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Background Flow-diverting devices (FDDs), such as the Pipeline Embolization Device, have been gaining traction for treating challenging posterior circulation aneurysms. Few previous studies have focused on using FDDs to treat aneurysms of the basilar quadrifurcation. Methods We retrospectively reviewed the use of FDDs to treat patients with basilar quadrifurcation aneurysms. Patients were assessed for aneurysm type, previous aneurysm treatment, technical success, periprocedural complications, and long-term aneurysm occlusion. Results 34 patients were assessed; aneurysms of the basilar apex (n=23) or superior cerebellar artery (SCA) (n=7), or both (n=1), and posterior cerebral artery (PCA) (n=3). The mean (SD) largest aneurysm dimension was 8.7 (6.1) mm (range 1.9-30.8 mm). 14 aneurysms were previously surgically clipped or endovascularly coiled. All aneurysms had a saccular morphology. Complete or near-complete occlusion was achieved in 30 of 34 patients (88%) at final angiographic follow-up, a mean (SD) of 6.6 (5.4) months (range 0-19 months) postoperatively. No patient experienced postoperative symptomatic occlusions of the SCA or PCA; 4 patients developed asymptomatic posterior communicating artery occlusions; 28 patients (82%) experienced no complications; whereas 3 (9%) experienced major complications and 3 (9%) experienced minor complications; and 1 patient died as a result of subarachnoid hemorrhage. Conclusion Flow diversion may be a safe and effective option to treat basilar quadrifurcation aneurysms. Previously treated basilar quadrifurcation aneurysms with recurrence or residual lesion may benefit from additional treatment with an FDD. Further prospective studies should be directed toward validating these findings. [ABSTRACT FROM AUTHOR]

Background Vasospasm following aneurysmal subarachnoid hemorrhage (SAH) contributes significant morbidity and mortality after brain aneurysm rupture. However, the association between vascular territory of vasospasm and clinical outcome has not been studied. We present a hypothesis- generating study to determine whether the location of vasospasm within the intracranial circulation is associated with functional outcome after SAH. Methods A retrospective analysis of a prospective, intention- to- treat trial for aneurysmal SAH was performed to supplement trial outcomes with in- hospital angiographic imaging and treatment variables regarding vasospasm. The location of vasospasm and the position on the vessel (distal vs proximal) were evaluated. Modified Rankin scale (mRS) outcomes were assessed at discharge and 6 months, and predictive models were constructed. Results A total of 406 patients were included, 341 with follow- up data at 6 months. At discharge, leftsided vasospasm was associated with poor outcome (odds ratio (OR), 2.37; 95% CI, 1.25 to 4.66; P=0.01). At 6 months, anterior cerebral artery (ACA) vasospasm (OR, 3.87; 95% CI, 1.29 to 11.88; P=0.02) and basilar artery (BA) vasospasm (OR, 6.22; 95% CI, 1.54 to 27.11; P=0.01) were associated with poor outcome after adjustment. A model predicting 6- month mRS score and incorporating vasospasm variables achieved an area under the curve of 0.85 and a net improvement in reclassification of 13.2% (P<0.01) compared with a previously validated predictive model for aneurysmal SAH. Conclusions In aneurysmal SAH, left- sided vasospasm is associated with worse discharge functional status. At 6 months, both ACA and BA vasospasm are associated with unfavorable functional status. [ABSTRACT FROM AUTHOR]

Background Transradial artery access (TRA) for neurointerventional procedures is gaining widespread acceptance. However, complications that were previously rare may arise as TRA procedures increase. Here we report a series of retained catheter cases with a literature review. Methods All patients who underwent a neurointerventional procedure during a 23-month period at a single institution were retrospectively reviewed for a retained catheter in TRA cases. In cases of retained catheters, imaging was reviewed for anatomical variances in the radial artery, and clinical and demographic case details were analyzed. Results A total of 1386 nondiagnostic neurointerventional procedures were performed during the study period, 631 (46%) initially via TRA. The 631 TRA cases were performed for aneurysm embolization (n=221, 35%), mechanical thrombectomy (n=116, 18%), carotid stent/angioplasty (n=40, 6%), arteriovenous malformation embolization (n=38, 6%), and other reasons (n=216, 34%). Thirty-nine (6%) TRA procedures crossed over to femoral access, most commonly because the artery of interest could not be catheterized (26/39, 67%). A retained catheter was identified in five cases (1%), and one (0.2%) patient had an entrapped catheter that was recovered. All six patients with a retained or entrapped catheter had aberrant radial anatomy. Conclusion Retained catheters for neurointerventional procedures performed via TRA are rare. However, this complication may be associated with variant radial anatomy. With the increased use of TRA for neurointerventional procedures, awareness of anatomical abnormalities that may lead to a retained catheter is necessary. We propose a simple protocol to avoid catheter entrapment, including in emergent situations such as TRA for stroke thrombectomy. [ABSTRACT FROM AUTHOR]

Study Design: Radiographic analysis., Objective: Evaluate the anatomical relationships of the bowel to the lateral surgical corridor and the spine in various surgical positions., Summary of Background Data: Retroperitoneal transpsoas lateral lumbar interbody fusion (LLIF) may be performed with patients in the prone position, allowing for lateral and posterior approaches to the spine without repositioning the patient. Few, if any, studies discuss changes of the bowel position during these procedures., Methods: Ten healthy volunteers underwent MRI in 3 positions: supine, prone with hips extended (prone-extension), and right lateral decubitus (left side up) with hips flexed (lateral decubitus-flexion). Anatomical relationships of the bowel to fixed spinal landmarks were assessed at L1-5, and the changes among participants' positions were compared., Results: Anterior bowel movement was noted with prone-extension (range: 0.32-1.39 cm) and lateral decubitus-flexion (range: 0.97-2.18 cm) positioning compared with supine positioning. Significant anterior movement of the bowel was observed at L1-2 (P=0.03) and L2-3 (P=0.04) disc levels in participants in the prone position and at L2-3 (P=0.002) and L3-4 (P=0.01) in those in the lateral position when compared with those in the supine position. No differences in bowel movement were found for prone and lateral positioning. The percentages of participants with bowels located in the operative corridor were similar among the surgical positions (all P>0.07). 3D volumetric analysis showed that the magnitude of these changes was greatest for the upper left colon., Conclusions: The results showed that the bowel was positioned anteriorly at L1-5 disc levels when participants were in prone-extension and lateral decubitus-flexion positions compared with the supine position. Overall, the magnitude of bowel positional change was small and variable. These findings suggest that the bowel does not fall away from the surgical corridor when performing retroperitoneal access for single-position prone surgery compared with the lateral decubitus-flexion position., Competing Interests: The authors report no conflicts of interest., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a debilitating neurological disease associated with poor neurological outcomes., Objective: To evaluate the association between timing of physical therapy (PT) initiation and neurological outcomes among patients treated for aSAH., Methods: Patients receiving definitive aneurysm treatment at a single quaternary center (January 1, 2014-July 31, 2019) with data available on PT initiation and the number of sessions were analyzed. Patients were compared based on whether PT initiation was delayed (>24 hours after definitive aneurysm treatment) or nondelayed (≤24 hours after treatment). The primary outcome was a poor neurological outcome at last follow-up (modified Rankin Scale [mRS] score >2). A propensity-adjusted score was generated and included as a covariate in a logistic regression analysis., Results: Among 382 patients, 260 (68%) had delayed and 122 (32%) had nondelayed PT initiation. A significantly greater percentage of patients in the delayed PT group had an mRS score of >2 at last follow-up (42% [n = 110] vs 20% [n = 24]; P < .001). Among 298 patients with a Hunt and Hess (HH) grade <4, the percentage with an mRS score of >2 at last follow-up was significantly higher in the delayed (34% [62/184]) than nondelayed (18% [21/114]) PT group ( P = .006). The logistic regression analysis showed that, among patients with an HH grade of <4, delayed PT initiation increased the risk of having an mRS score of >2 at follow-up (odds ratio = 1.90, 95% CI = 1.02-3.62, P = .047)., Conclusion: Delayed PT initiation after definitive aneurysm treatment was associated with poor neurological outcomes regardless of patient characteristics, neurological presentation, or aneurysm characteristics., Competing Interests: The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Andrew F. Ducruet is a consultant for Medtronic, Penumbra, Stryker, Cerenovus, Koswire, Balt, and Oculus. Ruchira M. Jha has nonrelated grants from NIH, Chuck Noll Foundation, and Barrow Neurological Foundation and is a paid consultant at Biogen., (© The Author(s) 2023. Published by Wolters Kluwer Health, Inc. on behalf of Congress of Neurological Surgeons.)

Objective: Vertebrobasilar dissecting (VBD) aneurysms are rare, and patients with these aneurysms often present with thromboembolic infarcts or subarachnoid hemorrhage (SAH). The morphological nature of VBD aneurysms often precludes conventional clip reconstruction or coil placement and encourages parent artery exclusion or endovascular stenting. Treatment considerations include aneurysm location along the vertebral artery (VA), the involvement of the posterior inferior cerebellar artery (PICA), and collateral blood flow. Outcomes after endovascular treatment have been well described in the neurosurgical literature, but microsurgical outcomes have not been detailed. Patient outcomes from a large, single-surgeon, consecutive series of microsurgically managed VBD aneurysms are presented, and 3 illustrative case examples are provided., Methods: The medical records of patients with dissecting aneurysms affecting the intracranial VA (V4), basilar artery, and PICA that were treated microsurgically over a 19-year period were reviewed. Patient demographics, aneurysm characteristics, surgical procedures, and clinical outcomes (according to modified Rankin Scale [mRS] scores at last follow-up) were analyzed., Results: Forty-two patients with 42 VBD aneurysms were identified. Twenty-six aneurysms (62%) involved the PICA, 14 (33%) were distinct from the PICA origin on the V4 segment of the VA, and 2 (5%) were located at the vertebrobasilar junction. Thirty-four patients (81%) presented with SAH with a mean Hunt and Hess grade of 3.2 at presentation. Six (14%) of the 42 patients had been previously treated using endovascular techniques. Nineteen aneurysms (45%) underwent clip wrapping, 17 (40%) were treated with bypass trapping, and 6 (14%) underwent parent artery sacrifice. The complete aneurysm obliteration rate was 95% (n = 40), and the surgical complication rate was 7% (n = 3). The 8 patients with unruptured VBD aneurysms were significantly more likely to be discharged home (n = 6, 75%) compared with 34 patients with ruptured aneurysms (n = 9, 27%; p = 0.01). Good outcomes (mRS score ≤ 2) were observed in 20 patients (48%). Eight patients (19%) died., Conclusions: These data demonstrate that patients with VBD aneurysms often present after a rupture in poor neurological condition, but favorable results can be achieved with open microsurgical repair in almost half of such cases. Microsurgery remains a viable treatment option, with the choice between bypass trapping and clip wrapping largely dictated by the specific location of the aneurysm and its relationship to the PICA.

Objective: The complex decision analysis of unruptured intracranial aneurysms entails weighing the benefits of aneurysm repair against operative risk. The goal of the present analysis was to build and validate a predictive scale that identifies patients with the greatest odds of a postsurgical adverse event., Methods: Data on patients who underwent surgical clipping of an unruptured aneurysm were extracted from the prospective National Surgical Quality Improvement Program registry (NSQIP; 2007-2014); NSQIP does not systematically collect data on patients undergoing intracranial endovascular intervention. Multivariable logistic regression evaluated predictors of any 30-day adverse event; variables screened included patient demographics, comorbidities, functional status, preoperative laboratory values, aneurysm location/complexity, and operative time. A predictive scale was constructed based on statistically significant independent predictors, which was validated using both NSQIP (2015-2016) and the Nationwide Inpatient Sample (NIS; 2002-2011)., Results: The NSQIP unruptured aneurysm scale was proposed: 1 point was assigned for a bleeding disorder; 2 points for age 51-60 years, cardiac disease, diabetes mellitus, morbid obesity, anemia (hematocrit < 36%), operative time 240-330 minutes; 3 points for leukocytosis (white blood cell count > 12,000/μL) and operative time > 330 minutes; and 4 points for age > 60 years. An increased score was predictive of postoperative stroke or coma (NSQIP: p = 0.002, C-statistic = 0.70; NIS: p < 0.001, C-statistic = 0.61), a medical complication (NSQIP: p = 0.01, C-statistic = 0.71; NIS: p < 0.001, C-statistic = 0.64), and a nonroutine discharge (NSQIP: p < 0.001, C-statistic = 0.75; NIS: p < 0.001, C-statistic = 0.66) in both validation populations. Greater score was also predictive of increased odds of any adverse event, a major complication, and an extended hospitalization in both validation populations (p ≤ 0.03)., Conclusions: The NSQIP unruptured aneurysm scale may augment the risk stratification of patients undergoing microsurgical clipping of unruptured cerebral aneurysms.