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BACKGROUND: Artificial intelligence (AI)-based algorithms have been developed to facilitate rapid and accurate computed tomography angiography (CTA) assessment in proximal large vessel occlusion (LVO) acute ischemic stroke, including internal carotid artery and M1 occlusions. In clinical practice, however, the detection of medium vessel occlusion (MeVO) represents an ongoing diagnostic challenge in which the added value of AI remains unclear.PURPOSE: To assess the diagnostic performance of AI platforms for detecting M2 occlusions.METHODS: Studies that report the diagnostic performance of AI-based detection of M2 occlusions were screened, and sensitivity and specificity data were extracted using the semi-automated AutoLit software (Nested Knowledge, MN) platform. STATA (version 16 IC; Stata Corporation, College Station, Texas, USA) was used to conduct all analyses.RESULTS: Eight studies with a low risk of bias and significant heterogeneity were included in the quantitative and qualitative synthesis. The pooled estimates of sensitivity and specificity of AI platforms for M2 occlusion detection were 64% (95% CI, 53 to 74%) and 97% (95% CI, 84 to 100%), respectively. The area under the curve (AUC) in the SROC curve was 0.79 (95% CI, 0.74 to 0.83).CONCLUSION: The current performance of the AI-based algorithm makes it more suitable as an adjunctive confirmatory tool rather than as an independent one for M2 occlusions. With the rapid development of such algorithms, it is anticipated that newer generations will likely perform much better.

Clinical trials addressing large core acute ischemic stroke (AIS) are ongoing across multiple international groups. Future development of clinical guidelines depends on meta-analyses of these trials calling for a degree of homogeneity of elements across the studies. This common data element study aims to provide an overview of key features of pertinent large core infarct trials.PubMed and ClinicalTrials.gov databases were screened for published and ongoing clinical trials assessing mechanical thrombectomy in patients with AIS with large core infarct. Nested Knowledge AutoLit living review platform was utilized to categorize primary and secondary outcomes as well as inclusion and exclusion criteria for patient selection in the trials.The most reported data element was ASPECTS score but with varied definitions of what constitutes large core. Non-utility-weighted modified Rankin score (mRS) was reported in 6/7 studies as the primary outcome, while the utility-weighted mRS was the outcome of interest in the TESLA trial, all of them at the 3 months mark, with only LASTE looking for mRS shift at the 6 months mark. Secondary outcomes had more variations. Mortality is reported separately only in 4/7 trials, all at the 3‑month mark. Additionally, the TENSION trial reported the frequency of serious adverse events, including mortality, at the 1‑week and 12-month mark.Overall, in large core trials there is a large degree of heterogeneity in the collected data elements. Differences in definition and timepoints render reaching a unified standard difficult, which hinders high quality meta-analyses and cohesive evidence-driven synthesis.

Aim: Stent-retriever (SR) thrombectomy has demonstrated superior outcomes in patients with acute ischemic stroke compared with medical management alone, but differences among SRs remain unexplored. We conducted a Systematic Review/Meta-Analysis to compare outcomes between three SRs: EmboTrap ® , Solitaire™, and Trevo ® . Methods: We conducted a PRISMA-compliant Systematic Review among English-language studies published after 2014 in PubMed/MEDLINE that reported SRs in ≥25 patients. Functional and safety outcomes included 90-day modified Rankin scale (mRS 0-2), mortality, symptomatic intracranial hemorrhage (sICH), and embolization to new territory (ENT). Recanalization outcomes included modified thrombolysis in cerebral infarction (mTICI) and first-pass recanalization (FPR). We used a random effects Meta-Analysis to compare outcomes; subgroup and outlier-influencer analysis were performed to explore heterogeneity. Results: Fifty-one articles comprising 9,804 patients were included. EmboTrap had statistically significantly higher rates of mRS 0-2 (57.4%) compared with Trevo (50.0%, p = 0.013) and Solitaire (45.3%, p Conclusion: The results of our Systematic Review/Meta-Analysis suggest that EmboTrap may be associated with significantly improved functional outcomes compared with Solitaire and Trevo. EmboTrap and Trevo may be associated with significantly lower rates of sICH and mortality compared with Solitaire. No significant differences in recanalization and ENT rates were found. These conclusions are tempered by limitations of the analysis including variations in thrombectomy techniques in the field, highlighting the need for multi-arm RCT studies comparing different SR devices to confirm our findings.

BackgroundPrevious studies comparing a direct aspiration first pass technique (ADAPT) and stent retrievers have inconsistent methodologies and data reporting, limiting the ability to accurately assimilate data from different studies that would inform treatment of acute ischemic stroke (AIS) treatment.ObjectiveTo conduct a systematic review to discuss and compare the findings of all relevant meta-analysis studies comparing the efficacy of the ADAPT and stent retriever techniques.MethodsThe study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), where meta-analyses comparing the efficacy of the ADAPT technique and stent retrievers in the treatment of AIS were included. We extracted all relevant data from the included studies and assessed the quality of the included meta-analyses using the Assessment of Multiple Systematic Review (AMSTAR-2).ResultsSeven relevant studies met our inclusion criteria and were suitable for the qualitative synthesis. All included studies obtained data from randomized controlled trials (RCTs) and observational investigations (including levels II, III, and IV). At the same time, none of them used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) for quality assessment. In accordance with AMSTAR-2, two studies were rated ‘high’, while the other five were rated ‘moderate’.ConclusionsPresent evidence is insufficient to clarify the superiority of one modality over the other. Further RCTs on this comparison must be conducted prior to designing further meta-analyses or making conclusive interpretations. Procedure duration and cost should be taken into consideration for any future studies.

Cross study heterogeneity has limited the evidence based evaluation of middle meningeal artery embolization (MMAE) as a treatment for chronic subdural hematoma (CSDH). Ongoing trials and prospective studies suggest that heterogeneity in upcoming publications may detract from subsequent meta-analyses and systemic reviews. This study aims to describe this data heterogeneity to promote harmonization with common data elements (CDEs) in publications. ClinicalTrials.gov and PubMed were searched for published or ongoing prospective trials of MMAE. The Nested Knowledge AutoLit living review platform was utilized to classify endpoints from randomized control trials (RCTs) and prospective cohort studies comparing MMAE with other treatments. The qualitative synthesis feature was used to determine cross study overlap of outcome related data elements. Eighteen studies were included: 12 RCTs, two non-randomized controlled studies, two prospective single arm trials, one combined prospective and retrospective controlled study, and one prospective cohort study. The most commonly reported data element was recurrence (15/18), but seven heterogenous (non-comparable) definitions were used for ‘recurrence’. Mortality was reported in 10/18 studies, but no common timepoint was reported in more than four studies. Re-intervention and CSDH volume were reported in eight studies, CSDH width in seven, and no other outcome was common across more than five studies. There was significant heterogeneity in data element collection even among prospective registered trials of MMAE. Even among CDEs, variation in definition and timepoints prevented harmonization. A standardized approach based on CDEs may be necessary to facilitate future meta-analyses and evidence driven evaluation of MMAE treatment of CSDH.

BackgroundPrevious randomized controlled trials (RCTs) and meta-analyses were underpowered to demonstrate the superiority of endovascular thrombectomy (EVT) over medical therapy (MEDT) in the treatment of acute ischemic stroke due to large vessel occlusion of the posterior circulation (PC-LVO). We performed an updated systematic review and meta-analysis after the publication of the BAOCHE and ATTENTION trials to determine whether EVT can benefit patients presenting with PC-LVO.MethodsUsing Nested Knowledge, we screened literature for RCTs on EVT in PC-LVO. The primary outcome was 90-day modified Rankin Scale (mRS) score 0–3, and secondary outcomes included 90-day mRS score 0–2, 90-day mortality, and rate of symptomatic intracranial hemorrhage (sICH). A random-effects model was used to compute rate ratios (RRs) and their corresponding 95% confidence intervals (CIs).ResultsFour RCTs with 988 patients, 556 patients in the EVT arm and 432 patients in the MEDT arm, were included in the meta-analysis. EVT resulted in significantly higher rates of mRS score 0–3 (RR=1.54; 95% CI 1.16 to 2.04; P=0.002) and functional independence (RR=1.83; 95% CI 1.08 to 3.08; P=0.024), and lower rates of mortality (RR=0.76; 95% CI 0.65 to 0.90; P=0.002) at 90-day follow-up compared with MEDT alone. However, EVT patients had higher rates of sICH (RR=7.48; 95% CI 2.27 to 24.61; PConclusionsEVT conferred significant patient benefit over MEDT alone in the treatment of PC-LVO. Future studies should better define patients for whom EVT is futile and determine factors that contribute to higher rates of sICH.

Background and aim The use of endoluminal flow diversion in bifurcation aneurysms has been questioned due to the potential for complications and lower occlusion rates. In this study we assessed outcomes of endovascular treatment of intracranial sidewall and bifurcation aneurysms with flow diverters Methods In July 2020, a literature search for all studies utilizing endoluminal flow diverter treatment for sidewall or bifurcation aneurysms was performed. Data were collected from studies that met our inclusion/exclusion criteria by two independent reviewers and confirmed by a third reviewer. Using random-effects meta-analysis the target outcomes including overall complications (hematoma, ischemic events, minor ischemic stroke, aneurysm rupture, side vessel occlusion, stenosis, thrombosis, transient ischemic stroke, and other complications), perioperative complications, and follow-up (long-term) aneurysm occlusion were intestigated. Results Overall, we included 35 studies with 1084 patients with 1208 aneurysms. Of these aneurysms, 654 (54.14%) and 554 (45.86%) were classified as sidewall and bifurcation aneurysm, respectively, based on aneurysm location. Sidewall aneurysms had a similar total complication rate (R) of 27.12% (95% CI, 16.56%–41.09%), compared with bifurcation aneurysms (R, 20.40%, 95% CI, 13.24%–30.08%) (p = 0.3527). Follow-up angiographic outcome showed comparable complete occlusion rates for sidewall aneurysms (R 69.49%; 95%CI, 62.41%–75.75%) and bifurcation aneurysms (R 73.99%; 95% CI, 65.05%–81.31%; p = 0.4328). Conclusions This meta-analysis of sidewall and bifurcation aneurysms treated with endoluminal flow diverters demonstrated no significant differences in complications or occlusion rates. These data provide new information that can be used as a benchmark for comparison with emerging devices for the treatment of bifurcation aneurysms.

Introduction Acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) often leads to mortality. Outcomes of patients with COVID-19-related ARDS compared to ARDS unrelated to COVID-19 is not well characterized. Areas covered We performed a systematic review of PubMed, Scopus, and MedRxiv 11/1/2019 to 3/1/2021, including studies comparing outcomes in COVID-19-related ARDS (COVID-19 group) and ARDS unrelated to COVID-19 (ARDS group). Outcomes investigated were duration of mechanical ventilation-free days, intensive care unit (ICU) length-of-stay (LOS), hospital LOS, and mortality. Random effects models were fit for each outcome measure. Effect sizes were reported as pooled median differences of medians (MDMs), mean differences (MDs), or odds ratios (ORs). Expert opinion Ten studies with 2,281 patients met inclusion criteria (COVID-19: 861 [37.7%], ARDS: 1420 [62.3%]). There were no significant differences between the COVID-19 and ARDS groups for median number of mechanical ventilator-free days (MDM: −7.0 [95% CI: −14.8; 0.7], p = 0.075), ICU LOS (MD: 3.1 [95% CI: −5.9; 12.1], p = 0.501), hospital LOS (MD: 2.5 [95% CI: −5.6; 10.7], p = 0.542), or all-cause mortality (OR: 1.25 [95% CI: 0.78; 1.99], p = 0.361). Compared to the general ARDS population, results did not suggest worse outcomes in COVID-19-related ARDS.

BackgroundThe benefit of mechanical thrombectomy (MT) and efficacy of different first-line MT techniques remain unclear for distal and medium vessel occlusions (DMVOs). In this systematic review, we aimed to compare the performance of three first-line MT techniques in DMVOs.MethodsThe PubMed database was searched for studies examining the utility of MT in DMVOs (middle cerebral artery M2-3-4, anterior cerebral artery, and posterior cerebral artery). Studies providing data for aspiration thrombectomy (ASP), stent retriever thrombectomy (SR), and combined SR+ASP technique were included. Non-comparative studies were excluded. Safety and efficacy data were collected for each technique. The Nested Knowledge AutoLit platform was utilized for literature search, screening, and data extraction. Pooled data were presented as descriptive statistics.Results13 studies comprising 2422 MT procedures were identified. The overall successful recanalization rate was 77.0% (1513/1964) for DMVOs. SR+ASP had a successful recanalization rate of 83.7% (297/355), SR had a 75.6% rate (638/844), while ASP alone had a 74.2% rate (386/520). The overall functional independence rate was 51.3% (851/1659) among DMVOs. The ASP alone group had a functional independence rate of 46.9% (219/467), while functional independence rates of the SR and SR+ASP groups were 51.5% (372/723) and 61.7% (174/282), respectively. Finally, the subarachnoid hemorrhage rates were 1.8% (4/217) for the ASP group, 9.3% (26/281) for the SR group, and 11.9% (41/344) for the SR+ASP group.ConclusionsOur systematic review supports the proposition that MT is a safe and effective treatment option for DMVOs. Additionally, while the SR+ASP group had consistently high rates of clot clearance and good neurological outcomes, the SR and SR+ASP groups also had higher rates of subarachnoid hemorrhage, highlighting the need for improved DMVO treatment devices.

Purpose To perform a systematic review and meta-analysis of randomized controlled trials that examined remdesivir treatment for COVID-19. Materials and methods A systematic literature search was performed using Pubmed, Embase, and ClinicalTrials.gov to identify studies published up to October 25, 2020 that examined COVID-19 treatment with remdesivir. A total of 3 randomized controlled trials that consisted of 1691 patients were included in the meta-analysis. Results The odds for mechanical ventilation (MV) or extracorporeal membrane oxygenation (ECMO) following treatment was significantly lower in the remdesivir group compared to the control group (OR = 0.48 [95% CI: 0.34; 0.69], p, Highlights • Remdesivir reduces the odds for mechanical ventilation or extracorporeal membrane oxygenation in COVID-19 patients. • Remdesivir improves the odds for hospital discharge. • Remdesivir does not lower the odds for mortality. • Remdesivir can attenuate COVID-19 progression, but it is less effective in treating critically-ill patients.

Objectives: To systematically review the clinical literature reporting the use of Lopinavir/ritonavir (LPV/r) for the treatment of patients with Cornonavirus disease 19 (COVID-19) to assess the efficacy of LPV/r for the treatment of COVID-19. Methods: The authors systematically searched PubMed and MedRxiv databases for studies describing treatment of COVID-19 patients using LPV/r compared to other therapies. Articles were excluded if they were case reports, opinion editorials, preclinical studies, single-armed studies, not written in English, not relevant to the topic, or published before May 2020. The included outcomes were viral clearance as measured by reverse-transcription polymerase chain reaction (RT-PCR) negativity and/or improvement on chest computed tomography (CT), mortality, and adverse events. Results: Among 858 total studies, 16 studies met the inclusion criteria and were included in the qualitative review. These studies consisted of 3 randomized control trials, 3 open-label trials, and 10 observational studies. Most of these studies did not report positive clinical outcomes with LPV/r treatment. Conclusion: The systematic review revealed insufficient evidence of effectiveness and clinical benefit of LPV/r in the treatment of COVID-19 patients. Specifically, LPV/r does not appear to improve clinical outcome, mortality, time to RT-PCR negativity, or chest CT clearance in patients with COVID-19.

Most studies define the technical success of endovascular thrombectomy (EVT) as a Thrombolysis in Cerebral Infarction (TICI) revascularization grade of 2b or higher. However, growing evidence suggests that TICI 3 is the best angiographic predictor of improved functional outcomes. To assess the association between successful TICI revascularization grades and functional independence at 90 days, we performed a systematic review and network meta-analysis of thrombectomy studies that reported TICI scores and functional outcomes, measured by the modified Rankin Scale, using the semi-automated AutoLit software platform. Forty studies with 8691 patients were included in the quantitative synthesis. Across TICI, modified TICI (mTICI), and expanded TICI (eTICI), the highest rate of good functional outcomes was observed in patients with TICI 3 recanalization, followed by those with TICI 2c and TICI 2b recanalization, respectively. Rates of good functional outcomes were similar among patients with either TICI 2c or TICI 3 grades. On further sensitivity analysis of the eTICI scale, the rates of good functional outcomes were equivalent between eTICI 2b50 and eTICI 2b67 (OR 0.81, 95% CI 0.52 to 1.25). We conclude that near complete or complete revascularization (TICI 2c/3) is associated with higher rates of functional outcomes after EVT.

Background There is limited evidence on the optimal endovascular strategy for treatment of distal medium-vessel occlusions (DMVO). The low-profile Tigertriever 13 stent-triever shows early promise as an adaptable device that can navigate the distal vasculature without increasing complication risk in DMVO. Methods Using Nested Knowledge, we screened literature for RCTs and cohort studies on the endovascular treatment of DMVO. The primary outcome was reperfusion success, as measured by thrombolysis in cerebral infarction (TICI) ≥ 2b and secondary outcomes included rate of symptomatic intracranial hemorrhage (sICH), mortality at 90 days, and modified Rankin scale (mRS) scores 0–2 at 90 days. A random-effects model was used to compute pooled prevalence rates and their corresponding 95% confidence intervals (CI). Results Eleven studies with 1402 patients, 167 patients treated by Tigertriever 13 and 1235 patients treated by other devices, were included in the meta-analysis. The rate of reperfusion success was similar in patients treated by Tigertriever 13 (83.2% [95% CI: 71.5–96.7%]) versus other devices (81.6% [95% CI: 75.3–88.4%], p > 0.05). The rate of sICH was also similar in patients treated by Tigertriever 13 (7.2% [95% CI: 4.1–12.5%]) versus other devices (6.9% [95% CI: 5.5–8.8%]). There was significant heterogeneity in the reporting of mortality and mRS. Conclusions Tigertriever 13 had similar rates of reperfusion success and sICH as other devices used for the treatment of DMVO. Heterogeneity in data element reporting prevented further analyses. Further studies evaluating Tigertriever 13 and other potential devices in DMVO should attempt to harmonize data element reporting.

OBJECTIVEBecause simple intracranial aneurysms (IAs) are increasingly treated endovascularly, neurovascular surgery has become focused on complex IAs that may require deconstructive aneurysm therapy with concomitant surgical bypass. The authors describe the decision-making process concerning cerebral revascularization and present outcomes that were achieved in a large case series of complex IAs managed with cerebral revascularization and parent artery occlusion.METHODSThe authors retrospectively reviewed the medical records, including neuroimaging studies, operative reports, and follow-up clinic notes, of all patients who were treated at the National Brain Aneurysm Center between July 1997 and June 2015 using cerebral revascularization as part of the management of an IA. They recorded the location, rupture status, and size of each IA, as well as neurological outcome using the modified Rankin Scale (mRS), aneurysm and bypass status at follow-up, and morbidity and mortality.RESULTSThe authors identified 126 patients who underwent revascularization surgery for 126 complex, atheromatous, calcified, or previously coiled aneurysms. Ninety-seven lesions (77.0%) were unruptured, and 99 (78.6%) were located in the anterior circulation. Aneurysm size was giant (≥ 25 mm) in 101 patients, large (10–24 mm) in 9, and small (≤ 9 mm) in 16 patients. Eighty-four low-flow bypasses were performed in 83 patients (65.9%). High-flow bypass was performed in 32 patients (25.4%). Eleven patients (8.7%) underwent in situ or intracranial-intracranial bypasses. Major morbidity (mRS score 4 or 5) occurred in 2 (2.4%) low-flow cases and 3 (9.1%) high-flow cases. Mortality occurred in 2 (2.4%) low-flow cases and 2 (6.1%) high-flow cases. At the 12-month follow-up, 83 (98.8%) low-flow and 30 (93.8%) high-flow bypasses were patent. Seventy-five patients (90.4%) undergoing low-flow and 28 (84.8%) high-flow bypasses had an mRS score ≤ 2. There were no statistically significant differences in patency rates or complications between low- and high-flow bypasses.CONCLUSIONSWhen treating challenging and complex IAs, incorporating revascularization strategies into the surgical repertoire may contribute to achieving favorable outcomes. In our series, low-flow bypass combined with isolated proximal or distal parent artery occlusion was associated with a low rate of ischemic complications while providing good long-term aneurysm control, potentially supporting its wider utilization in this setting. The authors suggest that consideration should be given to managing complex IAs at high-volume centers that offer a multidisciplinary team approach and the full spectrum of surgical and endovascular treatment options to optimize patient outcomes.

OBJECTIVEUndiagnosed hepatitis C virus (HCV) and HIV in patients present risks of transmission of bloodborne infections to surgeons intraoperatively. Presurgical screening has been suggested as a protocol to protect surgical staff from these pathogens. The authors sought to determine the incidence of HCV and HIV infection in elective craniotomy patients and analyze the cost-effectiveness of universal and risk factor–specific screening for protection of the surgical staff.METHODSAll patients undergoing elective craniotomy between July 2009 and July 2016 at the National Brain Aneurysm Center who did not refuse screening were included in this study. The authors utilized rapid HCV and HIV tests to screen patients prior to elective surgery, and for each patient who tested positive using the rapid HCV or HIV test, qualitative nucleic acid testing was used to confirm active viral load, and risk factor information was collected. Patients scheduled for nonurgent surgery who were found to be HCV positive were referred to a hepatologist for preoperative treatment. The authors compared risk factors between patients who tested positive on rapid tests, patients with active viral loads, and a random sample of patients who tested negative. The authors also tracked the clinical and material costs of HCV and HIV rapid test screening per patient for cost-effectiveness analysis and calculated the cost per positive result of screening all patients and of screening based on all patient risk factors that differed significantly between patients with and those without positive HCV test results.RESULTSThe study population of patients scheduled for elective craniotomy included 1461 patients, of whom 22 (1.5%) refused the screening. Of the 1439 patients screened, 15 (1.0%) tested positive for HCV using rapid HCV screening; 9 (60%) of these patients had active viral loads. No patient (0%) tested positive for HIV. Seven (77.8%) of the 9 patients with active viral loads underwent treatment with a hepatologist and were referred back for surgery 3–6 months after sustained virologic response to treatment, but the remaining 2 patients (22.2%) required urgent surgery. Of the 9 patients with active viral loads, 1 patient (11%) had a history of both intravenous drug abuse and tattoos. Two of the 9 patients (22%) had tattoos, and 3 (33%) were born within the age-screening bracket (born 1945–1965) recommended by the Centers for Disease Control and Prevention. Rates of smoking differed significantly (p < 0.001) between patients who had active viral loads of HCV and patients who were HCV negative, and rates of smoking (p < 0.001) and IV drug abuse (p < 0.01) differed significantly between patients who were HCV rapid-test positive and those who were HCV negative. Total screening costs (95% CI) per positive result were $3,877.33 ($2,348.05–$11,119.28) for all patients undergoing HCV rapid screening, $226.29 ($93.54–$312.68) for patients with a history of smoking, and $72.00 ($29.15–$619.39) for patients with a history of IV drug abuse.CONCLUSIONSThe rate of undiagnosed HCV infection in this patient population was commensurate with national levels. While the cost of universal screening was considerable, screening patients based on a history of smoking or IV drug abuse would likely reduce costs per positive result greatly and potentially provide cost-effective identification and treatment of HCV patients and surgical staff protection. HIV screening found no infected patients and was not cost-effective.

OBJECTIVEAdvances in endovascular therapy for the treatment of middle cerebral artery (MCA) aneurysms have led to scrutiny of its benefits compared with microsurgical repair. To provide information regarding complication rates and outcomes, the authors reviewed the results of a large series of unruptured MCA aneurysms treated with open microsurgery.METHODSThe authors included all patients who underwent surgical repair of an unruptured MCA aneurysm between 1997 and 2015. All surgical procedures, including clipping, wrapping, bypass, and parent artery occlusion, were performed by a single neurosurgeon. Aneurysm occlusion was assessed using intraoperative digital subtraction angiography (DSA) or DSA and indocyanine green videoangiography in all cases. Postoperatively, all patients were monitored in a neurointensive care unit overnight. Clinical follow-up was scheduled for 2–4 weeks after surgery, and angiographic follow-up was performed in those patients with subtotally occluded aneurysms at 1, 2, and 5 years postoperation.RESULTSThe authors treated 750 unruptured MCA aneurysms in 716 patients: 649 (86.5%) aneurysms were small, 75 (10.0%) were large, and 26 (3.5%) were giant. Most aneurysms (n = 677, 90%) were treated by primary clip reconstruction. The surgical morbidity rate was 2.8%, and the mortality rate was 0%. Complete angiographic aneurysm occlusion was achieved in 92.0% of aneurysms. At final follow-up, 713 patients had a modified Rankin Scale (mRS) score of 0, 2 patients had an mRS score of 2 or 3, and 1 had an mRS score of 4.CONCLUSIONSIn high-volume centers, microsurgical management of MCA aneurysms can be performed with very low morbidity rates. Currently, microsurgical repair appears to be a highly effective method of treating MCA aneurysms.

Although cardiac myxomas have been known to cause acute ischemic stroke and other cerebrovascular complications, intracranial embolization of metastatic tumor fragments is rare. This is likely because venous emboli generally cause pulmonary embolism. Pulmonary vein metastases and patent foramen ovales have previously shown to propagate intracranial embolic carcinomas, but these events are very uncommon, and are not well characterized. We report a rare case of large-cell, high-grade neuroendocrine lung cancer embolus occluding the basilar artery, which likely detached into the bloodstream from the lung after intruding into a pulmonary vein. The embolus was treated with endovascular aspiration, and achieved modified Thrombolysis In Cerebral Infarction 2c revascularization. After initial neurological recovery, the patient suffered respiratory arrest and support was withdrawn 48 h later. We discuss the tumor characteristics and implications for treatment of acute ischemic stroke in patients with cancer diagnoses.

The purpose of this systematic review and meta‐analysis was to examine clinical outcomes associated with convalescent plasma therapy in COVID‐19 patients. We performed a literature search on PubMed, medRxiv, Web of Science, and Scopus to identify studies published up to December 10th, 2020 that examined the efficacy of convalescent plasma treatment for COVID‐19. The primary endpoints were mortality, clinical improvement, and hospital length of stay. We screened 859 studies that met the search criteria, performed full‐text reviews of 56 articles, and identified 15 articles that fulfilled inclusion criteria for meta‐analysis. The odds of mortality were significantly lower in the convalescent plasma group compared to the control group (OR = 0.59 [95% CI = 0.44; 0.78], P

Background High-quality evidence exists for mechanical thrombectomy (MT) treatment of acute ischemic stroke (AIS) due to large vessel occlusion of the anterior circulation (AC-LVO). The evidence for MT treatment of posterior circulation large vessel occlusion (PC-LVO) is weaker, largely drawn from lower quality studies specific to PC-LVO and extrapolated from findings in AC-LVO, and ambiguous with regards to technical success. We performed a systematic review and meta-analysis to compare the technical success and functional outcomes of MT in PC-LVO versus AC-LVO patients. Methods We identified comparative studies reporting on patients treated with MT in AC-LVO versus PC-LVO. The primary outcome of interest was thrombolysis in cerebral infarction (TICI) ≥ 2b. Secondary outcomes included rates of TICI 3, 90-day functional independence, first-pass-effect, average number of passes, and 90-day mortality. A separate random effects model was fit for each outcome measure. Results Twenty studies with 12,911 patients, 11,299 (87.5%) in the AC-LVO arm and 1612 (12.5%) in the PC-LVO arm, were included. AC-LVO and PC-LVO patients had comparable rates of successful recanalization [OR = 1.02 [95% CI: 0.79–1.33], p = 0.848). However, the AC-LVO group had greater odds of 90-day functional independence (OR = 1.26 [95% CI: 1.00; 1.59], p = 0.050) and lower odds of 90-day mortality (OR = 0.58 [95% CI: 0.43; 0.79], p = 0.002). Conclusions MT achieves similar rates of recanalization with a similar safety profile in PC-LVO and AC-LVO patients. Patients with PC-LVO are less likely to achieve functional independence after MT. Future studies should identify PC-LVO patients who are likely to achieve favourable functional outcomes.

Objective Recent studies suggest that the clinical course and outcomes of patients with coronavirus disease 2019 (COVID-19) and myasthenia gravis (MG) are highly variable. We performed a systematic review of the relevant literature with a key aim to assess the outcomes of invasive ventilation, mortality, and hospital length of stay (HLoS) for patients presenting with MG and COVID-19. Methods We searched the PubMed, Scopus, Web of Science, and MedRxiv databases for original articles that reported patients with MG and COVID-19. We included all clinical studies that reported MG in patients with confirmed COVID-19 cases via RT-PCR tests. We collected data on patient background characteristics, symptoms, time between MG and COVID-19 diagnosis, MG and COVID-19 treatments, HLoS, and mortality at last available follow-up. We reported summary statistics as counts and percentages or mean±SD. When necessary, inverse variance weighting was used to aggregate patient-level data and summary statistics. Results Nineteen studies with 152 patients (mean age 54.4 ± 12.7 years; 79/152 [52.0%] female) were included. Hypertension (62/141, 44.0%) and diabetes (30/141, 21.3%) were the most common comorbidities. The mean time between the diagnosis of MG and COVID-19 was7.0 ± 6.3 years. Diagnosis of COVID-19 was confirmed in all patients via RT-PCR tests. Fever (40/59, 67.8%) and ptosis (9/55, 16.4%) were the most frequent COVID-19 and MG symptoms, respectively. Azithromycin and ceftriaxone were the most common COVID-19 treatments, while prednisone and intravenous immunoglobulin were the most common MG treatments. Invasive ventilation treatment was required for 25/59 (42.4%) of patients. The mean HLoS was 18.2 ± 9.9 days. The mortality rate was 18/152 (11.8%). Conclusion This report provides an overview of the characteristics, treatment, and outcomes of MG in COVID-19 patients. Although COVID-19 may exaggerate the neurological symptoms and worsens the outcome in MG patients, we did not find enough evidence to support this notion. Further studies with larger numbers of patients with MG and COVID-19 are needed to better assess the clinical outcomes in these patients.

We report a novel case of a radiation-induced cavernous malformation developing in a vestibular schwannoma previously treated with stereotactic radiosurgery. Eleven years after treatment, the patient presented with a large predominantly cystic lesion in the cerebellopontine angle. We performed surgery, and a solid vascular lesion was identified within the schwannoma, which was determined to be a cavernous malformation after histopathological analysis. We review the literature of radiation-induced cavernous lesions, illustrating that while rare, these lesions do pose concern as a long-term complication of brain radiation therapy. We also discuss the possibility that radiation-induced cavernous malformation-like lesions are pathologically distinct from cavernous malformations.

Background Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a very rare tumor with fewer than 70 cases reported in the literature. In general, this tumor occurs intracranially either within the brain parenchyma or in an extra-axial location, but it has also been described within the spine as an extra-axial lesion. Case Description We describe an unusual case of intracranial-extradural CAPNON involving the mastoid region. This may be only the second such case reported in the literature, as one patient with CAPNON has been reported involving the sinonasal region. Our patient was managed with surgical resection through a translabyrinthine approach with good early result. Conclusions We describe an unusual case of extradural CAPNON involving the mastoid bone. It appears that when located extradurally, this tumor may have a predilection for the bony sinuses. This little-known, generally benign entity can mimic more common lesions such as meningiomas, and should be considered in the differential diagnosis of skull base tumors, particularly when associated with heavy calcification.

Background Systematic reviews depend on time-consuming extraction of data from the PDFs of underlying studies. To date, automation efforts have focused on extracting data from the text, and no approach has yet succeeded in fully automating ingestion of quantitative evidence. However, the majority of relevant data is generally presented in tables, and the tabular structure is more amenable to automated extraction than free text. Objective The purpose of this study was to classify the structure and format of descriptive statistics reported in tables in the comparative medical literature. Methods We sampled 100 published randomized controlled trials from 2019 based on a search in PubMed; these results were imported to the AutoLit platform. Studies were excluded if they were nonclinical, noncomparative, not in English, protocols, or not available in full text. In AutoLit, tables reporting baseline or outcome data in all studies were characterized based on reporting practices. Measurement context, meaning the structure in which the interventions of interest, patient arm breakdown, measurement time points, and data element descriptions were presented, was classified based on the number of contextual pieces and metadata reported. The statistic formats for reported metrics (specific instances of reporting of data elements) were then classified by location and broken down into reporting strategies for continuous, dichotomous, and categorical metrics. Results We included 78 of 100 sampled studies, one of which (1.3%) did not report data elements in tables. The remaining 77 studies reported baseline and outcome data in 174 tables, and 96% (69/72) of these tables broke down reporting by patient arms. Fifteen structures were found for the reporting of measurement context, which were broadly grouped into: 1×1 contexts, where two pieces of context are reported in total (eg, arms in columns, data elements in rows); 2×1 contexts, where two pieces of context are given on row headers (eg, time points in columns, arms nested in data elements on rows); and 1×2 contexts, where two pieces of context are given on column headers. The 1×1 contexts were present in 57% of tables (99/174), compared to 20% (34/174) for 2×1 contexts and 15% (26/174) for 1×2 contexts; the remaining 8% (15/174) used unique/other stratification methods. Statistic formats were reported in the headers or descriptions of 84% (65/74) of studies. Conclusions In this cross-sectional pilot review, we found a high density of information in tables, but with major heterogeneity in presentation of measurement context. The highest-density studies reported both baseline and outcome measures in tables, with arm-level breakout, intervention labels, and arm sizes present, and reported both the statistic formats and units. The measurement context formats presented here, broadly classified into three classes that cover 92% (71/78) of studies, form a basis for understanding the frequency of different reporting styles, supporting automated detection of the data format for extraction of metrics.

Background Balloon guide catheters (BGCs) are designed to induce flow arrest during mechanical thrombectomy procedures for acute ischemic stroke due to large-vessel occlusion and have been associated with improved clinical and angiographic outcomes. We conducted a systematic review and meta-analysis evaluating the relative technical and clinical outcomes associated with BGC versus non-BGC approaches. Methods A systematic review of clinical literature using the PubMed database was undertaken to identify multiarm studies published between 2010 and 2021 reporting the use of BGC versus non-BGC approaches for stroke treatment. Data collected included complete recanalization (thrombolysis in cerebral infarction, TICI), first-pass effect TICI 3, puncture-to recanalization time, number of endovascular attempts, distal embolization, symptomatic intracerebral hemorrhage, 90-day modified Rankin Scale score 0–2, and 90-day mortality. Subgroup analyses assessed the impact of treatment device (stent-retrievers, contact aspiration, combination therapy, and not specified/other). A random effects model was fit for each outcome measure. Results Fifteen studies were included. Compared with non-BGC approaches, patients treated with BGCs had greater odds of TICI 3 (odds ratio [OR] 1.57; 95% confidence interval [95% CI] 1.08–2.29) and first-pass effect TICI 3 (OR 3.63; 95% CI 2.34–5.62), reduced puncture-to-revascularization time (mean difference –7.8; 95% CI –13.3 to –2.2), fewer endovascular attempts (mean difference –0.47; 95% CI –0.68 to –0.26), reduced odds of distal emboli (OR 0.34; 95% CI 0.17–0.71) and symptomatic intracerebral hemorrhage (OR 0.66; 95% CI 0.51–0.86), greater odds of 90-day modified Rankin Scale score 0–2 (OR 1.51; 95% CI 1.27–1.79), and reduced odds of mortality (OR 0.69; 95% CI 0.57–0.82). Conclusions BGCs yield superior technical and clinical outcomes while reducing patient complications.

We report a case of a 50-year-old woman whose 0.5 mm middle cerebral artery (MCA) aneurysm was treated with gauze wrapping at an outside facility. She returned 9 months later with seizures and an inflammatory process in the region of the prior aneurysm. Surgical re-exploration at that time was aborted. Two years later, she presented with a gauzoma associated with local inflammatory response and severe narrowing of the MCA. A common carotid artery to MCA bypass was performed, followed by surgical removal of the gauze and inflammatory material. Over a 3-month period, she recovered with significant improvement in her preoperative neurological deficits.

Beyond explicit reviewer commentary, editors may rely on other metrics when evaluating manuscripts under consideration for publication. One potential, indirect measure of merit may be the ease or difficulty in identifying reviewers willing to review a given paper. We sought to determine whether reviewer decisions to agree or decline to review a manuscript are associated with manuscript acceptance. Original Research submissions to “Radiology” from 1/1/2008 to 12/31/2011 were studied. Using Student’s t tests, we studied the association between the ratio number-of-reviewers-declining:number-of-reviewers-agreeing to review manuscripts (“decline:agree ratio”) and editor decision to accept or reject the manuscript. A subgroup analysis of papers in which all four invited reviewers agreed to review the paper (“universal agree-to-review group”) was performed. Pearson’s correlation was used to study decline:agree ratio and accepted manuscript citation rate. Original Research manuscript acceptance rate at Radiology was 14.5% (780/5375). Decline:agree ratio was similar between accepted and rejected manuscripts (0.87 ± 0.84 versus 0.90 ± 0.86 respectively, P = 0.35). “Universal agree-to-review” papers were accepted at similar rates to other papers (15.7% [22/140] versus 14.5% [758/5235] respectively, P = 0.69). Higher decline:agree ratios corresponded to lower manuscript citation rates (r = 0.09, P = 0.048). Our study, based on the lack of correlation between agreement to review rate and acceptance rate to Radiology and the direct correlation between agreement to review rate and manuscript citation rate, suggests that reviewers may have a preference for manuscripts with greater potential scientific relevance, but that reviewer motivation to agree to review does not include the expectation of manuscript acceptance.

Frameless stereotactic guidance (FSG) has previously been reported to have advantages over intraoperative computed tomography (CT) and frame-based imaging guidance methods in the targeting of intracranial lesions. We report our experience using FSG to minimize brain dissection during microsurgical repair of peripheral aneurysms. We used FSG as a surgical adjunct in the management of 91 peripheral aneurysms. It was used to localise and avoid larger bridging veins, enabling us to minimise unnecessary brain dissection by coming directly down on the aneurysm dome in unruptured lesions or targeting the parent artery just proximal to the aneurysm in ruptured cases. We treated 72 aneurysms located on the distal ACA (79%), 7 on the PCA (7.7%), 6 on the MCA distal to the MCA bifurcation (6.6%), and 6 on the SCA (6.6%). There were no complications related to FSG use. However, we noted a tendency to create an overly limited corridor to the aneurysm, which did not allow sufficient proximal or distal control of the parent artery. In these cases, we had to widen our exposure by further opening the interhemispheric fissure to obtain more proximal control once the aneurysm was reached. Subsequently, we learned to avoid this problem by creating a slightly wider corridor during the initial exposure. Using FSG as a surgical adjunct for peripheral intracranial aneurysms allowed us to safely limit craniotomy size and brain dissection while more confidently exposing these unusually situated lesions, facilitating aneurysm clipping in our series.

Background: When treating intracranial aneurysms with open microsurgery, rare cases arise in which an ipsilateral approach leads to poor visualization, lack of proximal control, or potential damage to nearby vital structures due to the anatomy of the aneurysm. Case Description: We describe a patient with a small, unruptured aneurysm arising from the medial aspect of the distal supraclinoid internal carotid artery (ICA), just below the ICA bifurcation. A contralateral surgical approach was chosen because our view of the aneurysm from an ipsilateral approach would have been obstructed by the ICA. The contralateral approach provided excellent exposure of the aneurysm and allowed for precise clip placement without complications. Conclusions: Contralateral approaches may be a good option for some small medially pointing aneurysm of large proximal cerebral arteries.

BACKGROUND: Corticosteroid treatment is an effective and common therapeutic strategy for various inflammatory lung pathologies and may be an effective treatment for coronavirus disease 2019 (COVID-19). The purpose of this systematic review and meta-analysis of current literature was to investigate the clinical outcomes associated with corticosteroid treatment of COVID-19. METHODS: We systematically searched PubMed, medRxiv, Web of Science, and Scopus databases through March 10, 2021 to identify randomized controlled trials (RCTs) that evaluated the effects of corticosteroid therapies for COVID-19 treatment. Outcomes of interest were mortality, need for mechanical ventilation, serious adverse events (SAEs), and superinfection. RESULTS: A total of 7737 patients from 8 RCTs were included in the quantitative meta-analysis, of which 2795 (36.1%) patients received corticosteroids plus standard of care (SOC) while 4942 (63.9%) patients received placebo and/or SOC alone. The odds of mortality were significantly lower in patients that received corticosteroids as compared to SOC (odds ratio [OR] = 0.85 [95% CI: 0.76; 0.95], P = .003). Corticosteroid treatment reduced the odds of a need for mechanical ventilation as compared to SOC (OR = 0.76 [95% CI: 0.59; 0.97], P = .030). There was no significant difference between the corticosteroid and SOC groups with regards to SAEs and superinfections. CONCLUSION: Corticosteroid treatment can reduce the odds for mortality and the need for mechanical ventilation in severe COVID-19 patients.

While intracranial ischemic insults often result in neuronal death and permanent neurological deficits, some patients may develop potentially reversible neurological dysfunction from persistent hypoperfusion, as surviving neurons remain in an "idling" state. We report a unique series of three patients with long-standing neurological deficits who underwent EC-IC bypass for repeated TIAs and demonstrated unexpected, rapid resolution of long-standing pre-existing neurological deficits. We suggest that these individuals harbored regions of underperfused, idling neurons that responded rapidly to restored cerebral reperfusion.

In the third century AD, under the pressure of plagues, external invasion, rising army costs, and usurpation, the Roman emperors incrementally debased the silver coinage that was produced at their imperial mints and incrementally took over civic mints. The debasement, from 2.7 g of silver to 0.04 g of silver in the equivalent of adenariusfrom 160–274ad, was accompanied by worries from emperors, mint-workers, and bankers about the value of the currency; however, the total loss of purchasing power of the Roman coinage from the same era was 50–70 %, far less than would be expected from the change in metallic content, if it were the primary source of value. The currency reform of Aurelian in 274ad, despite raising metallic values of coins, was followed by at least a 90 % reduction in the purchasing power of the silver coinage from 274–301ad, the year of Diocletian’s Edict on Maximum Prices, showing a paradoxically inverse relationship between metallic value and purchasing power.Based on this quandary, I argue that the Roman silver coinage of the third century CE became a fiat currency in some respects, deriving its guarantee from imperial iconography and assurances rather than from bullion value. The fiat nature of the silver coinage was largely present in usage as a medium of exchange for those without as much long-term interest in maintaining liquid stores of value; this is indicated by the differential debasement of thedenariusandaureus; imperial actions and hoarding practices indicate the extent to which the currency was accepted at nominal value. I examine the reactions of different social groups in order to determine the perceived value of the Roman coinage during this time, and in order to understand the paradoxical collapse in the currency’s value in the late third century.To demonstrate this, I will present the applicable elements of the modern concept of “fiat” to this context through portrayal of emperors and usurpers on coins, use coin hoard data to determine the effect of Gresham’s Law, and examine historical and papyrological accounts of currency reforms. I will also use evidence of the expansion of taxes in kind and the rejection of nominal value by both emperor and subjects to argue that the inflation following Aurelian’s reform resulted from an invalidation of the trust in imperial fiat.

Angiomatoid fibrous histiocytoma (AFH) is a tumour primarily occurring in the extremities which can very rarely occur as an isolated intracranial lesion. We report a case of a 22-year-old woman presenting with generalized seizure and visual field deficit due to an occipital mass, which immunohistochemistry showed to be an AFH.

Magnetic resonance imaging is considered low risk, yet recent studies have raised a concern of potential damage to DNA in peripheral blood leukocytes. This prospective Institutional Review Board-approved study examined potential double-strand DNA damage by analyzing changes in the DNA damage and repair markers γH2AX and 53BP1 in patients who underwent a 1.5 T gadolinium-enhanced cardiac magnetic resonance (MR) exam. Sixty patients were enrolled (median age 55 years, 39 males). Patients with history of malignancy or who were receiving chemotherapy, radiation therapy, or steroids were excluded. MR sequence data were recorded and blood samples obtained immediately before and after MR exposure. An automated immunofluorescence assay quantified γH2AX or 53BP1 foci number in isolated peripheral blood mononuclear cells. Changes in foci number were analyzed using the Wilcoxon signed-rank test. Clinical and MR procedural characteristics were compared between patients who had a >10% increase in γH2AX or 53BP1 foci numbers and patients who did not. The number of γH2AX foci did not significantly change following cardiac MR (median foci per cell pre-MR = 0.11, post-MR = 0.11, p = .90), but the number of 53BP1 foci significantly increased following MR (median foci per cell pre-MR = 0.46, post-MR = 0.54, p = .0140). Clinical and MR characteristics did not differ significantly between patients who had at least a 10% increase in foci per cell and those who did not. We conclude that MR exposure leads to a small (median 25%) increase in 53BP1 foci, however the clinical relevance of this increase is unknown and may be attributable to normal variation instead of MR exposure.

We report a case of a 50-year-old woman whose 0.5 mm middle cerebral artery (MCA) aneurysm was treated with gauze wrapping at an outside facility. She returned 9 months later with seizures and an inflammatory process in the region of the prior aneurysm. Surgical re-exploration at that time was aborted. Two years later, she presented with a gauzoma associated with local inflammatory response and severe narrowing of the MCA. A common carotid artery to MCA bypass was performed, followed by surgical removal of the gauze and inflammatory material. Over a 3-month period, she recovered with significant improvement in her preoperative neurological deficits.