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Rationale: Thromboembolism is a serious complication of endovascular treatment for ruptured cerebral aneurysms. The administration of antiplatelet agents before endovascular treatment for ruptured cerebral aneurysms may reduce the risk of thromboembolic complications. Aim: This study aimed to assess the safety and efficacy of preoperative aspirin administration in endovascular treatment for ruptured cerebral aneurysms. Sample size estimates: Assuming a 15% incidence rate of both intraoperative thromboembolic morbidity and symptomatic ischemic lesions on magnetic resonance imaging diffusion-weighted imaging scans assessed by an Independent Review Committee, a sample size of 484 will be required to detect a 10% improvement with aspirin administration with 90% power using the Pearson's chi-square test at a two-sided significance level of 2.5% for each primary outcome, after accounting for a 5% dropout rate. Methods and design: ASTOP is a multicenter, randomized, double-blind, placebo-controlled clinical trial. A total of 484 patients with ruptured cerebral aneurysms receiving coil embolization within 72 h of onset will be randomly assigned 1:1 to receive 200 mg of aspirin or placebo before the procedure. Study outcomes: The primary outcomes will be the incidence rates of intraoperative thromboembolic complications and symptomatic ischemic lesions on magnetic resonance imaging diffusion-weighted imaging scans evaluated by the Independent Review Committee. The secondary outcomes will be the incidence rate of cerebral ischemic events and all bleeding events within 14 days of enrollment and functional outcomes defined by the modified Rankin Scale score at 90 days. Discussion: This trial will provide valuable data on the role of antiplatelet agents during endovascular treatment for ruptured cerebral aneurysms. Trial registration: Registration: Japan Registry of Clinical Trials, Identifier: jRCTs031210421. [ABSTRACT FROM AUTHOR]

Aim: Assessing the indication for elective neuro‐endovascular treatment (EVT) in older patients requires consideration of the impact of systemic comorbidities on their overall reduced life expectancy. The objective of this study was to determine the long‐term outcomes of elective neuro‐EVT in patients aged ≥80 years, and to investigate the impact of pre‐existing cancer on their long‐term outcomes. Methods: Of the patients enrolled in multicenter observational registry, those aged ≥80 years undergoing elective neuro‐EVT between 2011 and 2020 were enrolled. A history of cancer was defined as a pre‐existing solid or hematologic malignancy at the time of EVT. The primary outcome was time to death from elective neuro‐EVT. Results: Of the 6183 neuro‐EVT cases implemented at 10 stroke centers, a total of 289 patients (median age, 82 years [interquartile range 81–84 years]) were analyzed. A total of 58 (20.1%) patients had a history of cancer. A total of 78 patients (27.0%) died during follow up. The 5‐year survival rate of enrolled patients was 64.6%. Compared with patients without a history of cancer, those with a history of cancer showed significantly worse survival (log‐rank test, P = 0.001). Multivariate Cox proportional hazards analysis showed history of cancer was an independent predictor of time to death from elective neuro‐EVT (HR 1.74, 95% CI 1.01–3.00, P = 0.047). Cancer was the leading cause of death, accounting for 25.6% of all deaths. Conclusions: The present study showed that history of cancer has a significant impact on time to death from elective neuro‐EVT in patients aged ≥80 years. Geriatr Gerontol Int 2024; 24: 211–217. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to compare the outcomes and safety in patients aged ≥75 years and those aged <75 years who underwent stent-assisted endovascular treatment for unruptured cerebral aneurysms, specifically focusing on perioperative antiplatelet therapy (APT). Methods: This multicenter retrospective study comprised patients who underwent stent-assisted coiling (SAC) or flow diverter stent (FDS) placement for unruptured cerebral aneurysms. The primary outcome was defined as the composite outcomes of perioperative thromboembolic events, bleeding events, or death. Results: Among 632 patients, 533 (84.3%) were aged <75 years and 99 (15.6%) were aged ≥75 years. No significant differences were observed in the dual APT duration. The primary outcome occurred in 14.3% of patients aged <75 years and in 14.1% of those aged ≥75 years, with no significant difference (p = 1.0). The composites of the primary outcome, including thromboembolic events, bleeding events, and death differed insignificantly. Similar findings were observed when the primary outcomes for SAC (12.7% vs. 11.5%, p = 0.95) and FDS (17.5% vs. 18.4%, p = 1.0) were analyzed. The 30-day, 1-year, and 2-year cumulative event-free survival rates for the primary outcome were 89.5, 87.2%, and 85.2%, respectively, in patients aged <75 years, and 90.9%, 88.7%, and 87.0%, respectively, in those aged ≥75 years. These trends were similar (log-rank test, p = 0.92). Conclusion: No significant differences were observed in the rates of the primary outcomes between patients aged <75 years and those aged ≥75 years. Therefore, refraining from stent-assisted treatment for unruptured aneurysms based solely on age might be inappropriate. [ABSTRACT FROM AUTHOR]

Background and Objectives: Although intraprocedural rupture (IPR) is rare, it is a devastating complication of endovascular treatment (EVT) for intracranial aneurysms. Very few studies have been conducted on IPR, and the safety and efficacy of management techniques of IPR have not been investigated., Methods: Patients who experienced IPR during EVT between 2013 and 2022 were enrolled from a multicenter observational registry. We examined the safety and efficacy of the management of IPR using imaging markers, including increased hemorrhage and ischemic lesions, which were evaluated using postoperative computed tomography and diffusion-weighted imaging, respectively., Results: Of the 3269 EVTs for intracranial aneurysms, 74 patients who experienced IPR (2.26%) were analyzed. Fifty-five patients (3.36%) experienced IPR among 1636 EVT cases for ruptured aneurysms. Multivariate analysis revealed that increased hemorrhage was significantly associated with poor outcomes (odds ratio [OR], 6.37 [95% CI, 1.00-40.51], P = .050), whereas ischemic lesions were not. Regarding management techniques of IPR, antihypertensive medication use was significantly associated with increased hemorrhage (OR, 14.16 [95% CI, 2.35-85.34], P = .004). Heparin reversal was an independent factor for ischemic lesions (OR, 8.92 [95% CI, 1.54-51.58], P = .014)., Conclusion: Although the setting of IPR may be miscellaneous, and optimal management varies depending on individual cases, heparin reversal might be associated with ischemic complications, and its role in the successful hemostasis in IPR during EVT for ruptured aneurysms remains unclear., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Subarachnoid hemorrhage due to the A1 segment of an anterior cerebral artery dissecting aneurysm is rare. Therefore, a standard treatment has not been established. Though several case reports of direct surgery exist, there are few reports on endovascular treatment. This is the first study to describe five patients who underwent endovascular treatment for ruptured A1 dissecting aneurysms. Between January 2001 and December 2022 in our affiliated centers, five cases of SAH-onset A1 dissecting aneurysms were treated with endovascular treatment. We describe in detail two representative cases, briefly summarize the other three, and analyze their complications and outcomes. In the five cases, four were female. Four were in their 50s, and one was in her 80s. The WFNS grades were as follows: three were 2, one was 4, and one was 5. No re-ruptures or symptomatic complications were observed. The modified Rankin Scale scores at the time of discharge were as follows; one was 0, one was 1, two were 2, and one was 5. One in five patients needed retreatment after endovascular trapping because of recanalization. Endovascular treatment may be an effective and viable treatment option for ruptured A1 dissecting aneurysms. Further studies are needed to collect detailed data on complications and outcomes.

Aim: To report our experience and the technique of two-step effective Onyx embolization from occipital artery (OA) for the obliteration of dural arteriovenous fistulas (DAVFs) with OA feeders., Material and Methods: The medical records of patients with intracranial DAVFs treated with trans-arterial embolization (TAE) using Onyx from the OA were retrospectively reviewed., Results: Seven patients were included. The methods of Onyx injection from the OA were categorized as simple Onyx injection into the shunt, and two-step embolization. Two-step embolization involved the Onyx or coil embolization of the OA distal to the branching site of the feeders in the first step, and Onyx was injected toward the target shunt in the second step. Simple Onyx injection was performed in two cases; in both cases, the residual shunt remained. By contrast, the two-step embolization technique was performed in five cases, and in all those cases, sufficient embolization of the DAVFs was achieved., Conclusion: Prior embolization using Onyx or coil of the distal OA helped prevent Onyx from unexpected embolization through the subcutaneous branches that were not associated with the shunt, thereby leading to effective embolization. This new two-step embolization technique from the OA may improve the obliteration rate of DAVFs with OA feeders using TAE with Onyx.

Objective: Cerebral venous sinus thrombosis (CVST) is one of the rare and severe complications of coronavirus disease 2019 (COVID-19) vaccines. CVST has also been reported to develop into dural arteriovenous fistula; however, there were no reports of dural arteriovenous fistula associated with COVID-19 vaccine-induced cerebral venous sinus thrombosis. Here, we describe a rare case of a transverse-sigmoid sinus dural arteriovenous fistula followed by CVST due to COVID-19 vaccination., Case Presentation: A 70-year-old patient presented with headache five days after receiving a second dose of COVID-19 vaccine. MRI showed a CVST in the superior sagittal sinus, left transverse sinus, and left sigmoid sinus. His headache improved after the administration of anticoagulant therapy. Six months later, a similar headache recurred, and cerebral angiography demonstrated a dural arteriovenous fistula in the left transverse sigmoid sinus and convexity dural arteriovenous fistulas in the left parietal cortex. The patient was treated twice with two sessions of transarterial embolization, and the shunts were completely occluded. His symptoms improved, and he was discharged with a modified Rankin Scale score of 0., Conclusion: Dural arteriovenous fistula can develop after CVST in association with COVID-19 vaccination., (©2024 The Japanese Society for Neuroendovascular Therapy.)

Background  The far lateral approach includes exposure of the C1 transverse process, vertebral artery, posterior arch of the atlas, and occipital condyle. We designed a method for systematic muscular-stage dissection and present our experience with this approach. Operative Methods  We used a horseshoe scalp flap that was reflected downward and medially. The lateral muscle layers were separated layer to layer to expose the suboccipital triangle. The medial muscle layers were separated in the midline and reflected in a single layer. At this stage, the midline of the C1 process and the foramen magnum were identified. The rectus capitis posterior major muscle was reflected to expose the posterior arch of the atlas. The C1 transverse process and vertebral artery were identified by reflection of the superior oblique muscle. The occipital condyle was separated accordingly. Results  We used this method of muscular dissection in 10 patients (foramen magnum meningioma, n  = 5; hypoglossal schwannoma, n  = 2; others, n  = 3). Systematic muscular-stage dissection facilitates identification of the anatomical landmarks with no vertebral artery injury. Gross total removal was obtained in all 9 patients with complex tumors. The patient with vertebral artery dissection successfully underwent proximal clipping. Conclusion  Our muscular-stage dissection could contribute to safe and effective surgery for the far lateral approach.