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IntroductionOur objective was to identify recent CPGs for the diagnosis and management of DMD and summarize their characteristics and reliability.MethodsWe conducted a scoping review of CPGs using MEDLINE, the Turning Research Into Practice (TRIP) database, Google Scholar, guidelines created by organizations, and other repositories to identify CPGs published in the last 5 years. Our protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses for scoping reviews. To assess the reliability of the CPGs, we used all the domains included in the Appraisal of Guidelines Research and Evaluation II.ResultsWe selected three CPGs published or updated between 2015 and 2020. All the guidelines showed good or adequate methodological rigor but presented pitfalls in stakeholder involvement and applicability domains. Recommendations were coherent across CPGs on steroid treatment, except for minor differences in dosing regimens. However, the recommendations were different for new drugs.DiscussionThere is a need for current and reliable CPGs that develop broad topics on the management of DMD and consider the challenges of developing recommendations for RDs.

Background Procedural intravenous cangrelor has been proposed as an effective platelet inhibition strategy for stenting in acute ischemic stroke. We aimed to compare the safety profile of low‐dose intravenous cangrelor versus dual oral antiplatelet therapy (DAPT) loading in patients with acute cervical tandem lesions. Methods We retrospectively identified cases from an international multicenter cohort who underwent intraprocedural administration of intravenous cangrelor (15 μg/kg followed by an infusion of 2 μg/kg per min) or DAPT loading during acute tandem lesions intervention. Safety outcomes included rates of symptomatic intracranial hemorrhage, parenchymal hematoma type 2, petechial hemorrhage, and in‐stent thrombosis. Inverse probability of treatment weighting matching was used to reduce confounding. Results From 691 patients, we included 195 patients, 30 of whom received intravenous cangrelor and 165 DAPT. The DAPT regimens were aspirin+clopidogrel (93.3%) or aspirin+ticagrelor (6.6%). After inverse probability of treatment weighting, the patients treated with cangrelor were not at greater odds of symptomatic intracranial hemorrhage (odds ratio [OR], 1.30 [95% CI, 0.09–17.3]; P=0.837), symptomatic intracranial hemorrhage–parenchymal hematoma type 2 (OR, 0.54 [95% CI, 0.05–4.98]; P=0.589), or petechial hemorrhage (OR, 1.11 [95% CI, 0.38–3.28]; P=0.836). Similarly, the rate of in‐stent thrombosis was not significantly different between the 2 groups (1.8% versus 0%; P=0.911). Conclusion Cangrelor at the half dose of the myocardial infarction protocol showed a similar safety profile compared with the commonly used DAPT loading protocols in patients with acute tandem lesions. Further studies with larger samples are warranted to elucidate the safety of antiplatelet therapy in tandem lesions.

Background Flow diverters are now considered first‐line tools for treating intracranial aneurysms. However, few devices are available for patients with large‐diameter vessels (LDVs). Hence, we evaluated the performance of the largest diameter Surpass Streamline for aneurysms in LDVs. Methods We performed a subanalysis of the SESSIA (Safety and Efficacy of the Surpass Streamline for Intracranial Aneurysms) multicenter cohort study of patients treated with Surpass Streamline between 2018 and 2021. Patients in whom a 5‐mm diameter Surpass Streamline was implanted were divided into 2 groups according to vessel diameter at the landing zones (LDV, ≥5.3 mm versus non‐LDV [N‐LDV],

Introduction Improvements in the safety and efficacy of curative embolization for brain arteriovenous malformations (bAVMs) have allowed to achieve comparable results to microsurgical resection and radiosurgery, especially for low‐grade bAVMs (Spetzler Martin [SM] grade I and II). However, whether this treatment modality is beneficial in the pediatric population remains unknown. Hence, we assessed the safety and efficacy of curative embolization for low‐grade bAVMs in children. In addition, we determined predictors of intraprocedural complications and predictors of complete occlusion in one embolization session. Methods Between 2010 and 2022, a retrospective analysis of all pediatric (≤18 years) patients who underwent curative embolization for low‐grade bAVMs was conducted at two institutions. Demographic data, clinical presentation, SM grade, and procedural characteristics were retrieved. The safety (intraprocedural complications and mortality) and efficacy (complete angiographic obliteration after the last embolization session) were evaluated. Multivariable logistic regression analysis was performed to identify potential predictive factors of intraprocedural complications and complete occlusion in one session. For selected variables, odds ratios (OR) with 95% confidence intervals (CI) and p value of the likelihood‐ratio test were presented. Results Sixty‐eight patients (41 females; mean age 12.9 ± 3.6 years) underwent a total of 102 embolization sessions. Fifty‐one bAVMs (75%) presented ruptured, and headache was the most common clinical presentation (50%). There were 24 (35%) SM grade I lesions and 44 (65%) grade II. Onyx was the most used embolic agent (33%) and the transarterial approach was the most common (93%). The mean volume of embolic agents in each patient was 2.4 ml (range 0.2 to 7.5 ml). Fourteen intraprocedural complications (14% of procedures) were observed and no deaths were reported. The most common complication was microcatheter‐related vessel perforation (6%). Single venous drainage decreased the risk of intraprocedural complications (OR = 0.19; 95% CI 0.04 – 0.78). Complete angiographic obliteration was achieved in 44 patients (65%). In 35 patients (52%) the bAVM was occluded with a single session. A small bAVM size was predictor of complete occlusion in one session (OR = 0.42; 95% CI 0.21 – 0.73). Conclusions Curative embolization in pediatric low‐grade bAVMs can be performed with an acceptable complete occlusion rate but with a high rate of intraprocedural complications. The risk of intraprocedural complications was low in bAVMs with a single venous drainage. The odds of complete occlusion in one session are high in small bAVMs. Curative embolization should be selected on an individual basis in order to achieve optimal results.

Introduction Posterior communicating artery (PComA) aneurysms are common and have a high risk of rupture. Flow diverters (FD) have demonstrated a safe and effective profile. However, the use of FD in PComA aneurysms has shown controversial results with high rates of recurrence and a high risk of potential ischemic complications. There, we aimed to evaluate the safety and efficacy of flow diversion for the treatment of PComA aneurysms with a meta‐analysis of the literature. Methods We performed a systematic search in Scopus, Embase, Medline, and Web of Science from inception until May 2022 for all the studies that reported the safety and effectiveness of FD for the treatment of intracranial aneurysms located in the posterior communicating artery. The primary effectiveness endpoint was a complete aneurysm occlusion rate at final follow‐up. The primary safety endpoint was a composite measure of cumulative events that occurred during and after the procedure. Events included death and ischemic/hemorrhagic complications. Random‐effects meta‐analysis was used to calculate proportions. Statistical heterogeneity across studies was assessed with I2 statistics. Results A total of 13 studies with 397 patients harboring 403 aneurysms were included in our analysis. Mean age was 48 years and mean aneurysm size was 5.3 mm. Complete aneurysm occlusion at final follow‐up was 74% (95% CI 66–81%; I2 = 54%). The primary safety composite outcome was 5% (95% CI 3–9%; I2 = 0%). The mortality rate was 1% (95% CI 0–2%; I2 = 0%). Subgroup analysis showed that patients with a non‐fetal PComA had a higher rate (76%; 95% CI 62%‐86%; I2 = 53%) of complete aneurysm occlusion compared to those with a fetal PComA (36%; 95% CI 21%‐54%; I2 = 0%). Conclusions Our findings show that flow diversion for the treatment of aneurysms located in the PComA is effective and safe. However, the same treatment for aneurysms located in a fetal‐type PComA did not show the same efficacy profile suggesting that these cases might require an alternative treatment to achieve permanent occlusion rates.

Introduction Paraclinoid aneurysms (PAs) have traditionally been treated with clipping. However, with the emergence of new techniques, endovascular treatment (EVT) has supplanted surgical treatment in recent years. We aimed to determine the safety and efficacy of EVT and microsurgical clipping for PAs. Methods A systematic review was performed in Scopus, Embase, Medline, Web of Science, and Cochrane from inception to March 2022 for all studies that tested the safety and efficacy of EVT or microsurgical clipping of PAs. Efficacy outcomes included complete aneurysm occlusion at last follow‐up, immediate complete occlusion, and an mRS 0–2 at last follow‐up. Safety outcomes included mortality, intraoperative and postoperative complications. We performed a random‐effects meta‐analysis of proportions and assessed the statistical heterogeneity across studies with I2 statistics. Results Eighty‐nine studies included 6496 patients, 3682 treated with EVT and 2814 with microsurgical clipping. Immediate complete occlusion rates were 92% (95% CI 88 – 96%; I2 = 60%) and 46% (95% CI 34 – 59%; I2 = 93%) for clipping and EVT, respectively. The rate of complete occlusion at last follow‐up was 94% (95% CI 91 – 96%; I2 = 0%) and 69% (95% CI 63 – 74%; I2 = 79%) for microsurgical clipping and EVT, respectively. Among EVT studies, the rate of complete occlusion was 54% (95% CI 48 – 59%; I2 = 50%), 52% (95% CI 39 – 64%; I2 = 73%), and 77% (95% CI 54 – 91%; I2 = 91%) for primary coiling, stent‐assisted coiling, and flow diversion, respectively. Among clipping studies, the rate of last follow‐up mRS 0–2 was 86% (95% CI 76 – 92%; I2 = 72%). Among EVT studies, the rate of last follow‐up mRS 0–2 was 94% (95% CI 86 – 98%; I2 = 93%). Mortality rate was 4% (95% CI 3 – 7%; I2 = 57%) and 1% (95% CI 0 – 3%; I2 = 0%) for clipping and EVT, respectively. Among EVT studies, the mortality rate was 3% (95% CI 1 – 6%; I2 = 0%) and 3% (95% CI 1 – 9%; I2 = 39%) for primary coiling and flow diversion, respectively. Intraoperative and postoperative complications were present in 9% (95% CI 6 – 14%; I2 = 68%) and 21% (95% CI 17 – 26%; I2 = 87%) among clipping studies, respectively. Intraoperative and postoperative complications were present in 6% (95% CI 4 – 9%; I2 = 64%) and 9% (95% CI 6 – 13%; I2 = 72%) among EVT studies, respectively. Conclusions In conclusion, microsurgical clipping and EVT for PAs are both safe and effective treatment modalities. Treatment via either approach should be determined on a case‐by‐case basis and according to institutional experience and resources.

Introduction The Woven EndoBridge (WEB) device was originally approved to treat intracranial wide‐necked saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of intracranial aneurysms (IA) in alternative locations with variable success. We aimed to evaluate the safety and efficacy of the WEB for IAs in off‐labeled locations using a meta‐analysis (MA) of the literature. Methods We performed a systematic review of all studies including patients treated with WEB for IAs in locations different than what is currently on‐label FDA until May 2022. Our primary efficacy and safety outcomes were adequate occlusion at last follow up and a composite of intraprocedural and postprocedural complications, respectively. The Raymond‐Roy (RR) scale and the Bicêtre Occlusion Scale Score (BOSS) were used to define complete (RR: 1; BOSS: 0‐0’) and adequate (RR:1‐2; BOSS: 0–2) occlusion. Additional safety outcomes included intraprocedural (thromboembolic, hemorrhagic, device deployment, or air embolism) and postprocedural (ischemic or hemorrhagic) complications, and mortality. We performed a random‐effects MA of proportions and assessed the certainty of the evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I2 statistics. Logistic regression of the patient level data was used to study the predictors of complete occlusion. Results Ten studies were selected, and 285 patients (79% female; mean age 58 years) with 288 aneurysms (35% ruptured) were included. Adequate and complete occlusion rates were 89% (95% CI 81–94%; I2 = 0%; moderate‐certainty evidence) and 64% (95% CI 57–70%; I2 = 13%; moderate‐certainty evidence), respectively. The composite safety outcome rate was 8% (95% CI 3–17%; I2 = 34%; very low‐certainty evidence). The intraprocedural and postprocedural complication rates were 6% (95% CI 4–10%; I2 = 0%; very low‐certainty evidence) and 1% (95% CI 0–1%; I2 = 33%; very low‐certainty evidence), respectively. The mortality rate was 2% (95% CI 1–7%; I2 = 0%; very low‐certainty evidence). Aneurysm width (OR = 0.5; p = 0.03) was the only significant predictor of complete occlusion. Conclusions The preliminary studies evaluating the use of WEB for the treatment of IAs in off‐labeled locations has demonstrated rates of adequate occlusion and procedural complications comparable to the landmark studies that evaluated the use of the WEB for on‐label bifurcation aneurysms. Given the level of evidence, we consider the interpretation of our results should be done cautiously until confirmation from larger prospective studies are obtained.

Introduction Flow diverters (FDs) have demonstrated a safe and effective profile for the treatment of intracranial aneurysms with complex morphologies and variable anatomic locations. However, aneurysmal persistence after flow diversion still presents in up to 25% of treated aneurysms. Herein, we aimed to perform a pooled analysis of two large studies (SCENT [Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Neck Wide Neck Aneurysms] and SESSIA [Safety and Efficacy of the Surpass Streamline for Intracranial Aneurysms]) to evaluate the predictors of occlusion at final follow‐up after treatment with a 72–96 wire device. Methods We pooled all data from the SCENT (prospective) and SESSIA (retrospective) studies that included patients treated with the Surpass Streamline. From the studies, a subset of patients with unruptured saccular aneurysms located in the internal carotid artery (ICA) up to its terminus were included. The authors collected baseline demographics, comorbidities, aneurysm dimensions, and procedural and follow‐up characteristics for each patient. For our analysis, the outcome was complete aneurysm occlusion, as reported by the studies. We performed a multivariable logistic regression to identify the predictors of complete occlusion. Next, we performed a mediation analysis framework to identify the causal relationship of the predictors with the outcome. Finally, we calculated the predicted probability of occlusion for the continuous predictors. Results A total of 348 patients with 348 aneurysms were included, 394 devices were implanted (1.13 per patient). Median age was 61 [22‐85] years, and 83.6% were females. Hypertension was the most common comorbidity (57%) followed by hyperlipidemia (36%). The ICA paraophthalmic segment was the most common location (45%), followed by the petrocavernous (29%) and supraclinoid (25%). Median aneurysm size was 7.5 [1‐29] mm, and neck size was 4.3 [1‐23] mm. At the final follow‐up, the complete occlusion rate was 73% (255/348). After adjusting for confounders and accounting for collinearity, the multivariable analysis identified aneurysm size (OR 0.89; 95% CI 0.85‐0.93;p< .001), procedural technical events (OR 0.31; 95% CI 0.15‐0.65;p = .002), and first device length (OR 0.98; 95% CI 0.96‐1.00;p = .036) as predictors of complete occlusion. Age had a non‐significant direct effect on complete occlusion (p = .091) but a significant indirect effect mediated through aneurysm size (p< .001) and technical events (p< .02). Using our model, the predicted probability of occlusion is≥ 75% in aneurysms measuring < 10 mm when no technical events are encountered. However, when technical events are encountered, the probability decreases to 50–75%. Conclusions Successful aneurysm occlusion after flow diversion is associated with aneurysm size, procedural technical events, and FD length. Age does not directly affect occlusion, but its influence is mediated through the aneurysm size and technical events. Therefore, a priori knowledge of the patient and aneurysm characteristics might guide FD selection to favor the best treatment outcomes.

BackgroundMany low- and middle-income countries, including Latin America, lack access to biomarkers for the diagnosis of prodromal Alzheimer's Disease (AD; mild cognitive impairment due to AD) and AD dementia. MRI visual rating scales may serve as an ancillary diagnostic tool for identifying prodromal AD or AD in Latin America. We investigated the ability of brain MRI visual rating scales to distinguish between cognitively healthy controls, prodromal AD and AD.MethodsA cross-sectional study was conducted from a multidisciplinary neurology clinic in Lima, Peru using neuropsychological assessments, brain MRI and cerebrospinal fluid amyloid and tau levels. Medial temporal lobe atrophy (MTA), posterior atrophy (PA), white matter hyperintensity (WMH), and MTA+PA composite MRI scores were compared. Sensitivity, specificity, and area under the curve (AUC) were determined.ResultsFifty-three patients with prodromal AD, 69 with AD, and 63 cognitively healthy elderly individuals were enrolled. The median age was 75 (8) and 42.7% were men. Neither sex, mean age, nor years of education were significantly different between groups. The MTA was higher in patients with AD (p < 0.0001) compared with prodromal AD and controls, and MTA scores adjusted by age range (p < 0.0001) and PA scores (p < 0.0001) were each significantly associated with AD diagnosis (p < 0.0001) but not the WMH score (p=0.426). The MTA had better performance among ages 75 years (AUC 0.85 [0.79–0.92]). For AD diagnosis, MTA+PA had the best performance (AUC 1.00) for all age groups.ConclusionsCombining MTA and PA scores demonstrates greater discriminative ability to differentiate controls from prodromal AD and AD, highlighting the diagnostic value of visual rating scales in daily clinical practice, particularly in Latin America where access to advanced neuroimaging and CSF biomarkers is limited in the clinical setting.

Introduction: The Population, Hypertension, Age, Size, Earlier Subarachnoid Hemorrhage (SAH), Site (PHASES) score was developed in North America, Europe, and Japan and it is a widely used model in day‐to‐day clinical practice for intracranial aneurysm (IA) rupture risk stratification. Here, we aimed to determine the predictors of aneurysm rupture and assess the components of the PHASES score in a Latin American population. Methods: Four hundred eighty‐six Peruvian patients presented at our institution with ruptured IAs between 2010 and 2020. We retrospectively collected the following variables: age, sex, a hypertension or diabetes mellitus history, previous SAH, the aneurysm size in millimeters (4), presence of a pseudoaneurysm, and aneurysm location. We then performed two separate multivariate analysis. For the first one, we included variables using a stepwise approach with a cut‐off p‐value of 0.2 in univariate logistic regression. For the second one, we evaluated the PHASES score components. A p‐value of 0.05 was considered statistically significant. Results: The median age was 56 years old, and 114 females were included. One hundred seventy‐five patients had a hypertension history, 21 had a diabetes history, and 11 had a previous SAH. Seventy‐eight patients had an aneurysm with 20mm. There were 372 patients with a saccular aneurysm and an associated pseudoaneurysm was found in 197 patients. The most common location was posterior communicating artery (n = 219), followed by the anterior cerebral artery (n = 125), the middle cerebral artery (MCA) (n = 58), branches from the posterior circulation (n = 33), and finally by a paraclinoid aneurysm (n = 33). In our initial multivariate analysis, only the presence of an associated pseudoaneurysm was an independent predictor for aneurysm rupture (OR 7.93; 95% CI 3.45 – 18.25). An age >70 years (OR 1.12; 95% CI 0.3 – 4.12), the male sex (OR 1.39; 95% CI 0.54 – 3.62), a hypertension history (OR 1.14; 95% CI 0.53 – 2.44), a size of 10–20mm (OR 1.46; 95% CI 0.46‐ 4.64), and location in the MCA (OR 1.07; 95% CI 0.25 – 4.57) also predicted a higher rupture risk but without statistical significance. When we performed a multivariate logistic regression of the factors making up the PHASES score, we found that only the age (OR 1.79; 95% CI 1.11‐ 2.88) and a hypertension history (OR 1.61; 95% CI 1.14 – 2.27) were independent predictors of aneurysm rupture. Conclusions: Based on our findings and its limitations, we observed that the presence of an associated pseudoaneurysm was a predictor for aneurysm rupture. Moreover, we found that only two of the five components of the PHASES score were predictors of the event in our population: the age and a hypertension history. Therefore, new research should be carried out in the Latin American population to establish predictors for the development of clinical predictive models in this field.

Introduction: The PHASES score was developed to predict the 5‐year risk of rupture for intracranial aneurysms (IAs). However, only populations from North America, Europe, and Japan were included in the original study. As the population of origin is an item in the score, it has yet to be applied in a Latin American population. We aimed to determine the best approximation to employ this model in this previously unstudied population. Methods: We extracted the data of 848 Peruvian patients with ruptured (n = 486) and unruptured (n = 362) IAs from 2010 to 2020. According to the PHASES score, the North American and European (other than Finish), Japanese, and Finnish populations are rated with 0, 3 and 5 points, respectively. Therefore, we developed three PHASES‐derived models in which our Peruvian population is rated with 0 (Model A), 3 (Model B), and 5 (Model C) points. We compared the observed probability of each model to the expected probability reported by the original PHASES score using a scatter plot. We then compared the goodness‐of‐fit of each model using the Hosmer‐Lemeshow test in STATA version 14. Results: Nineteen percent of the patients were female. Hypertension was found in 34% of patients and 15% were >70 years. Fifty‐four percent of the aneurysms were smaller than 7mm, 25% ranged between 7 and 9.9mm, 18% were between 10 and 19.9mm, and 3% were larger than 20mm. Previous subarachnoid hemorrhage was found in 4%. The location of the aneurysms was the internal carotid artery in 4%, the middle cerebral artery in 4%, and arteries of the anterior and posterior circulation (including the anterior and posterior communicating artery) in 92%. When Model A was applied, 63% of the patients among the ruptured subgroup have an estimated 5‐year risk of rupture of 3% while in the unruptured subgroup an estimated risk of

Introduction: Frontotemporal dementia (FTD) is a complex syndrome characterized by changes in behavior, language, executive control, and motor symptoms. Its annual economic burden per patient in developed countries has been classified as considerable, amounting to US$119,654 per patient, almost double the patient costs reported for Alzheimer's disease. However, there is little information regarding cost-of-illness (COI) for FTD in Latin-America (LA).Aim: To describe the costs related to FTD in LA.Methods: We included COI studies on FTD conducted in LA published in English, Spanish, or Portuguese from inception to September 2020. We carried out a systematic search in Pubmed/Medline, Scopus, Web of Science, Scielo, Cochrane, and gray literature. For quality assessment, we used a COI assessment tool available in the literature. All costs were reported in USD for 1 year and adjusted for inflation.Results: We included three studies from Argentina, Brazil, and Peru. Direct costs (DCs) included medication (from US$959.20 to US$ 4,279.20), health care costs (from US$ 2,275.80 to US$7,856.16), and caregiver costs (from US$9,634.00 to US$28,730.28). Indirect costs (ICs) amounted to US$43,076.88.Conclusions: In LA countries, the reporting of costs related to FTD continues to be oriented toward DCs. They remain lower than in developed countries, possibly due to the limited health budget allocated. Only one Brazilian report analyzed ICs, representing the highest percentage of the total costs. Therefore, studies on the COI of this disease in LA are essential, focusing on both out-of-pocket spending and the potential economic loss to patients' homes and families.