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Background and objectivesThis study investigates geographic disparities in aneurysmal subarachnoid hemorrhage (aSAH) care for Black patients and aims to explore the association with segregation in treatment facilities. Understanding these dynamics can guide efforts to improve healthcare outcomes for marginalized populations.MethodsThis cohort study evaluated regional differences in segregation for Black patients with aSAH and the association with geographic variations in disparities from 2016 to 2020. The National Inpatient Sample (NIS) database was queried for admission data on aSAH. Black patients were compared to White patients. Segregation in treatment facilities was calculated using the dissimilarity (D) index. Using multivariable logistic regression models, the regional disparities in aSAH treatment, functional outcomes, mortality, and end-of-life care between Black and White patients and the association of geographical segregation in treatment facilities was assessed.Results142,285 Black and White patients were diagnosed with aSAH from 2016 to 2020. The Pacific division (D index = 0.55) had the greatest degree of segregation in treatment facilities, while the South Atlantic (D index = 0.39) had the lowest. Compared to lower segregation, regions with higher levels of segregation (global F test p

Introduction We present a patient with a giant vertebrobasilar system aneurysm. This case provides an in‐depth analysis of the pathologic mechanism resulting in catastrophic distal hemorrhage following stent deployment due to the shared effects of normal perfusion pressure breakthrough (NPPB) and the Windkessel phenomenon. The Windkessel phenomenon and NPPB occur before and after treatment of various vascular malformations, respectively. These phenomena are hypothesized to contribute to the loss of cerebrovascular autoregulation. High flow lesions and giant aneurysms reduce blood flow in downstream vessels, causing chronic distal vasodilation to protect against ischemia. Sudden restoration of normal pulsatile flow, following treatment, compromises the integrity of distal vessels leading to potential catastrophic intracerebral hemorrhage. Methods A retrospective review of the patient’s medical record was performed. Results A 60‐year‐old female initially presenting with pulsatile neck mass was found to have dolichoectasia of the right cervical internal carotid artery and two large, irregular, vertebrobasilar aneurysms. Managed conservatively for 10 years before developing gait ataxia, new imaging revealed growth of the now giant, more distal aneurysm. Flow diversion with partial coiling of the aneurysms was pursued. Following deployment, DynaCT demonstrated catastrophic thalamic and midbrain hemorrhage with intraventricular extension. A review of intra‐aneurysmal pressure measurements, angiography, MRI, and neuromonitoring data strongly suggests rupture of multiple deep perforators following the conversion to laminar flow when the flow diverting chain was finalized. This suggests giant aneurysms chronically depress the distal pulse pressure by acting as a Windkessel reservoir. Flow diversion bypasses the reservoir increasing pulse pressure distal to the aneurysm, exceeding autoregulatory capacity, leading to hemorrhage. Conclusions This is the first case in the literature to describe NPPB and the Windkessel phenomenon in the attempt to treat giant aneurysms with flow diversion. Flow diversion bypasses the reservoir, suddenly changing turbulent flow to laminar flow. The resultant dramatic rise in pulse pressure distal to the aneurysm can exceed the autoregulatory mechanisms of small distal vessels such as perforating branches. While demonstrating a poor outcome, awareness of these mechanisms and meticulous intra‐operative blood pressure management may reduce or prevent complications. Further modeling of flow dynamics both before and following treatment of these aneurysms may lead to altered guidelines in the temporality of treatment due to potential catastrophic sequelae.

Introduction Intracranial pseudoaneurysms (IPA) are rare and potentially life‐altering lesions. Although IPAs represent less than 1% of all intracranial aneurysms, they account for more than 19% of pediatric intracranial aneurysms. The goal of this study was to systematically review the management and outcomes of pediatric patients who developed pseudoaneurysms following head trauma. Methods Following PRISMA guidelines, a systematic literature review was performed using PubMed, EMBASE, OVID Medline and Web of Science databases from date of database inception to May 2022. Studies were selected based on predetermined inclusion and exclusion criteria. Simultaneously, a retrospective analysis was conducted on pediatric patients who underwent endovascular evaluation and treatment for intracranial pseudoaneurysms originating from head trauma at a single institution. Results A total of 221 articles were identified in our review, 51 studies met inclusion criteria. A total of 80 patients were treated for 81 intracranial traumatic pseudoaneurysms, including 5 cases from our institution, with 46 males, 28 females, and a mean age of 9.90 years (range 0.04 ‐18 years). 71 total pseudoaneurysms were the result of external trauma while 10 resulted from iatrogenic trauma. Vessels of the anterior circulation were injured in 75.3% (61/81) of cases. Posterior circulation was involved in 24.7% (20/81) of cases. The internal carotid artery was the most impacted vessel at 45.7% (37/81). The next most common territory injured was the anterior cerebral artery and its distal branches, including the pericallosal and callosomarginal arteries, at 17.3% (14/81). The basilar artery was the third most affected artery, representing 12.3% (10/81) of cases. Hemorrhage was present in 41 patients (51.3%). Subarachnoid hemorrhage was present in 33.8% (27/80), while intracerebral hemorrhage and interventricular hemorrhage (IVH) were present 22.5% and 18.8% of cases, respectively. A total of 92 procedures were performed, with only 8 patients requiring more than 1 procedure for treatment. Only 1 patient required more than 2 procedures. Aneurysm embolization, parent vessel occlusion, parent vessel reconstruction, and aneurysm trapping were performed in 31.5%, 22.8%, 43.5%, and 2.2% of cases, respectively. The intraoperative complication rate was 3.26%, all were ischemic in nature. Two of these ischemic complications resulted focal neurological deficits from parent vessel occlusion. Aneurysm recurrence was encountered in 7 cases, with 6 of these resulting from coil embolization. In patients treated with parent vessel reconstruction, 1 aneurysm ruptured post‐treatment and 2 patients experienced in‐stent thrombosis. Overall, 83.8% of patients had a good neurological outcome and 77.8% of aneurysms were completed occluded on follow‐up imaging. Conclusions The development of pseudoaneurysms in the pediatric population are an important consideration in cases of traumatic head injuries or iatrogenic vessel trauma. These lesions grow rapidly and can carry a high risk of morbidity and mortality if left untreated. Our findings suggest that endovascular treatment of traumatic pseudoaneurysms in the pediatric populations is safe and effective, with high rates of aneurysm occlusion and good neurological outcome. Overall, complications rates are low. Aneurysm embolization can carry an increased risk of aneurysm recurrence.

Mixed methods research (MMR) can support enhanced understanding of complex educational issues, like the inclusion and support of individuals with disabilities in community and school settings. In this systematic review, we explored the extent to which MMR has been used in research exclusively focused on disability across special education (SPED), general education (GE), and disability studies in education (DSE; n = 115 studies). We examined research explicitly considering individuals with extensive support needs (ESNs) in this literature. We highlight the prevalence of MMR exploring topics relevant to individuals with ESN and features of this body of work, including (a) participants in these studies, (b) the presence of theoretical and/or conceptual framing for the research, (c) the goals/aims of the research studies, (d) the purposes for mixing, and (e) the data-generation methods used by the authors. We discuss patterns in the data that reflect differences across subfields, presumptions of competence, and ways ableism shapes research studies. Implications for research and practice to improve inclusive experiences for individuals with ESN are discussed.