Demographic and clinical predictors of multiple intracranial aneurysms in patients with subarachnoid hemorrhage

Sex Differences in Outcome of Aneurysmal Subarachnoid Hemorrhage and Its Relation to Postoperative Cerebral Ischemia

BACKGROUND

Whether there is a sex difference in the outcome of aneurysmal subarachnoid hemorrhage (aSAH) remains controversial, and clarifying the role of women in postoperative cerebral ischemic events can help us to understand its relationship with poor prognosis. Therefore, the purpose of this study was to elucidate the relationship between the three aspects of sex differences, postoperative cerebral ischemia, and poor prognosis after aSAH.

METHODS

A total of 472 patients admitted within 72 h after aSAH between January 2018 and December 2022 were included. We systematically analyzed the characteristics of sex differences in aSAH and explored the relationship between delayed cerebral ischemia (DCI), surgery-related cerebral infarction (SRCI), and poor prognosis (modified Rankin Scale > 2).

RESULTS

Compared with women, men were in worse condition and had more intracerebral hematoma (p = 0.001) on admission, whereas women were older (p < 0.001) and had more multiple aneurysms (p = 0.002). During hospitalization, men were more likely to experience emergency intubation (p = 0.036) and tracheotomy (p = 0.013). Women achieved functional independence at discharge at a similar rate to men (p = 0.394). Among postoperative complications, the incidence of DCI (22% vs. 12%, p = 0.01) and urinary tract infection (p = 0.022) was significantly higher in women. After adjusting for age, multivariable regression analysis showed that hypertension (odds ratio [OR] 2.139, 95% confidence interval [CI] 1.027-4.457), preoperative rerupture (OR 12.240, 95% CI 1.491-100.458), pulmonary infection (OR 2.297, 95% CI 1.070-4.930), external ventricular drainage placement (OR 4.382, 95% CI 1.550-12.390), bacteremia (OR 14.943, 95% CI 1.412-158.117), SRCI (OR 8.588, 95% CI 4.092-18.023), venous thrombosis (OR 5.283, 95% CI 1.859-15.013), higher modified Fisher grades (p = 0.003), and Hunt-Hess grades (p = 0.035) were associated with poor prognosis, whereas DCI (OR 1.394, 95% CI 0.591-3.292) was not an independent risk factor for poor prognosis. The proportion of patients who fully recovered from cerebral ischemia was higher in the DCI group (p < 0.001) compared with the SRCI group, and more patients were discharged with modified Rankin Scale > 2 in the SRCI group (p = 0.005).

CONCLUSIONS

Women have a higher incidence of DCI, but there is no sex difference in outcomes after aSAH, and poor prognosis is associated with worse admission condition and perioperative complications. SRCI is a strong independent risk factor for poor prognosis, whereas DCI is not.

Application of zone classification in multiple intracranial aneurysmal subarachnoid hemorrhage treatment strategies

Background

The options of surgical approach and treatment stage are two challenging treatment strategy issues with multiple intracranial aneurysmal subarachnoid hemorrhage (MIA-SAH).

Methods

We retrospectively analyzed data from patients with MIA-SAH who underwent surgery in our center between January 1, 2014 and September 1, 2022. To define "zone classification", the cranial cavity was divided into four zones by the planes of cerebral falx and tentorium cerebelli. Aneurysms isolated to one zone were defined as zone classification I; those crossing two zones were defined as zone classification II; those crossing three zones were defined as zone classification III; and those crossing four zones were defined as zone classification IV. General and aneurysmal-related characteristics of patients with different zone classifications were collected and compared between two surgical approaches. Multivariate logistic regression analysis was used to identify factors independently associated with multistage treatment options.

Results

A total of 226 patients with 523 aneurysms were included. The proportion of patients undergoing endovascular treatment increased with higher zone classification (I: 85.4%; II: 94.0%; III: 100.0%; IV: 100.0%). The proportion of patients receiving one-stage treatment decreased with higher zone classification (I: 60.2%; II: 33.6%; III: 0.0%; IV: 0.0%). Compared with patients undergoing microsurgical clipping, more patients undergoing endovascular treatment had zone classification II-IV (56.9% vs. 31.8%, p = 0.025). Zone classification II-IV (odds ratio [OR] = 3.821, 95% confidence interval [CI]: 2.041-7.154, p < 0.001), endovascular treatment (OR = 8.756, 95% CI: 2.589-29.609, p < 0.001), and size of all unruptured aneurysms <3 mm (OR = 4.531, 95% CI: 2.315-8.871, p < 0.001) were each independently associated with multistage treatment.

Conclusions

Zone classification provides a new idea in MIA-SAH treatment strategies, especially regarding surgical approach and treatment stage options.

Aneurysmal Subarachnoid Hemorrhage and Sex Differences: Analysis of Epidemiology, Outcomes, and Risk Factors

BACKGROUND

The differences in outcomes after aneurysmal subarachnoid hemorrhage (aSAH) between the sexes have not been concretely determined. This study aimed to evaluate the differences in epidemiology, outcomes, and risk factors between male and female patients with aSAH.

METHODS

We performed a multicenter, retrospective study of patients with aSAH from 2017 to 2020. We investigated the epidemiological differences between the two sexes. Propensity score matching (PSM) was used to compare short-term outcomes between the sexes. Binary logarithmic regression was performed to investigate the odds ratio (OR) for dependent survival in patients of different sexes.

RESULTS

A total of 5,407 consecutive patients with aSAH were included in this study, and the female-to-male ratio was 1.8:1. The peak incidence of aSAH occurred in the 6th and 7th decades in males and females, respectively. There were more female patients with internal carotid artery or posterior communicating artery aneurysms (53.2%), and there were more male patients with anterior cerebral artery or anterior communicating artery aneurysms (43.2%). The incidence of multiple aneurysms was greater in female patients (21.5% vs. 14.2%, P < 0.001). There was no significant difference in outcomes before and after PSM at discharge. The dependent survival risk was related only to the clinical condition on admission in women. In addition, age > 50 years (OR 1.88, 95% confidence interval 1.17-3.02; P = 0.01) and hypertension (OR 1.81, 95% confidence interval 1.25-2.61; P = 0.002) were also risk factors for male patients.

CONCLUSIONS

There were more female patients with aneurysms than male patients in this study. Most aneurysm locations were different between the two groups. There was no significant difference in discharge outcomes before and after PSM. The risk factors for dependent survival were different between female and male patients.

Risk of unruptured aneurysms in subarachnoid hemorrhage patients with multiple intracranial aneurysms: a multicenter, longitudinal, comparative study from China

BACKGROUND

In aneurysmal subarachnoid hemorrhage patients with multiple intracranial aneurysms (aSAH-MIA patients), the risk of secondary unruptured intracranial aneurysms is inconsistent. This study aimed to explore the risk of unruptured aneurysms in Chinese aSAH-MIA patients.

METHODS

The medical records and angiographic images of aSAH-MIA patients from eight cerebrovascular centers in China were retrospectively reviewed and analyzed. Patients with a single unruptured intracranial aneurysm (UIA) and no prior aSAH were used as controls. Propensity score matching (PSM) was employed to balance the differences in age, gender, aneurysm size, aneurysm site, and follow-up duration between the two groups.

RESULTS

The study included 267 unruptured aneurysms from 204 aSAH-MIA patients and 769 single UIA. After PSM, 201 aneurysms were enrolled in the aSAH-MIA group and 201 aneurysms in the control group. The mean follow-up was 2.2 years. Thirty-four aneurysm instability events (28 growth and 6 rupture, 16.9%) occurred during follow-up in the aSAH-MIA group and 16 instability events (13 growth and 3 rupture, 8%) occurred in the control group. Risk factors for aneurysmal instability were aneurysm irregularity (OR 2.53; 95% CI 1.18 to 4.31), higher size ratio (OR 1.23; 95% CI 1.37 to 4.39), and middle cerebral artery location (OR 1.86; 95% CI 1.03 to 3.17). The risk of aneurysmal instability was substantially elevated in the aSAH-MIA group (HR 2.07; 95% CI 1.12 to 3.02).

CONCLUSIONS

Unruptured aneurysms in Chinese aSAH-MIA patients exhibited higher risks of growth and rupture than in patients with a single UIA. Middle cerebral artery location, higher size ratio and irregular shape were associated with higher risk of growth or rupture.

Rupture discrimination of multiple small (< 7 mm) intracranial aneurysms based on machine learning-based cluster analysis

BACKGROUND

Small multiple intracranial aneurysms (SMIAs) are known to be more prone to rupture than are single aneurysms. However, specific recommendations for patients with small MIAs are not included in the guidelines of the American Heart Association and American Stroke Association. In this study, we aimed to evaluate the feasibility of machine learning-based cluster analysis for discriminating the risk of rupture of SMIAs.

METHODS

This multi-institutional cross-sectional study included 1,427 SMIAs from 660 patients. Hierarchical cluster analysis guided patient classification based on patient-level characteristics. Based on the clusters and morphological features, machine learning models were constructed and compared to screen the optimal model for discriminating aneurysm rupture.

RESULTS

Three clusters with markedly different features were identified. Cluster 1 (n = 45) had the highest risk of subarachnoid hemorrhage (SAH) (75.6%) and was characterized by a higher prevalence of familiar IAs. Cluster 2 (n = 110) had a moderate risk of SAH (38.2%) and was characterized by the highest rate of SAH history and highest number of vascular risk factors. Cluster 3 (n = 505) had a relatively mild risk of SAH (17.6%) and was characterized by a lower prevalence of SAH history and lower number of vascular risk factors. Lasso regression analysis showed that compared with cluster 3, clusters 1 (odds ratio [OR], 7.391; 95% confidence interval [CI], 4.074-13.150) and 2 (OR, 3.014; 95% CI, 1.827-4.970) were at a higher risk of aneurysm rupture. In terms of performance, the area under the curve of the model was 0.828 (95% CI, 0.770-0.833).

CONCLUSIONS

An unsupervised machine learning-based algorithm successfully identified three distinct clusters with different SAH risk in patients with SMIAs. Based on the morphological factors and identified clusters, our proposed model has good discrimination ability for SMIA ruptures.

Spontaneous subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.

Lysyl oxidase family gene polymorphisms and risk of aneurysmal subarachnoid hemorrhage: a case-control study

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease caused by intracranial aneurysm (IA) rupture. Lysyl oxidase (LOX) family genes (LOX-like [LOXL] 1-4) have roles in collagen cross-linking in the extracellular matrix (ECM) and may be associated with IA rupture. We aimed to explore the association between LOX polymorphisms and the risk of aSAH.

Methods

This case-control study included 2 cohorts: 133 single ruptured and 115 unruptured IA patients, and 65 multiple ruptured and 71 unruptured IA patients. Genotyping of 27 single nucleotide polymorphisms (SNPs) in LOX was performed. Logistic regression analysis was performed to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) of the SNPs of LOX and the risk of aSAH.

Results

LOX rs1800449 and LOXL4 rs3793692 were positively associated with the risk of single IA rupture in the recessive model (OR =5.66, 2.06; 95% CI =1.22–26.24, 1.11–3.82, respectively) and LOX rs10519694 demonstrated a protective effect on single IA rupture (dominant model: OR =0.42, 95% CI =0.21–0.83; recessive model: OR =0.16, 95% CI =0.04–0.65; additive model: OR =0.46, 95% CI =0.28–0.78). LOXL1 rs2165241, LOXL2 rs1063582, and LOXL3 rs17010021 showed risk effects on multiple IAs rupture. LOXL3 rs17010022 showed a protective effect on multiple IAs ruptures (dominant model: OR =0.41, 95% CI =0.21–0.82; additive model: OR =0.51, 95% CI =0.30–0.85).

Conclusions

LOX and LOXL4 may be susceptibility genes for single IA rupture, whereas LOXL1-3 may have a role in susceptibility to multiple IAs ruptures in the Chinese population, suggesting that LOX family genes may be associated with aSAH.

Sex differences in neurovascular disorders

Neurovascular disorders is a heterogenous group of diseases, including one of the most time critical disorders in emergency medicine; stroke. Sex differences are extensively described in neurovascular disorders, ranging from differences in symptom presentation, risk factors, treatment and outcomes. For example, women with stroke, more often present with generalized weakness, reduced consciousness and headache than men. Furthermore, there are differences in risk factors, outcomes and in the effect of secondary prevention. Women have a higher risk of cerebral venous thrombosis and developing cerebral aneurysms. In general, women have been underrepresented in trials on neurovascular disorders. This chapter provides an extensive overview of sex differences in stroke in general and in the differences specially seen in ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage and in cerebral venous thrombosis.

Clinical Characteristics and Outcome of Patients with Multiple Intracranial Aneurysms from a University Hospital in Nepal

Objective  The risk factors, management strategies, and outcomes of patients with multiple intracranial aneurysms (MIAs) are different compared with that of patients with a single aneurysm. Data are scarce regarding patients with MIAs from developing countries. The objective of this study was to describe the clinical characteristics, management strategies, and outcomes of patients treated microsurgically from Nepal.

Methods  The clinical records of patients confirmed to have MIAs and microsurgically clipped between July 2014 and December 2019 were retrospectively reviewed. Data on demographic and clinical characteristics, computed tomography findings, multiplicity and location of aneurysms, management strategies, and the 1-year outcome were abstracted and analyzed.

Results  Two hundred cerebral aneurysms were microsurgically clipped in 170 consecutive patients during the study period. Twenty-six (13.0%) patients harbored 60 aneurysms. The mean age of the patients was 58.5 (43–73) years. Smoking and hypertension were found in 20 (76.9%) and 16 (61.5%) patients, respectively. The majority of patients [17 (65.4%)] were in good grades at presentation. Twenty-one patients had two aneurysms, four had three aneurysms, and one patient had five aneurysms. The middle cerebral artery was the commonest (20) followed by distal anterior cerebral artery (14) and anterior communicating artery (13) involved in multiplicity. A single-stage surgery was performed on 17 patients. Serial clipping was performed in six patients. In three patients, a single aneurysm on the contralateral side was left untreated for various reasons. The favorable outcome was achieved in 23 (88.5%) patients whereas three (11.5%) patients had an unfavorable outcome. One patient died.

Conclusion  The demographic and clinical characteristics of patients in our series are comparable with those described in the published literature from other countries. With an individualized treatment strategy, an acceptable outcome can be achieved in the majority of the patients.

Timing and outcome of bystanders treatment in patients with subarachnoid hemorrhage associated with multiple aneurysms

In case of subarachnoid hemorrhage (SAH) associated with multiple intracranial aneurysms (MIAs), the main goal of acute treatment is securing the source of bleeding (index aneurysm). Indications and timing of bystanders treatment are instead still debated as the risk of new SAHs in patients harboring MIAs is not yet established. However, even if technically feasible, a simultaneous management of all aneurysms remains questionable, especially for safety issues. We retrospectively reviewed our last 5-year experience with SAH patients harboring MIAs entered in a clinic-radiological monitoring for bystanders follow-up in order to evaluate the occurrence of morphological changes, bleeding events, and safety and efficacy of a delayed treatment. We included 39 patients with mean age of 59.5 ± 12.2 years who survived a SAH. Among them, 14 underwent treatment, whereas 25 continued follow-up. The mean time between index and bystanders treatment was 14.3 ± 19.2 months. Patients undergoing bystanders treatment were mainly female and in general younger than patients undergoing observation. No cases of growth or bleeding were observed among bystanders within the two groups during the follow-up, which was longer than 1 year for the intervention group, and almost 40 months for the observation group. No major complications and mRS modifications were observed after bystanders treatment. Our data seem to suggest that within the short follow-up, intervention and observation seem to be likewise safe for bystander aneurysms, showing at the same time that a delayed management presents a similar risk profile of treating unruptured aneurysms in patients with no previous history of SAH.

Unruptured cerebral aneurysm risk stratification: Background, current research, and future directions in aneurysm assessment

Background:

The optimal management of unruptured cerebral aneurysms is widely debated in the medical field. Rapid technology advances, evolving understanding of underlying pathophysiology, and shifting practice patterns have made the cerebrovascular field particularly dynamic in recent years. Despite progress, there remains a dearth of large randomized studies to help guide the management of these controversial patients.

Methods:

We review the existing literature on the natural history of unruptured cerebral aneurysms and highlight ongoing research aimed at improving our ability to stratify risk in these patients.

Results:

Landmark natural history studies demonstrated the significance of size, location, and other risk factors for aneurysm rupture, but prior studies have significant limitations. We have begun to understand the underlying pathophysiology behind aneurysm formation and rupture and are now applying new tools such as flow dynamics simulations and machine learning to individualize rupture risk stratification.

Conclusion:

Prior studies have identified several key risk factors for aneurysmal rupture, but have limitations. New technology and research methods have enabled us to better understanding individual rupture risk for patients with unruptured cerebral aneurysms.

Chronobiological Patterns of Aneurysmal Subarachnoid Hemorrhage in Central China

Background:

Aneurysmal subarachnoid hemorrhage (aSAH) is an acute and sometimes fatal cerebrovascular disease. The chronobiological patterns of aSAH are still unclear worldwide. This 15-year time-series study aims to clarify the chronobiological patterns including seasonal, monthly, weekly, and circadian distributions of aSAH.

Methods:

We retrospectively analyzed the medical records of aSAH patients in central China. To investigate seasonal and weekly distributions, we used the χ2 goodness-of-fit test to analyze the uniformity of the onset time. To explore monthly and circadian distributions, we established Fourier models to show the rhythmicity in chronobiological patterns. Subgroup analyses were conducted to assess the impact of age, gender, hypertension statuses, and aneurysmal characteristics (number, size, and location) on the chronobiological patterns of aSAH.

Results:

A total of 1469 patients with aSAH were recruited in the study. The seasonal and monthly distribution exhibited significantly higher incidence in winter and January/December and lower incidence in summer and July. The weekly distribution of aSAH onset showed no significant uneven variation. The circadian distribution of aSAH exhibited a significant pattern (p = 0.0145), with a morning peak around 8:00, and a late afternoon peak at 16:00–20.00. The circadian rhythmicity varied in subgroups of different ages, genders, and aneurysmal locations.

Conclusion:

The occurrence of aSAH exhibits significant circannual and circadian patterns among the Chinese population. Patients with aSAH of different ages, genders, and aneurysmal locations would present different chronobiological patterns.

Sex Differences in Cerebral Aneurysms and Subarachnoid Hemorrhage

Sex differences in cerebral aneurysm occurrence and characteristics have been well described. Although sex differences in outcomes following ischemic stroke have been identified, the effect of sex on outcomes following hemorrhagic stroke, and in particular, aneurysm treatment has been less studied. We describe the current state of knowledge regarding the impact of sex on treatment and outcomes of cerebral aneurysms. Although prior studies suggest that aneurysm prevalence and progression may be related to sex, we did not find clear evidence that outcomes following subarachnoid hemorrhage vary based on sex. Last, we identify areas for future research that could enhance understanding of the role sex plays in this context.

Modifiable risk factors for intracranial aneurysms: Evidence from genetic studies

Background:

Intracranial aneurysm (IA) is a crucial health concern with limited strategies for prevention and treatment.

Aim:

To identify potentially modifiable risk factors, such as socioeconomic, behaviors, dietary, and cardiometabolic factors, for IA and its subtypes.

Methods:

Summary statistics for IA were derived from a genome-wide association study with an overall 79,429 participants. Single nucleotide polymorphisms associated with modifiable risk factors at genome-wide significance ( P = 5 × 10–8) were used as instrumental variables. The inverse-variance-weighted method, weighted-median method, Mendelian randomization (MR)-Egger regression, MR-Pleiotropy RESidual Sum and Outlier, and multivariable MR analyses were performed to evaluate the effect estimates.

Results:

Genetically predicted educational attainment, insomnia, smoking, and systolic and diastolic blood pressure (SBP and DBP) were significantly associated with the risk of IA. The odds ratios (ORs) were 0.44 (95% confidence interval (CI): 0.37–0.52) for educational attainment, 1.15 (95% CI: 1.08–1.23) for insomnia, 1.56 (95% CI: 1.38–1.75) for smoking initiation, 2.69 (95% CI: 1.77–4.07) for cigarette per day, 2.65 (95% CI: 1.72–4.08) for lifetime smoking, 1.07 (95% CI: 1.06–1.09), and 1.06 (95% CI: 1.04–1.10) for SBP and DBP, respectively. Similar effect estimates were observed for unruptured IAs and aneurysmal subarachnoid hemorrhage.

Conclusions:

This study provided genetic evidence that several modifiable risk factors, including blood pressure, smoking, educational attainment, and insomnia were associated with the risk of IA.

The value of long-term angiographic follow-up following Pipeline embolization of intracranial aneurysms

BACKGROUND

Flow diversion of intracranial aneurysms with the Pipeline Embolization Device (PED) is commonly performed, but the value of long-term angiographic follow-up has not been rigorously evaluated. Here we examine the prevalence of actionable findings of aneurysm recurrence and development of in-stent stenosis in a cohort of patients that underwent long-term angiographic follow-up at multiple time points.

METHODS

Angiographic data from eligible patients were retrospectively assessed for aneurysm occlusion, in-stent stenosis, and aneurysm regrowth or recurrence. Patients were included in this study if they underwent angiographic imaging at 6 months post-treatment and at least one later time point.

RESULTS

100% (132/132) of aneurysms occluded at 6 months remained occluded at final follow-up. 85.7% (6/7), 56.3% (27/48), and 25% (6/24) of aneurysms with entry remnant, subtotal filling, and total filling, respectively, at 6 months were completely occluded at final follow-up. 98.7% (147/149) of PED constructs that demonstrated no stenosis at 6 months demonstrated no stenosis at final angiography, while 44.4% (8/18) of PED constructs demonstrating in-stent stenosis at 6 months had resolution of stenosis on final angiography.

CONCLUSIONS

Among patients who undergo treatment of intracranial aneurysms with PED, the value of long-term angiography in patients demonstrating complete aneurysm occlusion and no in-stent stenosis on 6 month post-treatment angiography is low.

Effect of the FDA Safety and Innovation Act on racial and gender diversity in neurosurgical device trials

OBJECTIVE

The US FDA uses evidence from clinical trials in its determination of safety and utility. However, these trials have often suffered from limited external validity and generalizability due to unrepresentative study populations with respect to clinical patient demographics. Section 907 of the FDA Safety and Innovation Act (FDASIA) of 2012 attempted to address this issue by mandating the reporting of certain study demographics in new device applications. However, no study has been performed on its effectiveness in the participant diversity of neurosurgical device trials.

METHODS

The FDA premarket approval (PMA) online database was queried for all original neurosurgical device submissions from January 1, 2006, to December 31, 2019. Endpoints of the study included racial and gender demographics of reported effectiveness trials, which were summated for each submission. Chi-square tests were performed on both endpoints for before and after years of FDASIA passage and implementation.

RESULTS

A total of 33 device approvals were analyzed, with 14 occurring before SIA implementation and 19 after. Most trials (96.97%) reported gender to the FDA, while 66.67% reported race and 63.64% reported ethnicity. Gender breakdown did not change significantly post-SIA (53.30% female, p = 0.884). Racial breakdown was significantly different from the 2010 US Census for all races (p < 0.001) both pre- and post-SIA. Only Native American race was significantly different in terms of representation post-SIA, increasing from 0% to 0.63% (p = 0.0187). There was no significant change in ethnicity.

CONCLUSIONS

The FDASIA, as currently written, does not appear to have had a significant impact on the racial or gender diversity of neurosurgical device clinical trial populations. This may be due to the noncompulsory nature of its guidance, or a lack of more stringent regulation on the composition of clinical trials themselves.

External Validation of the PHASES Score in Patients with Multiple Intracranial Aneurysms

OBJECTIVES

This study sought to assess whether the Population, Hypertension, Age, Size, Earlier Subarachnoid Hemorrhage, Site (PHASES) score can do risk stratification of patients with multiple aneurysms (MIAs).

MATERIAL AND METHODS

Patients between January 1, 2016 and January 1, 2019 were recruited retrospectively. The PHASES score was applied to assess the theoretical risk of IA rupture. For patients-level analyses, four modes of the application of the score were used: largest IA PHASES score, highest PHASES score, sum PHASES score, and mean PHASES score.

RESULTS

A total of 701 patients with 1673 IAs were included in this study. At aneurysm-level analysis, the average PHASES score was 3.0 ± 3.0 points, with 2.8 ± 3.0 points and 4.1 ± 2.9 points in the unruptured and ruptured groups, respectively (p < 0.001). At the patient-level analysis, for the largest IA PHASES score, the areas under the curves (AUC) was 0.572. The discrimination performance of the largest IA PHASES score decreases as IA number increases, with AUCs were 0.597, 0.518, and 0.450 in the 2 IAs, 3 IAs and, 4 or more IAs subgroups, respectively. For highest PHASES score, sum PHASES score, and mean PHASES score, the AUCs were 0.577, 0.599, and 0.619, respectively.

CONCLUSIONS

In this study, PHASES score only serve as a weak tool in decision-making settings for MIAs patients; as such, more accurate models should be developed for MIAs patients and the cumulative effect of MIA may should be considered.

Development and validation of a novel nomogram to predict aneurysm rupture in patients with multiple intracranial aneurysms: a multicentre retrospective study

Background and purpose

Approximately 15%–45% of patients with unruptured intracranial aneurysms have multiple intracranial aneurysms (MIAs). Determining which one is most likely to rupture is extremely important for treatment decision making for MIAs patients. This study aimed to develop and validate a nomogram to evaluate the per-aneurysm rupture risk of MIAs patients.

Methods

A total of 1671 IAs from 700 patients with MIAs were randomly dichotomised into derivation and validation sets. Multivariate logistic regression analysis was used to select predictors and construct a nomogram model for aneurysm rupture risk assessment in the derivation set. The discriminative accuracy, calibration performance and clinical usefulness of this nomogram were assessed. We also developed a multivariate model for a subgroup of 158 subarachnoid haemorrhage (SAH) patients and compared its performance with the nomogram model.

Results

Multivariate analyses identified seven variables that were significantly associated with IA rupture (history of SAH, alcohol consumption, female sex, aspect ratio >1.5, posterior circulation, irregular shape and bifurcation location). The clinical and morphological-based MIAs (CMB-MIAs) nomogram model showed good calibration and discrimination (derivation set: area under the curve (AUC)=0.740 validation set: AUC=0.772). Decision curve analysis demonstrated that the nomogram was clinically useful. Compared with the nomogram model, the AUC of multivariate model developed from SAH patients had lower value of 0.730.

Conclusions

This CMB-MIAs nomogram for MIAs rupture risk is the first to be developed and validated in a large multi-institutional cohort. This nomogram could be used in decision-making and risk stratification in MIAs patients.

Risk factors involved in the formation of multiple intracranial aneurysms

BACKGROUND

Although several risk factors of the multiple intracranial aneurysms (MIAs) formation has been reported, the results are controversial. We aimed to find out the risk factors of MIAs formation by analyzing our clinic data combined with a meta-analysis.

MATERIAL AND METHODS

A retrospective review work of medical records for the patients with aneurysms was undertaken. Univariate analysis was used to examine all mentioned variables. Binary logistic regression analysis was used to identify the risk factors of MIAs formation.

RESULTS

In the retrospective review work, a total of 565 patients with aneurysm were included in this study. Of these 565 participants, 449 patients suffered SIAs and 116 patients suffered MIAs. Univariate analysis showed a significant difference in terms of female, cigarette smoking, family history of hypertension, and primary hypertension between the SIAs and MIAs group. The binary logistic regression analysis showed that the female (OR = 1.624), primary hypertension (OR = 1.563), and family history of hypertension (OR = 2.496) were independent risk factors of the formation of MIAs (for each P < 0.05). With regard to the meta-analysis results, it revealed that there was significant difference in the rates of female (P < 0.001), cigarette smoking (P < 0.001), primary hypertension (P = 0.001), and higher age (P = 0.011) among the MIAs patients.

CONCLUSIONS

A higher rate of the formation of MIAs is closely associated with the elder and female. Patients with hypertension history, cigarette smoking, and family primary hypertension history also affected the formation of MIAs, these risk factors should be a guard against.

A meta-analysis of executive functions among survivors of subarachnoid haemorrhage

Subarachnoid Haemorrhage (SAH) is a type of stroke which is suggested to result in Executive Functioning (EF) deficits. Within the SAH research, EF is typically assessed as a unitary cognitive construct. Therefore, the nature and extent to which the different components of EF are impacted post SAH remain unclear. In this meta-analysis, 10 studies met selection criteria including 248 SAH participants, treated by endovascular coiling. Participants were assessed by EF measures and compared with 230 controls. Searches were conducted in November 2018 including Medline, PsychINFO, Web of Science, Scopus and CINAHL databases. EF measures were assigned to categories including Cognitive Flexibility, Working Memory, Inhibitory Control and Planning/Problem Solving [Diamond, 2013. Executive functions. Annual Review of Psychology, 64(1), 135-168. https://doi.org/10.1146/annurev-psych-113011-143750]. A statistically significant effect was found for overall EF. Cognitive Flexibility (G = -0.76) and Inhibitory Control (G = -0.51) generated moderate effect sizes, while Working Memory and Planning/Problem Solving found a small effect size (G = -0.45 and G = -0.49, respectively). The I² statistic suggested small to moderate heterogeneity between studies, hypothesized to relate to different cognitive tools. Underlying components of EF appear to be differentially impacted post SAH, with Cognitive flexibility demonstrating the largest degree of deficit. Recommendations for a standardized and uniform assessment of EF post SAH are outlined.

Single-stage clipping with bifrontal and bilateral frontotemporal craniotomies for subarachnoid hemorrhage with multiple cerebral aneurysms using Sugita head holding system: A case report

Background:

Subarachnoid hemorrhage with multiple aneurysms is very challenging because it is difficult to identify the ruptured aneurysm. We could not identify the ruptured aneurysm preoperatively, so we decided to treat all of the aneurysms as a single-stage surgery.

Case Description:

A 79-year-old woman was diagnosed with subarachnoid hemorrhage with multiple cerebral aneurysms at the right distal anterior cerebral artery, left middle cerebral artery, and right internal carotid artery- posterior communicating artery bifurcation. We could not identify the ruptured aneurysm preoperatively. We fixed her head using the Sugita head holding system (Mizuho Co., Ltd., Tokyo) and performed clipping for each aneurysm with bifrontal craniotomy and bilateral frontotemporal craniotomy as a single-stage operation. The last aneurysm seemed ruptured, and clipping for all the aneurysms was successful. She was discharged with a good postoperative course. The Sugita head holding system allowed turning the head of the patient toward the right and left with single fixation, leading to this single-stage operation.

Conclusion:

Several methods for identifying a ruptured aneurysm from multiple aneurysms have been reported, but under limited medical resources, this procedure would be one of the treatment strategies.

Tumor-induced peripheral immunosuppression promotes brain metastasis in patients with non-small cell lung cancer

INTRODUCTION

Brain metastases are a significant source of morbidity and mortality for patients with lung cancer. Lung cancer can induce local and systemic immunosuppression, promoting tumor growth and dissemination. One mechanism of immunosuppression is tumor-induced expansion of programmed death-ligand 1 (PD-L1) expressing myeloid cells. Here, we investigate peripheral blood immune phenotype in NSCLC patients with or without brain metastasis.

METHODS

Peripheral blood was collected from patients with lung metastatic brain tumors and pre-metastatic lung cancer. Immunosuppressive monocytes, myeloid-derived suppressor cells (MDSCs), and regulatory T cells (Tregs) were quantified through flow cytometry. T cell reactivity was analyzed via ELISpot. Brain metastasis conditioned media was collected from tumor-derived cell cultures and analyzed for cytokines by ELISA. Naïve monocytes were stimulated with brain metastasis conditioned media to evaluate PD-L1 stimulation.

RESULTS

Patients with brain metastatic lung carcinoma demonstrated increased peripheral monocyte PD-L1, MDSC abundance, and Treg percentage compared to early stage pre-metastatic patients and healthy controls. Patients with elevated peripheral monocyte PD-L1 had less reactive T cells and worse survival. Brain metastasis conditioned media stimulation increased monocyte PD-L1, and conditioned media IL-6 levels correlated with PD-L1 induction. Treatment with anti-IL-6 or anti-IL-6 receptor antibodies reduced PD-L1 expression. In summary, patients with lung cancer and brain metastases exhibit multiple markers of peripheral immunosuppression.

CONCLUSIONS

The frequency of PD-L1+ myeloid cells correlated with the presence of brain metastases. Tumor-derived IL-6 was capable of inducing PD-L1+ myeloid cells in vitro, suggesting that monitoring of immunosuppressive factors in peripheral blood may identify new targets for therapeutic intervention in selected patients.

Association of single and multiple aneurysms with tobacco abuse: an @neurIST risk analysis

OBJECTIVE

Although several studies have suggested that the incidence of intracranial aneurysms (IAs) is higher in smokers, the higher prevalence of subarachnoid hemorrhage (SAH) in smokers remains uncertain. It is unclear whether smoking additionally contributes to the formation of multiple aneurysms and the risk of rupture. The aim of this study was to determine whether smoking is associated with IA formation, multiplicity, or rupture.

METHODS

Patients from the prospective multicenter @neurIST database (n = 1410; 985 females [69.9%]) were reviewed for the presence of SAH, multiple aneurysms, and smoking status. The prevalence of smokers in the population of patients diagnosed with at least one IA was compared with that of smokers in the general population.

RESULTS

The proportion of smokers was higher in patients with IAs (56.2%) than in the reference population (51.4%; p < 0.001). A significant association of smoking with the presence of an IA was found throughout group comparisons (p = 0.01). The presence of multiple IAs was also significantly associated with smoking (p = 0.003). A trend was found between duration of smoking and the presence of multiple IAs (p = 0.057). However, the proportion of smokers among patients suffering SAH was similar to that of smokers among patients diagnosed with unruptured IAs (p = 0.48).

CONCLUSIONS

Smoking is strongly associated with IA formation. Once an IA is present, however, smoking does not appear to increase the risk of rupture compared with IAs in the nonsmoking population. The trend toward an association between duration of smoking and the presence of multiple IAs stresses the need for counseling patients with IAs regarding lifestyle modification.

Systemic and local immunosuppression in patients with high-grade meningiomas

AIM

Despite current treatments, high-grade meningiomas continue to have a poor prognosis. Immunotherapy targeting immune checkpoints, such as PD-L1, has demonstrated significant success in controlling numerous malignancies. In this study, we investigate the extent of systemic and local immunosuppression in meningiomas to assess the potential benefit of immune checkpoint inhibitors for the treatment of high-grade meningiomas.

METHODS

Peripheral blood was collected from patients undergoing resection of meningiomas (WHO grade I, n = 18; grade II, n = 25; grade III, n = 10). Immunosuppressive myeloid cells (CD45+CD11b+PD-L1+), myeloid-derived suppressor cells (MDSCs) (CD11b+CD33+HLA-DRlow), and regulatory T cells (Tregs) (CD3+CD4+CD25+FoxP3+) were quantified through flow cytometry. Tissue sections from the same patients were assessed for PD-L1 expression and T cell infiltration via immunohistochemistry.

RESULTS

Patients with grade III meningiomas demonstrated increased peripheral monocyte PD-L1 compared to patients with grade I/II meningiomas and healthy controls. Peripheral MDSC abundance was increased in grades II and III meningioma patients. PD-L1 staining of meningioma tissue demonstrated increased positivity in grade III meningiomas. Intratumoral PD-L1 was not associated with progression-free survival. High-grade meningiomas had increased T-cell infiltration. However, a significant proportion of these T cells were exhausted PD1+ T cells and immunosuppressive Tregs.

CONCLUSIONS

Patients with meningiomas exhibit signs of peripheral immunosuppression, including increased PD-L1 on myeloid cells and elevated MDSC abundance proportional to tumor grade. Additionally, the tumors express substantial PD-L1 proportional to tumor grade. These results suggest a role for immune checkpoint inhibitors targeting the PD-L1/PD-1 pathway in combination with standard therapies for the treatment of high-grade meningiomas.

Machine Learning Application for Rupture Risk Assessment in Small-Sized Intracranial Aneurysm

The assessment of rupture probability is crucial to identifying at risk intracranial aneurysms (IA) in patients harboring multiple aneurysms. We aimed to develop a computer-assisted detection system for small-sized aneurysm ruptures using a convolutional neural network (CNN) based on images of three-dimensional digital subtraction angiography. A retrospective data set, including 368 patients, was used as a training cohort for the CNN using the TensorFlow platform. Aneurysm images in six directions were obtained from each patient and the region-of-interest in each image was extracted. The resulting CNN was prospectively tested in 272 patients and the sensitivity, specificity, overall accuracy, and receiver operating characteristics (ROC) were compared to a human evaluator. Our system showed a sensitivity of 78.76% (95% CI: 72.30%-84.30%), a specificity of 72.15% (95% CI: 60.93%-81.65%), and an overall diagnostic accuracy of 76.84% (95% CI: 71.36%-81.72%) in aneurysm rupture predictions. The area under the ROC (AUROC) in the CNN was 0.755 (95% CI: 0.699%-0.805%), better than that obtained from a human evaluator (AUROC: 0.537; p < 0.001). The CNN-based prediction system was feasible to assess rupture risk in small-sized aneurysms with diagnostic accuracy superior to human evaluators. Additional studies based on a large data set are necessary to enhance diagnostic accuracy and to facilitate clinical application.

Ruptured intracranial aneurysm in a patient with autosomal recessive polycystic kidney disease

Aneurysmal rupture can result in devastating neurological consequences and can be complicated by comorbid disease processes. Patients with autosomal recessive polycystic kidney disease (ARPKD) have a low rate of reported aneurysms, but this may be due to the relative high rate of end-stage illnesses early in childhood. Authors here report the case of a 10-year-old boy with ARPKD who presented with a Hunt and Hess grade V subarachnoid hemorrhage requiring emergency ventriculostomy, embolization, and decompressive craniectomy. Despite initial improvements in his neurological status, the patient succumbed to hepatic failure. Given the catastrophic outcomes of subarachnoid hemorrhage in young patients, early radiographic screening in those with ARPKD may be warranted.