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Vascular inflammation is widely recognized as an important factor in the atherosclerotic process, particularly in terms of plaque development and progression. Conventional tests, such as measuring circulating inflammatory biomarkers, lack the precision to identify specific areas of vascular inflammation. In this context, noninvasive imaging modalities can detect perivascular fat changes, serving as a marker of vascular inflammation. This review aims to provide a comprehensive overview of the key concepts related to perivascular carotid fat and its pathophysiology. Additionally, we examine the existing literature on the association of pericarotid fat with features of plaque vulnerability and cerebrovascular events. Finally, we scrutinize the advantages and limitations of the noninvasive assessment of pericarotid fat., (© 2024 by American Journal of Neuroradiology.)

Despite the progress made in understanding the management and outcomes of Moyamoya angiopathy (MMA), several aspects of the disease remain largely unknown. In particular, evidence on the disease history and management of MMA is lacking, mainly due to methodological and selection biases in the available studies and the lack of large, randomized prospective studies. Therefore, the care of MMA patients remains limited to a few expert centers worldwide, and management is often based on local expertise and available resources. Over the years, recommendations or expert opinions have been written to provide guidance to physicians in the treatment of this condition with the goal of reducing the risk of stroke recurrence and long-term disability. However, there is no complete agreement between the available guidelines and recommendations due to differences in the articles addressed, methodologies, expertise, and validated approaches to literature review. This lack of consensus on the management of MMA may confuse clinicians and highlight some important issues and points. The aim of this comprehensive review article is to critically examine three recent guidelines and recommendations on MMA, discussing their differences and similarities and highlighting gaps in MMA care that need to be covered., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: KF has consulted for Ovid therapeutics, Blueprint Orphan, and Recursion pharmaceutical. KS is a site primary investigator for a study funded by UCB. GL has consulted for Nested Knowledge and Superior Medical Editors. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Background and Objectives: First-line therapy for most intracranial dural arteriovenous fistulas (dAVFs) is endovascular embolization, but some require microsurgical ligation due to limited endovascular accessibility, anticipated lower cure rates, or unacceptable risk profiles. We investigated the most common surgically treated dAVF locations and the approaches and outcomes of each., Methods: The Consortium for Dural Arteriovenous Fistula Outcomes Research database was retrospectively reviewed. Patients who underwent dAVF microsurgical ligation were included. Patient demographics, angiographic information, surgical details, and postoperative outcomes were collected. The 5 most common surgically treated dAVF locations were analyzed about used surgical approaches and postoperative outcomes. Univariate analyses were performed with statistical significance set at a threshold of P < .05., Results: In total, 248 patients in the Consortium for Dural Arteriovenous Fistula Outcomes Research database met inclusion criteria. The 5 most common surgically treated dAVF locations were tentorial, anterior cranial fossa (ACF), transverse-sigmoid sinus (TSS), convexity/superior sagittal sinus (SSS), and torcular. Most tentorial dAVFs were approached using a suboccipital, lateral supracerebellar infratentorial approach (39.3%); extended retrosigmoid approach (ERS) (25%); or posterior subtemporal approach (19.6%). All ACF dAVFs used a subfrontal approach; 5.3% also included an anterior interhemispheric approach. Most TSS dAVFs were ligated via ERS (31.3%) or subtemporal (31.3%) approaches. All convexity/SSS dAVFs used an interhemispheric approach. All torcular dAVFs used the suboccipital, lateral supracerebellar infratentorial approach, with 10.5% undergoing simultaneous ERS craniotomy. Angiographic occlusion rates after microsurgery were 85.5%, 100%, 75.8%, 79.2%, and 73.7% for tentorial, ACF, TSS, convexity/SSS, and torcular dAVFs, respectively (P = .02); the permanent neurological complication rates were 1.8%, 2.6%, 9.1%, 0%, and 0% (P = .31). There were no statistically significant differences in development of complications (P = .08) or Modified Rankin Scale at the last follow-up (P = .11) by fistula location., Conclusion: Although endovascular embolization is the first-line treatment for most intracranial dAVFs, surgical ligation is an important alternative. ACF and tentorial fistulas particularly demonstrate high rates of postoperative obliteration., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background: Anterior communicating artery (ACOM) aneurysms are among the most common aneurysms associated with aneurysmal subarachnoid hemorrhage (International Study of Unruptured Intracranial Aneurysms I (N Engl J Med 339:1725-1733, 1998), Wiebers (Lancet 362:103-110, 2003)). Surgical clipping of posterior-superiorly projecting ACOM aneurysms can be challenging, as the ipsilateral A2 can interfere with clip trajectory and ACOM perforating vessels obstructed from view. Intraluminal coils can further increase the difficulty of the procedure., Method: The relevant surgical anatomy with illustration is presented. A video detailing our technique on an illustrative case is provided., Conclusion: Surgical clipping of posterior-superiorly projecting ACOM aneurysms can require complex clip configurations. We describe the key steps of posterior-superiorly projecting ACOM aneurysm clipping through a lateral supraorbital craniotomy and fenestrated tandem clipping., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Objective: Advances in surgical technology and microneurosurgery have led to increased utilization of so-called minimally invasive approaches, including the supraorbital eyebrow (SE) and minipterional (MPT) approaches for lesions involving the interpeduncular region. This study aimed to describe and compare anatomical landmarks, along with highlighting the advantages and disadvantages of the SE and MPT approaches to the interpeduncular region., Methods: Ten formalin-fixed, latex-injected cadaveric specimens were used to perform bilateral SE and MPT approaches to the interpeduncular region. The operative depth of each approach to key anatomical landmarks was measured. Forty-five axial thin-slice computed tomography studies were reviewed to calculate the operative angles, with consideration of the midline as a reference. A 3D interactive anatomical model generated through the photogrammetry scanning technique was described., Results: The depths of the operative corridors of the SE and MPT approaches to the interpeduncular fossa were 83.4 ± 1.8 mm and 67.7 ± 3.2 mm, respectively (p < 0.001). The mean angle of the MPT approach to the interpeduncular fossa was significantly wider than the one provided by the SE approach (39.9° ± 5.1° vs 28.4° ± 3.6°, p < 0.001). The interpeduncular region can consistently be accessed through the carotid-oculomotor triangle with the SE approach, as well as with the MPT approach. Furthermore, the SE route offered adequate access to the interpeduncular fossa through the opticocarotid triangle. The MPT route provided direct access to the upper prepontine cistern and anterior mesencephalic zone (AMZ)., Conclusions: The MPT approach provides a wider and shorter operative corridor and can be employed for lesions in the interpeduncular region with extension to the prepontine cistern and ventrolateral midbrain lesions requiring access through the AMZ. The SE approach is better suited for ventromedial midbrain lesions requiring access via the interpeduncular fossa safe entry zone. Additional studies analyzing these approaches in a clinical setting will help to delineate their reliability and efficacy.

Competing Interests: We declare no competing interests.

Introduction: In the current paper, the "carotid artery calcium score" method is presented with the target to offer a metric method to quantify the amount of calcification in the carotid artery., Model and Definition: The Volume of Interest (VOI) should be extracted and those voxels, with a Hounsfield Unit (HU) value ≥130, should be considered. The total weight value is determined by calculating the sum of the HU attenuation values of all voxels with values ≥130 HU. This value should be multiplied by the conversion factor ("or voxel size") and divided by a weighting factor, the attenuation threshold to consider a voxel as calcified (and therefore 130 HU): this equation determines the Carotid Artery Calcium Score (CACS) ., Results: In order to provide the demonstration of the potential feasibility of the model, the CACS was calculated in 131 subjects (94 males; mean age 72.7 years) for 235 carotid arteries (in 27 subjects, unilateral plaque was present) considered. The CACS value ranged from 0.67 to 11716. A statistically significant correlation was found (rho value = 0.663, p value = .0001) between the CACS in the right and left carotid plaques. Moreover, a statistically significant correlation between the age and the total CACS was present (rho value = 0.244, p value = .005), whereas no statistically significant difference was found in the distribution of CACS by gender ( p = .148). The CACS was also tested at baseline and after contrast and no statistically significant difference was found., Conclusion: In conclusion, this method is of easy application, and it weights at the same time the volume and the degree of calcification in a unique parameter. This method needs to be tested to verify its potential utility, similar to the coronary artery calcium score, for the risk stratification of the occurrence of cerebrovascular events of the anterior circulation. Further studies using this new diagnostic tool to determine the prognostic value of carotid calcium quantification are needed., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Tentorial dural arteriovenous fistulas (dAVFs) are categorized based on venous drainage and location. Although their angioarchitecture may initially appear intimidating, once "decodified," treatment is straightforward. Posteromedial tentorial dAVFs have an arterialized draining vein that emanates from the inferior tentorium along the posterior third of the straight sinus, just slightly off the midline., Method: With the aid of anatomical dissections, intraoperative photos, and operative videos, we outline the key steps for surgical treatment of posteromedial tentorial dAVFs., Conclusion: Posteromedial tentorial dAVFs constitute a precise and well-defined subtype of tentorial dAVF for which surgical ligation has an important role., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Familial cerebral cavernous malformation (CCM) syndrome is characterized by multiple, non-contiguous cavernous malformations. The lesion burden may affect morbidity. Our aim was to identify risk factors for high lesion burden in these patients., Methods: Patients with radiologically confirmed CCM were screened between 2015 and 2023. Only familial or presumed familial CCM patients were included. Demographic information and medical history at the time of diagnosis were evaluated. The first diagnostic MRI was used to determine T2 total and T2 large lesion (≥5 mm) count. Chi-square was used to determine risk factors for total T2 large lesion count ≥5., Results: Of 107 patients with familial or presumed familial CCM (55.1 % female, age 42.4 years), the median total T2 lesion count and large lesion count was 4 (range: 1-109) and 2 (range: 0-50) respectively. Current tobacco use was a risk factor for T2 large lesion count ≥5., Conclusion: Further studies combining familial cohorts and assessing length of exposure may be useful to confirm tobacco as a risk factor for T2 large lesion formation in familial CCM., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Flemming has consulted with Ovid Therapeutics and Blue Print Orphan. Dr. Lanzino has no relevant disclosures. Kyle Wicker has no relevant disclosures., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Diseases of the carotid arteries can be classified into different categories based on their origin. Atherosclerotic carotid disease remains the most encountered arterial wall pathology. However, other less-common non-atherosclerotic diseases can have detrimental clinical consequences if not appropriately recognized. The underlying histological features of each disease process may result in imaging findings that possess features that are obvious of the disease. However, some carotid disease processes may have histological characteristics that manifest as non-specific radiologic findings. The purpose of this manuscript is to review various non-atherosclerotic causes of carotid artery disease as well as their histologic-radiologic characteristics to aid in the appropriate recognition of these less-commonly encountered pathologies., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The management of superior cerebellar aneurysms is still controversial. Although several techniques are available, the deep localization of the lesion and the limited number of cases increase the complexity of decision-making for optimal treatment. Only a few cases of dissecting and fusiform aneurysms of the superior cerebellar artery (SCA) are described in the literature, many of which are without long follow-ups. The study aims to offer an exhaustive retrospective analysis of patients affected by SCA fusiform and dissecting aneurysms treated at our institution from 2008 to 2023, highlighting outcomes and complications. Moreover, a comprehensive narrative review was performed. A total of seven patients were treated at our institution. After a title and abstract screen, fifty-five papers met the criteria for inclusion in the review. In our case series, conservative treatment was proposed as the first therapeutic option in four cases (57.1%), while endovascular treatment (EVT) was in three cases (42.9%). A good recovery was observed in 66% of patients presenting with subarachnoid hemorrhage (SAH), while every patient without SAH achieved a good clinical outcome. A poor outcome was observed only in one patient with a dissecting aneurysm causing SAH, who also suffered a pontine infarction. In the literature review, conservative treatment was proposed as a first therapeutic option in eleven cases (16.6%), open microsurgical techniques in 19 patients (28.8%), and EVT in 31 patients (46.9%). Fatal outcome was documented in five patients (7.5%), all characterized by the rupture of the vascular lesion, while 6.1% of cases had non-fatal poor outcomes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: The role of stereotactic radiosurgery (SRS) in the management of intracranial dural arteriovenous fistula (dAVF) is unclear given the rarity of this lesion and the variability in treatment paradigms. This study describes a 3-decade experience with the SRS technique and its outcomes for patients with dAVF., Methods: The authors conducted a retrospective analysis of patients with dAVF who had undergone single-fraction SRS in the period from 1990 to 2021. The imaging modality initially used for targeting was angiography alone, then angiography plus MRI, and most recently MRI alone., Results: Two hundred twenty-two patients underwent SRS alone (n = 56, 25%) or SRS plus embolization (n = 166, 75%), depending on the severity of symptoms or the presence of cortical venous drainage (CVD). Most patients were women (64%), and the median patient age was 60 years. Common presenting symptoms were pulsatile bruit (55%), visual change or chemosis (21%), headache (10%), and intracerebral hemorrhage (5%). The most frequent dAVF location was the transverse or sigmoid sinus (44%), followed by the cavernous sinus (24%), jugular bulb (9%), and torcula (5%). CVD was noted in 28% of cases, and venous ectasia in 5%. Borden dAVF types among the patients were I (72%), II (20%), and III (8%). Cognard dAVF types among the patients were I (44%), IIa (27%), IIb (5%), IIa+b (15%), III (4%), and IV (5%). The median SRS treatment volume was 7.6 cm3; the median margin and maximum doses were 18 and 36 Gy, respectively. Follow-up after SRS was available for 209 patients (median follow-up 31 months). Obliteration was noted in 75% of the patients (110/147) with follow-up vascular imaging; the median time to obliteration was 37 months. Multivariate analysis revealed that a cavernous sinus dAVF location was predictive of radiological obliteration (HR 1.86, 95% CI 1.08-3.18, p = 0.024). The absence of CVD was predictive of obliteration in subgroup analysis of non-cavernous sinus dAVF (HR 0.53, 95% CI 0.29-0.98, p = 0.04). Symptoms resolved in 86% of patients (160/185) with clinical follow-up. Twelve patients (5.4%) had complications related to angiography for SRS planning (n = 2, 0.9%), embolization (n = 3, 1.4%), post-SRS hemorrhage (n = 1, 0.5%), delayed sinus thrombosis (n = 1, 0.5%), radiation-induced tumors (n = 2, 0.9%), and chronic encapsulated expanding hematoma (n = 3, 1.4%)., Conclusions: SRS alone or in conjunction with embolization provided obliteration and symptom relief for the majority of patients with dAVF, with a low rate of procedure-related morbidity. Patients are at risk for late radiation-related complications, which can require treatment many years after SRS.

Background: The optimal duration for dual antiplatelet therapy (DAPT) after stent-assisted coiling (SAC) of intracranial aneurysms is unclear. Longer-term therapy may reduce thrombotic complications but increase the risk of bleeding complications., Methods: A retrospective review of prospectively maintained data at 12 institutions was conducted on patients with unruptured intracranial aneurysms who underwent SAC between January 1, 2016 and December 31, 2020, and were followed ≥6 months postprocedure. The type and duration of DAPT, stent(s) used, outcome, length of follow-up, complication rates, and incidence of significant in-stent stenosis (ISS) were collected., Results: Of 556 patients reviewed, 450 met all inclusion criteria. Nine patients treated with DAPT <29 days after SAC and 11 treated for 43-89 days were excluded from the final analysis as none completed their prescribed duration of treatment. Eighty patients received short-term DAPT. There were no significant differences in the rate of thrombotic complications during predefined periods of risk in the short, medium, or long-term treatment groups (1/80, 1.3%; 2/188, 1.1%; and 0/162, 0%, respectively). Similarly, no differences were found in the rate of hemorrhagic complications during period of risk in any group (0/80, 0%; 3/188, 1.6%; and 1/162, 0.6%, respectively). Longer duration DAPT did not reduce ISS risk in any group., Conclusions: Continuing DAPT >42 days after SAC did not reduce the risk of thrombotic complications or in-stent stenosis, although the risk of additional hemorrhagic complications remained low. It may be reasonable to discontinue DAPT after 42 days following non-flow diverting SAC of unruptured intracranial aneurysms., Competing Interests: Competing interests: RAH received grants from NIH, Microvention, CNX, Interline Endowment, and Stryker, consulting fees from Medtronic, Cerenous, Balt, Rapid Medical, Stryker, Microvention, Phenox, and Q’Apel, is a Board Member of MIVI, Three Rivers Medical Inc, Shape Medical, eLum, and Corindus, and holds stock options from InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc., Scientia, Rist, BlinkTBI, Corindus, and NTI. DKL is a consultant for Asahi, Stryker, Corindus, Siemens, and Medtronic, received honoraria from Cerenovus, Medtronic, and Stryker, is on the Advisory Board of INFINITY (trial), received grants from Mentice, has a leadership role with WLNC and Advocate Health and holds stock from Syncron, Three Rivers Inc., Q’apel, VIZ.AI, Methinks, Vastrax, Borvo, BendIT, Collavidence, NDI, Prometheus, NextGen, Galaxy, Global Intervention, and Sim&Cure. AHS is a co-investigator for NIH - 1R01EB030092-01, Project Title: High Speed Angiography at 1000 frames per second, mentor for Brain Aneurysm Foundation Carol W. Harvey Chair of Research, Sharon Epperson Chair of Research, Project Title: A Whole Blood RNA Diagnostic for Unruptured Brain Aneurysm: Risk Assessment Prototype Development and Testing, received consulting fees from Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Asahi Intecc Co Ltd, Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Contego Medical, Cordis, Corindus, Inc., Endostream Medical, Ltd, FreeOx Biotech, SL, Hyperfine Operations, Inc., Imperative Care, InspireMD, Ltd, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Peijia Medical, Penumbra, Piraeus Medical, Inc., Q’Apel Medical, Inc., Rapid Medical, Serenity Medical, Inc., Silk Road Medical, Shockwave Medical, Inc., StimMed, LLC, Stryker Neurovascular, Synchron Australia Pty Ltd, VasSol, Vesalio, Viz.ai, Inc., and WL Gore, holds a patent for a clot retrieval system for removing occlusive clot from a blood vessel, holds stock options of Adona Medical, Inc., Bend IT Technologies, Ltd, BlinkTBI, Inc., Borvo Medical, Inc., Cerebrotech Medical Systems, Inc., CerebrovaKP, Code Zero Medical, Inc., Cognition Medical, Collavidence, Inc., Contego Medical, CVAID Ltd, E8, Inc., Endostream Medical, Ltd, FreeOx Biotech, SL, Galaxy Therapeutics, Inc., Hyperion Surgical, Inc., Imperative Care, Inc., InspireMD, Ltd, Instylla, Inc., Launch NY, Inc., Neurolutions, Inc., NeuroRadial Technologies, Inc. (sold to Medtronic in 2021), Neurovascular Diagnostics, Inc., Peijia Medical, PerFlow Medical, Ltd, Piraeus Medical, Inc., Q’Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp), Rist Neurovascular, Inc. (purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, Sim & Cure, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, Viseon, Inc., Whisper Medical, Inc., Willow Medtech, Inc. and is on the National PI/Steering Committees of Cerenovus EXCELLENT and ARISE II Trial, the Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFT DIRECT Trials, the MicroVention FRED Trial & CONFIDENCE Study, the MUSC POSITIVE Trial, the Penumbra 3D Separator Trial, the COMPASS Trial, the INVEST Trial, the MIVI neuroscience EVAQ Trial, the Rapid Medical SUCCESS Trial, and the InspireMD C-GUARDIANS IDE Pivotal Trial. MRL received a grant from Stryker and Medtronic, consulting fees from Medtronic, Metis Innovative, and Aeaean Advisers, is a member of the DSMB for Arsenal Medical and the editorial board of the Journal of NeuroInterventional Surgery, holds stock options from Proprio, Stroke Diagnostics, Stereotaxis, Fluid Biomed, Hyperion Surgical, and Synchron and received gifts/services from Stryker and Medtronic. GL holds stock options from Superior Medical editors and Nested knowledge. RWC received consulting fees from Medtronic and Microvention. PTK received grants from NIH, Siemens research, the Joe Niekro Foundation, and Medtronic research, consulting fees from Stryker Neurovascular, is a member of the editorial board of the Journal of NeuroInterventional Surgery, and holds stock options from Vena Medical, Deinde, Prometheus, Neurofine, and Vented. No other disclosures were reported., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Major advances in neurocritical care and the modalities used to treat aneurysms have led to improvement in the outlook of patients with aneurysmal subarachnoid hemorrhage. Yet, several knowledge gaps remain widely open. Variability in practices stems from the lack of solid evidence to guide management, which recent guidelines from professional organizations aim to mitigate. In this article, the authors review some of these gaps in knowledge, highlight important messages from recent management guidelines, emphasize aspects of our practice that we consider particularly useful to optimize patient outcomes, and suggest future areas of research., Competing Interests: Disclosure G. Lanzino is a consultant for Nested Knowledge and Superior Medical Editors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Stroke, a leading global cause of mortality and neurological disability, is often associated with atherosclerotic carotid artery disease. Distinguishing between symptomatic and asymptomatic carotid artery disease is crucial for appropriate treatment decisions. Radiomics, a quantitative image analysis technique, and ML have emerged as promising tools in medical imaging, including neuroradiology. This systematic review and meta-analysis aimed to evaluate the methodological quality of studies employing radiomics for atherosclerotic carotid artery disease analysis and ML algorithms for culprit plaque identification using CT or MRI., Materials and Methods: Pubmed, WoS and Scopus databases were searched for relevant studies published from January 2005 to May 2023. RQS assessed methodological quality of studies included in the review. QUADAS-2 assessed the risk of bias. A meta-analysis and three meta regressions were conducted on study performance based on model type, imaging modality and segmentation method., Results: RQS assessed methodological quality, revealing an overall low score and consistent findings with other radiology domains. QUADAS-2 indicated an overall low risk, except for a single study with high bias. The meta-analysis demonstrated that radiomics-based ML models for predicting culprit plaques had a satisfactory performance, with an AUC of 0.85, surpassing clinical models. However, combining radiomics with clinical features yielded the highest AUC of 0.89. Meta-regression analyses confirmed these findings. MRI-based models slightly outperformed CT-based ones, but the difference was not significant., Conclusion: In conclusion, radiomics and ML hold promise for assessing carotid plaque vulnerability, aiding in early cerebrovascular event prediction. Combining radiomics with clinical data enhances predictive performance., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Background and Purpose: The value of long-term serial imaging of dissecting pseudoaneurysm (dPSA) is poorly characterized. This study investigated the long-term radiographic evolution of dPSA., Methods: We performed a query in our institutional craniocervical artery dissection registry to identify cases with spontaneous dPSA who had at least one year of follow-up with serial angiographic imaging. We performed Wilcoxon rank-sum pairwise comparison test to determine if there was a significant change in the aneurysm size over time., Results: This observational cohort study included 76 patients (46 females; 64 dPSA in the internal carotid artery [ICA] and 12 in the vertebral artery [VA]) with a median age of 49.5 years (range 24-77). The initial median dPSA size was 8 mm (interquantile range(iqr) = 5.88-11mm), and the final median dPSA size was 7 mm (iqr = 4-11 mm). Most patients had either no change or reduction in dPSA size in the serial follow-up, with no significant change over time. All the patients had favorable outcomes at the last follow-up, and most patients were symptom-free from dPSA (92 %). Two patients (2.6%) experienced recurrent ischemic strokes in the same territory as the initial ischemic stroke without any change in dPSA size., Conclusion: Further serial scans for dPSA after one year may be deferred in the absence of interim clinical symptoms as most dPSA either remains stable or decreases in size. Recurrent stroke, although a rare event, was not associated with an increase in dPSA size., Competing Interests: Declaration of competing interest The authors declare no relevant interests for this study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Thalamic cavernous malformations are challenging lesions to approach given their deep location and proximity to eloquent neurovascular structures. Several approaches to this region exist, and small nuances in the location of the lesion dictate different surgical trajectories. For cavernous malformations presenting to the superomedial surface of the thalamus, the interhemispheric transcallosal approach affords an excellent trajectory as the anterior two-thirds of the superomedial thalamus constitutes the lateral aspect of the floor of the body of the lateral ventricle. In addition, when the cavernous malformation extends laterally, the contralateral adjunct of the interhemispheric transcallosal approach provides optimal visualization of the lateral aspect of the lesion. In this video, we present the case of a 31-year-old woman who presented to our institution with a giant hemorrhagic thalamic cavernous malformation that resulted in rapid neurological decline characterized by ataxia, right hemiparesis, and diplopia. The cavernous malformation was removed using an interhemispheric contralateral transcallosal approach. The patient had near complete resolution of her preoperative deficits with mild residual weakness in her right hand at 3-month follow-up. At 3-year follow-up, magnetic resonance imaging revealed no active cavernous malformation, and the patient had no recurrence of symptoms. This manuscript was conducted in accordance with the ethical standards of our institution's Institutional Review Board. The patient gave informed consent for surgery and video recording., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Purpose: Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA., Methods: An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability., Results: In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25 mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac., Conclusions: The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)