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Objective: Transient neurological events (TNEs) are frequently observed after revascularization surgery for moyamoya disease (MMD). However, clinical features and pathophysiology of TNEs in MMD are still unclear. This study was aimed to clarify the incidence and time course of TNEs and to determine the independent predictors of TNEs in MMD., Patients and Methods: A total of 195 hemispheres in 171 consecutive patients with MMD who had undergone combined direct and indirect bypass surgery were analyzed. Preoperative clinical characteristics and radiographic features were recorded. The incidence and clinical feature of postoperative TNEs were evaluated. Multivariate logistic regression analyses were performed to identify the risk factors for postoperative TNEs. Outcomes were compared between patients who had TNEs with those without TNEs at the time of discharge., Results: Postoperative TNEs were detected in 40 (20.5%) of 195 operated hemispheres, including 17 (42.5%) aphasia, 9 numbness of the extremities (22.5%), 6 seizures (15%), 5 motor weakness (12.5%), 4 dysarthria (10%) and 6 others (15%). The incidence of TNEs was significantly higher in adult patients than in pediatric ones. Multivariate analysis revealed that female, left-sided surgery and the presence of the edematous lesion was an independent predictor of TNEs after surgery in MMD (OR, 3.0; 95% CI, 1.1-8.2; P = 0.03, OR, 2.9; 95% CI, 1.2-7.0; P = 0.02 and OR, 17.4; 95% CI, 5.7-53.0; P < 0.01, respectively). DSA stage (OR 0.05, 95% CI 0.0-0.5, p = 0.005; OR 0.08, 95% CI 0.0-0.4, p = 0.008), PCA involvement (OR 2.75, 95% CI 1.0-7.4, p = 0.046), left-sided surgery (OR 2.73, 95% CI 1.2-6.5, p = 0.022) and edematous lesion (OR 21.2, 95% CI 7.6-59.7, <0.001) were significantly associated with TNE severity. Compared with patients without postoperative TNEs, no significant differences in mRS score between the two groups were detected., Conclusions: Female, left-sided surgery and edematous lesion were independent risk factors for postoperative TNEs; the left-sided surgery and edematous lesion were also independently associated with the severity of TNE. Although patients with postoperative TNEs had worse neurological status during the perioperative period, postoperative TNEs had no associations with worse mRS score at the time of discharge., (Copyright © 2019. Published by Elsevier B.V.)

Objective: Moyamoya disease (MMD) is a cerebrovascular disorder, currently defined as progressive stenosis of intracranial internal carotid artery and its main branches with secondary formation of netlike vessels. Its precise formation mechanism, however, is unknown. We propose that MMD is caused by abnormal embryonic development of the cerebral arteries and also propose a mechanism for MMD formation., Methods: The anterior, middle, and posterior cerebral arteries, anterior choroidal arteries (AChoA) and posterior choroidal arteries, and posterior corpus callosum arteries were analyzed separately for each patient with MMD to determine whether the arteries exhibited the following characteristics, which we regarded as remnants of primitive vessels: 1) plexiform arteries rather than normal artery trunks; 2) clustered arteries converging at locations of normal artery trunks; and 3) dilated AChoA., Results: We retrospectively analyzed 39 consecutive patients with MMD, of whom 30 had anterior cerebral arteries, 31 middle cerebral arteries, 10 posterior cerebral arteries, 30 AChoAs, 18 posterior choroidal arteries, and 20 posterior corpus callosum arteries and had the characteristics of primitive vessel remnants. Altogether, 82.05% of the patients had the remnants of primitive vessels., Conclusions: MMD is more likely to be caused by abnormalities of cerebral artery development, which mainly occur in the embryonic period or postnatally. The abnormality developing processes include sprouting angiogenesis, vessel fusion, and pruning, which primarily affect cranial ramus of primitive internal carotid artery, may occasionally affect the caudal ramus of the primitive internal carotid artery, and rarely affect the vertebrobasilar artery system. So-called moyamoya vessels comprise unfused primitive small vessels; to compensate, enlarged AChoAs remain undegenerated but are not dilated., (Copyright © 2019. Published by Elsevier Inc.)

Background: Recurrent stroke after surgical revascularization is still a big issue for moyamoya disease (MMD). This study aims to identify predictors for postoperative stroke and unfavorable outcome in ischemic-type MMD., Methods: We identified a consecutive series of patients with ischemic-type MMD who underwent revascularization between January 2005 and December 2012. Predictors for postoperative stroke and functional outcomes were assessed with logistic and Cox regression analysis., Results: A total of 346 patients underwent 437 revascularization procedures and the mean follow-up period was 4.0 years. The incidence of perioperative stroke was 6.9%. Being adult at onset (odds ratio [OR], 5.033; 95% confidence interval [CI], 1.447-17.506; P = 0.011) and posterior cerebral artery (PCA) stenosis (OR, 3.364; 95% CI, 1.588-7.265; P = 0.002) before surgery were predictors of perioperative stroke. The annual subsequent stroke rate beyond 30 days after surgery was 1.2%. Subsequent stroke events tended to occur throughout the first 5 years after surgery in adults, whereas in children they mainly occurred within the first 2 years after surgery. Age at onset (OR, 1.025; 95% CI, 1.003-1.048; P = 0.023), ischemic stroke or transient ischemic attack at presentation (OR, 2.703; 95% CI, 1.062-6.875; P = 0.037), and PCA involvement (OR, 2.664; 95% CI, 1.462-4.854; P = 0.001) were associated with higher risk of overall postoperative stroke. PCA involvement (OR, 2.62; 95% CI, 1.33-5.15; P = 0.005), internal carotid artery supraclinoid segment occlusion (OR, 2.76; 95% CI, 1.27-6.03; P = 0.011), and older age at onset (OR, 1.03; 95% CI, 1.01-1.05; P = 0.033) were predictive of unfavorable outcome., Conclusions: Patients with ischemic-type MMD at an older age and more severe angiopathy might be at higher risk of recurrent stroke and unfavorable outcome after revascularization., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Anterior cerebral artery (ACA) territory, a crucial area of intellectual development in children, is frequently involved in the progress of moyamoya disease (MMD). However, revascularization surgeries for this area are not as established as surgeries for middle cerebral artery (MCA) territory. This study aimed to describe our experience and study the effect of revascularizing ACA territory with periocranium and dural leaflets, which is referred to as 'encephalo-duro-periosteal-synangiosis (EDPS)'., Patients and Method: Fourteen hemispheres of 9 MMD patients who had undergone EDPS from November 2015 till July 2017 in our hospital were retrospectively included. Clinical characteristics and procedure-related information were recorded. Cerebral perfusion was evaluated by computed tomography perfusion (CTP). Absolute and relative (r) CTP parameters of ROIs in ACA territory at the level of centrum semiovale and middle basal ganglia were calculated. Preoperative and postoperative parameters were compared., Results: All EDPS procedures were technically successful with no postoperative complications. The mean operating time was 75.00 ± 22.53 min per hemisphere. Postoperative absolute cerebral blood flow (CBF), rCBF were significantly increased and absolute time to peak (TTP), rTTP, absolute mean transit time (MTT) were significantly reduced in ACA territory at centrum semiovale level (P = 0.002, 0.045, 0.007, 0.005 and 0.039 respectively). Improved outcomes were achieved in five patients, stabilization in three and one patient had deterioration out of intracerebral hemorrhage during follow-up., Conclusion: EDPS is a simple but effective technique to revascularize ACA territory for MMD. EDPS significantly improved cerebral blood perfusion of frontal lobe in the majority of patients without increasing procedure-related risks., (Copyright © 2019. Published by Elsevier B.V.)

Background: Different gene expression profiles are observed in intracranial aneurysm tissues. Understanding these genes and what regulates their expression will provide insight into the pathogenesis of intracranial aneurysms. We investigated whether differences in DNA methylation regulate gene expression in intracranial aneurysms., Methods: We compared 20 intracranial aneurysm tissue specimens with 20 matched specimens from the superficial temporal artery as controls. We identified the gene expression profiles in these samples using the GeneChip Human U133 Plus 2.0 array and evaluated DNA methylation modifications using the Infinium HumanMethylation450 BeadChip Kit., Results: A total of 11,022 differentially methylated sites between aneurysm tissues and matched control tissues were identified, and 2142 differentially expressed gene transcripts were detected based on the 2 gene expression profiles. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses and verification analysis showed that the MYH11, LIFR, and TLR4 genes were associated with the occurrence and development of intracranial aneurysms. These genes mainly encode cell adhesion molecules or are involved in the NF-κB, JAK-STAT, and ERK/JNK signaling pathways., Conclusions: In the development of intracranial aneurysms, DNA methylation plays an important role in the regulation of genetic expression involved in immune and inflammatory reactions, cell function, cell maintenance, and cell signal transduction., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Aspirin has been implicated in the postoperative management of moyamoya disease (MMD) in order to avoid bypass failure and decrease the incidence of subsequent stroke. However, its effect has not been completely determined yet., Methods: In this study, we retrospectively reviewed data of 184 adult patients (197 hemispheres) presented with ischemic-onset MMD who had undergone direct or combined revascularization in our hospital, to clarify the effect of postoperative aspirin therapy in the management of moyamoya disease. Fifty-nine hemispheres that had been administered with aspirin (100 mg/day) after bypass surgery were defined as the "aspirin group," whereas 138 that hadn't been given aspirin postoperatively were defined as the "control group"., Results: Among 197 hemispheres, the mortality rate was 0. The incidence of postoperative newly developed infarction, transient ischemic attack, and hemorrhage were not significantly different between the aspirin and control groups. The patency rate of bypass graft was not significantly different between the groups, either. Notably, more patients experienced major stroke in the control group (9/138) than the aspirin group (1/59), but no statistical difference was found (P > 0.05). In the aspirin group, more patients had improved outcome than the control group (P = 0.04)., Conclusions: Our findings showed that aspirin might not decrease the incidence of postoperative ischemic stroke or increase patency rate of bypass graft, but it does not increase the risk of hemorrhages, either. Also, postoperative aspirin therapy might improve outcome. More studies are needed to provide evidence for postoperative antiplatelet therapy in MMD management., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Seizure is the second-most common presentation in patients with arteriovenous malformations (AVMs) and superimposes a significant burden on pediatric patients. Postoperative seizure risk in unruptured AVMs is underreported in the pediatric AVM literature. We aimed to characterize and identify predictive factors for postoperative seizures in this study., Methods: We performed a retrospective review of all surgically treated pediatric patients with unruptured AVM at our institution from 2001 to 2014. Patients younger than 18 years of age were included. Baseline variables was compared against our outcome of interest, which was defined as patients with or without follow-up seizures. Multivariable Cox regression was performed to identify potential predictive factors., Results: The average age of all patients was 13.1 years, and 68.2% were male. Nine patients were asymptomatic (13.6%), and seizure presentation occurred in 57.6% (n = 38). During an average follow-up of 4.2 years, 12 (18.2%) patients experienced postoperative seizures, with 5 (17.9%) of 28 patients with seizures being de novo. In patients with seizure presentation, 81.6% were completely seizure-free throughout follow-up. In multivariable analysis, larger AVM size (hazard ratio [HR] 1.63, P = 0.023) and temporal location (HR 8.35, P = 0.007) were found to increase the risk of follow-up seizures. On the contrary, seizure presentation (HR 1.91, P = 0.369) and postoperative infection (HR 2.37, P = 0.265) were not associated., Conclusions: Surgery may eliminate most seizures with low risk of inducing de novo seizures in pediatric patients with unruptured AVM. Predictive factors for postoperative seizures included large AVM size and temporal location. For selected unruptured AVMs with small size and nontemporal location, consideration of surgery as primary treatment for persistent seizures is a reasonable option., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To compare two 3-dimensional (3D) printed models of intracranial aneurysms for simulation and training for complex aneurysm surgery., Methods: The study included 6 complex or large aneurysm cases. We printed two 3D models of complex aneurysms based on computed tomography angiography data using a 3D printer: a whole model, which was all-in-one printed hollow aneurysm method with colorful and multiple materials and included the hollow aneurysm, adjacent arteries, skull base, and nerves, and a regional model that included the hollow aneurysm and adjacent arteries. The 3D models were used for surgical planning and for practice in craniotomy and clipping. Neurosurgeons rated the models via questionnaires., Results: Both 3D aneurysm models were accurate: the diameter, width, and neck of the aneurysms in the models were not significantly different from the computed tomography angiography data (P > 0.05). Furthermore, the models were useful for selecting clips before surgery. The whole 3D model improved understanding of the surgical view more than the regional model did (P < 0.05); however, the clip application felt more realistic in the regional model (P < 0.05). The process time for making the whole model is shorter (P < 0.05) but more expensive (P < 0.05) compared with the regional model., Conclusions: The whole and regional 3D printed aneurysm models were accurate. The whole model was more useful for planning the trajectory of approach to the aneurysm when it was located in close proximity to bone and nerves, whereas the regional 3D aneurysm model was appropriate for aneurysms not involving bone and nerves. This will help neurosurgeon choose the proper 3D model for the complex aneurysm surgery according to the comparison., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To study clinical outcome of giant intracranial aneurysms (diameter ≥25 mm) treated with different surgical modalities and to analyze factors affecting prognosis., Methods: A retrospective analysis was performed of 204 consecutive patients with giant intracranial aneurysms who underwent surgical treatment in our department from 1995 to 2008. Clinical outcome was evaluated with the Glasgow Outcome Scale., Results: Surgical modalities included direct aneurysm neck clipping in 102 patients (50.0%), parent artery reconstruction in 51 patients (25.0%), proximal artery ligation in 23 patients (11.3%; 4 patients combined with revascularization), trapping in 26 patients (12.7%), and wrapping in 2 patients (1.0%). Follow-up data were available for 181 patients (88.7%), with a mean follow-up period of 62 months (range, 12-164 months). A good outcome (Glasgow Outcome Scale score 5) was observed in 114 patients (63.0%), and a poor outcome (Glasgow Outcome Scale score 1-4) was observed in 67 patients (37.0%). Independent factors that affected prognosis were age and location of aneurysm. Older age (≥50 years) and location of aneurysm in posterior circulation were associated with poor outcome. In 85 patients with preoperative subarachnoid hemorrhage, patients with a higher Hunt and Hess grade (≥3) had a worse outcome compared with patients with a low Hunt and Hess grade (1 or 2). Surgical modalities and other factors were not significantly associated with clinical outcome., Conclusions: Giant intracranial aneurysms are effectively treated with craniotomy and surgical treatment. Older age, aneurysm location in posterior circulation, and higher Hunt and Hess grade are risk factors affecting prognosis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: We describe our single-center experience treating unruptured brain arteriovenous malformations (uBAVMs) with microsurgical treatment., Methods: During a 7-year period, 282 patients with uBAVMs were surgically treated at our institution. Patient clinical features, postsurgical complications, arteriovenous malformation obliteration rate, seizure control, and functional outcome were collected and analyzed. Seizure control was evaluated with the Engel classification system. Patient functional outcome was assessed with modified Rankin Scale score., Results: Complete obliteration was achieved in 98.2% of cases. Surgical mortality rate was zero, and overall mortality rate was 1.1%. Good functional outcome (modified Rankin Scale score 0-1) was achieved in 86.9% of all patients, including 92.5% of patients with Spetzler-Martin (S-M) grade I and II uBAVMs, 80.6% of patients with S-M grade III uBAVMs, and 62.5% of patients with S-M grade IV and V uBAVMs. Poor outcome was significantly associated with arteriovenous malformation size ≥6 cm, deep venous drainage, eloquent location, and poor seizure control (all P < 0.05). For 177 patients with presurgical seizures, good seizure outcome (Engel class I) was achieved in 124 (70.1%) patients after microsurgical treatment. A short history of seizure occurrence, fewer presurgical seizures, and generalized tonic-clonic seizure type may be predictors of good seizure outcome (all P < 0.05)., Conclusions: Good functional outcome can be achieved by microsurgical resection in S-M grade I and II and selected grade III uBAVMs. Surgical resection for high-grade (grade IV and V) uBAVMs is challenging. A high seizure-free rate can be achieved in patients with initial seizure presentation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Quasi-moyamoya disease (MMD) is characterized by moyamoya vasculopathy and well-recognized comorbidity. Whether the recently identified MMD susceptibility gene variant, p.R4810K (rs112735431), is associated with quasi-MMD remains unclear., Methods: This study was a 2-hospital-based case-control study that was conducted in the neurosurgical departments of Beijing Tiantan Hospital and Peking University International Hospital. A total of 42 patients and 161 controls were enrolled. The p.R4810K polymorphism was assessed with Sanger sequencing. A review of the pertinent literature on the p.R4810K polymorphism and quasi-MMD was performed., Results: The mean age of patients at diagnosis was 34.9 ± 16.5 years with a one-peak distribution in the forties; 57.1% of the patients were female. The p.R4810K heterozygous variant was identified in 5 patients, including 3 patients with atherosclerosis, 1 patient with Graves disease, and 1 patient with rheumatoid arthritis; it was also observed in one control. The frequencies of the A allele and the G/A genotype of rs112735431 (p.R4810K) were significantly greater in the patients with quasi-MMD than in the control groups (5.95% vs. 0.31%, odds ratio [OR] 20.316, P = 0.002; 11.9% vs. 0.6%, OR 21.622, P = 0.002, respectively). In the subgroup analysis, the rs112735431 G/A genotype was significantly associated with arteriosclerotic or autoimmune quasi-MMD (P = 0.006, OR 25.263, confidence interval 2.501-255.175; P = 0.015, OR 29.091, confidence interval 2.444-346.334, respectively)., Conclusions: The p.R4810K variant was associated with atherosclerotic and autoimmune quasi-MMD in a Chinese population, and a lower prevalence of this variant in patients with quasi-MMD compared with patients with MMD was observed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To elucidate the clinical features, risk factors for contralateral progression, and long-term outcomes of patients with unilateral moyamoya disease (MMD)., Methods: We retrospectively reviewed 109 patients with unilateral MMD treated at Beijing Tiantan Hospital. Clinical features, radiologic findings, and outcomes were analyzed., Results: The mean age at diagnosis was 30.8 ± 14.2 years with a one-peak distribution in the thirties. The ratio of women to men was 1.1:1. Familial occurrence was 5.5%. The primary symptoms at initial presentation were transient ischemic attack (39.4%), infarction (22%), and hemorrhage (26.6%). The distribution of the initial Suzuki stage was as follows: stage 2, n = 33; stage 3, n = 35; stage 4, n = 27; stage 5, n = 11, and stage 6, n = 3. Contralateral abnormality on initial angiography occurred in 19 adult patients (17.4%). Posterior cerebral artery involvement was observed in 28 (25.7%) patients. During the average follow-up of 43.8 ± 21.3 months, contralateral progression was observed in 18 patients (16.5%). Contralateral abnormalities (P = 0.033) on initial angiography and infarction at initial presentation (P = 0.041) were significantly associated with contralateral progression in adults and children, respectively. Approximately 91.7% of patients had a modified Rankin Scale score of 0-2 during follow-up., Conclusions: A one-peak pattern in age distribution, lower grade of Suzuki stage, fewer familial cases, and posterior cerebral artery involvement were observed in patients with unilateral MMD. Contralateral abnormalities on initial angiography and infarction at onset were risk factors for contralateral progression in adult and pediatric patients, respectively. Good functional outcomes can be anticipated in the vast majority of surgically treated patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: We aimed to describe our single-center experience in treating cerebellar arteriovenous malformations (AVMs) with microsurgical resection., Methods: During a 16-year period, 181 patients with cerebellar AVMs were surgically treated at the Department of Neurosurgery in Beijing Tiantan Hospital. Patient functional status was evaluated using modified Rankin Scale (mRS) scores both before treatment and at the last follow-up. The mRS scores at the last follow-up were dichotomized as good outcome (mRS <3) and poor outcome (mRS ≥3). The treatment modalities, post-treatment complications, obliteration rate, and follow-up outcomes were analyzed., Results: Of the 181 patients, 172 (95%) patients presented with initial hemorrhage and 62 (34%) patients experienced rehemorrhage before microsurgical treatment. Complete obliteration of the AVMs was achieved in 177 (97.8%) patients. Good functional outcome was achieved in 144 (80%) of the patients. The surgical mortality rate was 4.4% (8/181), and overall mortality rate was 6.6% (12/181). Poor outcome was significantly associated with increasing age (P = 0.035; odds ratio [OR], 1.030; 95% CI 1.002-1.060), presurgical mRS ≥3 (P = 0.029; OR, 2.563; 95% CI 1.101-5.968), eloquent AVM location (P = 0.015; OR, 3.058; 95% CI 1.244-7.516), and presurgical rehemorrhage (P = 0.008; OR, 3.266; 95% CI 1.358-7.858)., Conclusion: Good outcome can be achieved by microsurgical resection in most patients with cerebellar AVMs. Increasing age at surgery, poor presurgical functional status, eloquent AVM location, and presurgical rehemorrhage are independent predictors of poor outcomes after AVM resection. We recommend early surgical resection for all surgically accessible cerebellar AVMs to prevent subsequent hemorrhage and resultant poor neurologic outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: We aimed to summarize the clinical presentation, risk of hemorrhage, and predictors of posthemorrhage outcome in patients with cerebellar arteriovenous malformations (AVMs)., Methods: We searched our AVM database at Beijing Tiantan Hospital and identified 225 patients with cerebellar AVMs between the year 2000 and 2015. The clinical presentation and hemorrhage risk were analyzed in all patients. Further analysis of predictors for immediate posthemorrhage outcome was performed in patients with ruptured AVMs. Posthemorrhage modified Rankin Scale (mRS) scores were dichotomized into nonsevere outcome (mRS ≤3) and severe outcome (mRS >3). Univariate and multivariate logistic regression analyses were applied to test the risk factors of hemorrhage and predictors of severe outcome., Results: Of the 225 patients, 197 (88%) presented with hemorrhage. Patients with initial hemorrhage were much younger than those with unruptured AVMs (univariate: P = 0.003; multivariate: P = 0.002). Single arterial supply (odds ratio [OR], 2.846; 95% confidence interval [CI], 1.022-7.922) and exclusively deep venous drainage (OR, 3.361; 95% CI, 1.045-10.813) were the other 2 independent risk factors for hemorrhagic presentation. Regarding the neurologic outcome immediately after hemorrhagic presentation, we used 3 models of multivariate logistic regression. Severe neurologic outcome (mRS >3) was associated with eloquent or deep AVM location, associated aneurysm, and the presence of intraventricular hemorrhage (all P < 0.05)., Conclusion: Cerebellar AVMs have an aggressive nature of hemorrhage. Younger age, single feeding artery, and exclusively deep venous drainage were independent risk factors for hemorrhagic presentation. Eloquent location, associated aneurysm, and presence of intraventricular hemorrhage may predict severe immediate posthemorrhage outcome., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to identify the risk factors for subsequent hemorrhage in patients with untreated cerebellar arteriovenous malformations (AVMs)., Methods: We searched our AVM database at Beijing Tiantan Hospital and identified 149 patients with cerebellar AVMs who were at least 1 month treatment free after initial diagnosis between 2000 and 2015. The patients were followed up from initial diagnosis until subsequent hemorrhage, initiation of treatment, or the end of 2015. The natural history of cerebellar AVMs was analyzed., Results: The overall annual rupture rate was 8.6%, with a mean follow-up period of 4.2 years (range, 1 month to 15 years). The annual rupture rate for previously ruptured AVMs was 10.8% during the whole follow-up period, 12.4% in the first 5 years (18.8% in the first year and 9.0% in the subsequent 4 years) and 6.7% in more than 5 years after initial diagnosis. The overall annual rupture rate for previously unruptured AVMs was 4.0%. Childhood at diagnosis, AVM size ≥3 cm and exclusively deep venous drainage were independent risk factors for subsequent hemorrhage. Previous AVM rupture significantly increased the hemorrhagic risk during the first 5 years but did not significantly affect subsequent hemorrhage thereafter., Conclusions: Childhood at diagnosis, large AVM size, and AVMs with exclusively deep venous drainage are independent risk factors for subsequent hemorrhage in patients with cerebellar AVMs. Previous rupture may increase the hemorrhagic risk during the first 5 years after diagnosis but may not significantly increase the risk in the following years., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased intracranial pressure, and these patients are unstable with a high risk of rebleeding. Computed tomography angiography (CTA) has been proposed as an examination tool for the rapid detection of ruptured aneurysms. We aimed to determine the safety and efficacy of CTA alone for surgical treatment of poor-grade aSAH compared with digital subtraction angiography (DSA)., Methods: We conducted a multicenter retrospective analysis of 144 patients with poor-grade aSAH who underwent surgical treatment for 2 different cohorts. Patients were grouped into CTA alone and DSA groups. Baseline characteristics, postoperative complications, and clinical outcomes at discharge and at last follow-up were compared between the 2 groups. Multivariate logistic regression models were used to assess the association between CTA alone and clinical outcomes after we adjusted for potential confounders., Results: Of the 116 patients included, 42 (36.2%) patents received CTA alone and 74 patients (63.7%), including 12 patients with CTA and DSA and 62 patients with DSA alone, received DSA before surgical treatment. Patients with larger ruptured aneurysms (P = 0.006), aneurysm sizes of larger than 5 mm (P = 0.025), presence of single aneurysms (P = 0.018), and presence of intraventricular hemorrhage (P = 0.019) more often received CTA alone. All ruptured aneurysms were clipped successfully during surgery. There were no statistically significant differences in postoperative complications and clinical outcomes between the 2 groups., Conclusions: Although CTA alone can be safely and effectively used in most patients requiring surgical treatment, additional DSA may be considered in patients with smaller ruptured aneurysms or in those with multiple aneurysms., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To explore outcomes after microsurgery of brain arteriovenous malformations (AVMs) that failed to be obliterated by Gamma Knife radiosurgery (GKRS)., Methods: From January 2000 to January 2014, 42 consecutive patients underwent surgical resection of persistent AVMs after GKRS. These 42 patients with AVMs who underwent radiosurgery (radiosurgery group) were individually matched with 42 patients with AVMs who did not undergo radiosurgery (no radiosurgery group) based on patient and AVM characteristics. The modified Rankin Scale was used to assess neurologic status of patients. The effects of GKRS on AVM resection and surgical outcomes were analyzed., Results: After GKRS, the mean AVM volume was significantly reduced by 76.8% (P < 0.01), the size was reduced by 41% (P < 0.01), and the Spetzler-Martin grade was reduced in 61.9% of the patients (P < 0.01). During the time interval from radiosurgery to surgical resection, subsequent hemorrhages led to significant neurologic deterioration (P = 0.046). Compared with the control group, the frequency of preoperative embolization, operative time, and blood loss were significantly lower in the radiosurgery group (all P < 0.05). The no radiosurgery group had a significantly higher rate of worsening in mRS scores at 6 months after surgery (40.5% vs. 16.7%, P = 0.029). Good neurologic status (mRS score <3) was achieved in 81% of the radiosurgery group and 83% of the no radiosurgery group at the final follow-up evaluation., Conclusions: GKRS performed several years before microsurgical resection can facilitate resectability of AVMs and decrease the rate of postoperative neurologic deterioration. For patients with persistent AVMs several years after GKRS, microsurgical resection is recommended to achieve good clinical outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To identify whether age, sex, and lesion location are associated with initial presentation in patients with brain arteriovenous malformations (AVMs)., Methods: Collected data of 3299 consecutive patients with AVM treated at Beijing Tiantan Hosptial from January 1980 to January 2015 were analyzed. The variables assessed were age at diagnosis, sex, AVM location, and mode of initial presentation., Results: Initial presentation was AVM hemorrhage in 57.9%, seizure in 20.9%, chronic headache in 14.9%, focal neurologic deficit in 5.2%, and incidental in 1.2%. Younger age and female sex were associated with initial hemorrhage (all P < 0.05). Hemorrhage was more likely to occur in patients with AVMs in the basal ganglia, the corpus callosum, the ventricles, the cerebellum, and the brainstem (all P < 0.05). Male sex was associated with initial seizure (P < 0.05). Initial seizure was more likely to occur in patients with AVMs in the frontal, temporal, parietal, frontotemporal, and frontoparietal lobe (all P < 0.05). Compared with frontal AVMs, temporal AVMs were more likely to present with hemorrhage (P < 0.05) and less likely to present with seizure (P < 0.05). AVMs involving the occipital lobe were more likely to present with chronic headaches (P < 0.05)., Conclusions: Initial AVM presentation varied with patient age, sex, and AVM locations. Younger age, female sex, and deep and infratentorial locations may be associated with initial hemorrhage. Male sex and frontal, temporal, and parietal AVM locations may be predictors of initial seizure. Chronic headache was more likely to occur in patients with AVMs involving the occipital lobe., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: We reviewed our prospective study of patients with occipital arteriovenous malformations (AVMs) to assess whether the display of optic radiation diffusion tensor imaging (DTI) during neuronavigation-guided surgery can reduce the severity of postoperative visual field deficits (VFDs) and to evaluate the factors associated with visual field preservation., Methods: Forty-six consecutive patients with occipital AVMs were randomized in our study. DTI of the optic radiation was displayed during neuronavigation surgery in 24 patients. The other 22 patients were treated surgically without neuronavigation. Modified Rankin Scale (mRS) scores and visual fields were evaluated preoperatively, immediately after surgery, and at the last follow-up., Results: The patients' baseline characteristics and AVM features were statistically similar between the 2 surgical groups. The postoperative obliteration rate was 100%. The postoperative mRS scores did not differ between the 2 groups (P > 0.05). Preexisting VFDs were more common (P = 0.00004) in patients who bled than in those with unruptured AVMs. The application of DTI-incorporated neuronavigation reduced the frequency and severity of postoperative VFDs (P = 0.013 and 0.001, respectively). Visual fields were more likely to be preserved in patients with an AVM >5 mm from the optic radiation (P = 0.025)., Conclusions: A history of hemorrhage is an independent risk factor for VFDs associated with occipital AVMs. Although not showing superiority in postoperative mRS, functional MRI navigation-guided surgery may help to radically resect occipital AVMs and preserve patient visual fields. A 5-mm distance from the optic radiation may be a suitable safety margin for visual field preservation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The goal of this study was to discuss the surgical indications, surgical approaches, and prognostic factors of cerebellar cavernous malformation (CM)., Methods: We retrospectively reviewed the presentation, surgery, and outcome of 58 consecutive patients who underwent resection of cerebellar CMs between 2009 and 2013 in our center., Results: The study population consisted of 31 males and 27 females, mean age 39.9 years. Fifty-eight patients experienced 67 symptomatic hemorrhages. The median diameter of all lesions was 2.2 ± 0.9 cm (range, 0.8-4.8 cm). The locations were classified into 3 groups: group 1, cerebellar hemisphere (17 cases, 29.3%); group 2, vermis (18 cases, 31.0%); and group 3, cerebellar peduncle (23 cases, 39.7%). Complete resection was achieved in all patients without surgical mortality. Postoperatively, 11 patients developed new surgical complications, including facial paralysis in 6 patients, ataxia in 2 patients, dizziness in 2 patients, and decrease in facial sensation in 1 patient. The mean modified Rankin Scale (mRS) at final follow-up was significantly improved compared with the preoperative score (0.5 ± 0.5 vs. 1.4 ± 0.7, P = 0.035). The symptoms and neurologic deficits improved in most patients. The lesion location was the only factor that predicted a worse outcome, and the mRS was significantly lower in group 3 than groups 1 and group 2 (P = 0.019)., Conclusions: Patients with cerebellar CMs usually achieve favorable outcomes via surgery. Cerebellar peduncle CMs cause significantly more neurologic deficits than other locations. A reasonable surgical approach and meticulous manipulation are necessary to prevent impairment of neurologic function., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Aggressive surgery seems mandatory for poor-grade middle cerebral artery (MCA) aneurysm with associated intracerebral hemorrhage (ICH). However, primary decompressive craniectomy (DC) is controversial. We performed a case control study to define the role of primary DC., Materials and Methods: We analyzed data from the two cohorts: a multicenter prospective poor-grade aSAH registry study (AMPAS); and the National Clinical Research Center for Neurological Diseases (NCRC-ND) database of poor-grade patients. Outcome was assessed by modified Rankin Scale (mRS) and was dichotomized into favorable (mRS 0-3) and unfavorable outcome (mRS 4-6). We compared major complication rates, mortality and outcomes between primary DC and control groups., Results: Twenty-four patients with primary DC were included in the study group. Fourteen patients without DC were included in the control group. Patients with younger age and lower Glasgow coma score (GCS) more often underwent primary DC. Major complications did not differ between the two groups. Fourteen (58%) patients had a favorable outcome, and the mortality was 29%. Primary DC appeared to have lower in-hospital mortality and have better outcome. Adjusting for age and admission GCS, primary DC was not significantly associated with decreased mortality and improved outcomes., Conclusions: Although primary DC does not increase postoperative complication and mortality risk, current results showed primary DC does not seem to be significantly associated with improved outcomes. However, more than one half of patients most benefit from primary DC. Further prospective controlled studies are warranted to clarify the issue., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objective: To observe the hemodynamic changes of the superficial temporal artery (STA) by color Doppler and the correlation between the results of angiography and the hemodynamic changes of the STA after superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery for moyamoya disease., Methods: This study included 26 cases of moyamoya disease; standard STA-MCA bypass surgery were performed in all patients. GE-LOGIQ9 color ultrasound with 7L transducer was used to monitor STA hemodynamic changes, including peak systolic velocity (PSV), end-diastolic velocity (EDV), mean flow velocity (Vm), pulse index (PI), and resistance index (RI), preoperatively and 1 week and 3 months after surgery in 10 cases. In 22 cases, color Doppler of STA and digital subtraction angiography of the external carotid artery (ECA), internal carotid artery (ICA), common carotid artery (CCA), and vertebral artery (VA) were performed preoperatively and 1 week after surgery. Based on the patency of STA-MCA on angiography, the patients were divided into two groups: 11 patients were in the patent group, and 11 patients were in the nonpatent group. Statistical significance was evaluated using analysis of variance of random block design and paired samples t test. SPSS software version 11.5 was used., Results: In the 10 cases, there was no significant difference among the three imaging series in PSV. Compared with the preoperative values, the values of EDV and Vm 1 week and 3 months after surgery were significantly higher (P < 0.05). The difference was not significant, however, between 1 week and 3 months after surgery. The PI and RI at 1 week and 3 months after surgery were significantly lower than the preoperative values (P < 0.05); there was no significant difference between 1 week and 3 months after surgery. Among the 22 cases, the values of PSV, EDV, and Vm increased significantly (P < 0.05) and the values of PI and RI decreased significantly(P < 0.01) after surgery in the patent group. In the nonpatent group, the values of PSV and PI decreased significantly after surgery (P < 0.05). EDV, Vm, and RI had no significant changes after surgery., Conclusions: Higher blood flow can develop in anastomosed STA after STA-MCA bypass surgery. The hemodynamic changes of STA after surgery mainly occurred at an early period after operation with little change at 3-month follow-up examination. The increase of blood flow in STA may be due to the low resistance of the intracranial vascular bed. Postoperative Doppler examination of the STA may predict angiographic results of the anastomosis in the early postoperative period. Continuous observation is necessary to identify an accurate correlation between quantitative alteration of the Doppler parameters and angiographic results., (Copyright © 2011 Elsevier Inc. All rights reserved.)