transition to CMO may improve clinician's experience of the end-of-life process through enhanced nursing inclusion and involvement and organized communication with the neurocritical care team. [ABSTRACT FROM AUTHOR]

Objective: The recently published arteriovenous malformation-related intracerebral haemorrhage (AVICH) score showed better outcome prediction for patients with arteriovenous malformation (AVM)-related intracerebral haemorrhage (ICH) than other AVM or ICH scores. Here we present the results of a multicentre, external validation of the AVICH score.Methods: All participating centres (n=11) provided anonymous data on 325 patients to form the Spetzler-Martin (SM) grade, the supplemented SM (sSM) grade, the ICH score and the AVICH score. Modified Rankin score (mRS) at last follow-up (mean 25.6 months) was dichotomized into favourable (mRS 0-2, n=210) and unfavourable (mRS 3-6;n=115). Univariate and AUROC analyses were performed to validate the AVICH score.Results: Except nidus structure and AVM size, all single parameters forming the SM, sSM, ICH and AVICH score and the scores itself were significantly different between both outcome groups in the univariate analysis. The AVICH score was confirmed to be the highest predictive outcome score with an AUROC of 0.765 compared with 0.705 for the ICH score and 0.682 for the sSM grade.Conclusion: The multicentre-validated AVICH score predicts clinical outcome superior to pre-existing scores. We suggest the routine use of this score for future clinical outcome prediction and in clinical research.Trial Registration Number: NCT02920645. [ABSTRACT FROM AUTHOR]