Flow diversion for compressive unruptured internal carotid artery aneurysms with neuro- ophthalmological symptoms: a systematic review and meta-analysis

 Results

• 22 studies included, 594 patients treated with flow diverters for compressive ICA aneurysms
• Pooled rates of symptom recovery: 47.4% complete, 74.5% improvement
• Rates of transient worsening: 7.1%, permanent worsening: 4.9%  
• Isolated visual symptoms: 30.6% complete recovery, 56.6% improvement
• Isolated oculomotor symptoms: 47.8% complete recovery, 78% improvement
• Aneurysm complete occlusion rate: 68.6%
• Morbidity rate: 5%, mortality rate: 3.9%

Comparison to Previous Research

• Recovery rates are comparable to previous meta-analyses on surgical clipping, coiling, and parent vessel occlusion for similar aneurysms
• Morbidity and mortality rates are slightly higher than some previous studies like PUFS trial
• Occlusion rates align with other flow diverter studies
• Emphasizes importance of early treatment, improving chances of recovery 10-fold if treated within 1 month of symptom onset

 Applications

• Provides evidence for flow diversion as a valid treatment option for compressive ICA aneurysms
• Informs clinical decision-making and patient selection for flow diversion
• Suggests early treatment is critical for best outcomes
• Adds to knowledge of expected recovery rates, risks, and occlusion rates with this technique

The results generally confirm flow diversion as an appropriate treatment for these aneurysms, though early intervention is key. The data help set expectations on likelihood of recovery and risks. This study adds a comprehensive analysis to the existing literature on flow diversion for this indication.

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turning point in the nihilism surrounding surgery for ICH

Based on my review, here are the key points about the results and findings:

This article discusses the results of the ENRICH trial, which evaluated minimally invasive surgery plus thrombolysis (MIPS) compared to medical management for the treatment of spontaneous lobar intracerebral hemorrhage (ICH). The key findings are:
The ENRICH trial met its primary endpoint, demonstrating that MIPS led to superior functional outcomes at 6 months compared to medical management alone in patients with lobar ICH.
MIPS was associated with higher rates of hematoma evacuation and lower mortality compared to medical management.
An adaptive trial design allowed early stopping of enrollment for patients with anterior basal ganglia ICH due to futility, limiting the conclusions to lobar ICH.
Uncommon but methodologically sound features of the trial design included use of a utility-weighted mRS, Bayesian statistics, and an adaptive design.
These results are a major breakthrough, providing the first robust evidence that surgical evacuation can improve outcomes in a select group of ICH patients. Prior large randomized trials showed no benefit of surgery over medical management.
The success of ENRICH appears due to improved patient selection, surgical technique, and timing compared to prior studies. It parallels recent successes for endovascular thrombectomy in ischemic stroke. The findings will likely lead to an increased role for minimally invasive surgery in guidelines and clinical practice for lobar ICH meeting ENRICH criteria.
Key outstanding questions remain regarding optimal patient selection, timing, and surgical techniques. Direct comparative effectiveness studies with other interventions like endoscopic evacuation are still needed. Implementation may be limited by resource availability, especially in lower income regions. Overall though, this trial represents an exciting turning point in the nihilism surrounding surgery for ICH.

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This is very important review that provides a comprehensive summary of mechanical cervicocerebral circulatory disorders in children, with several key implications:

– It emphasizes that pediatric patterns differ substantially from adults for these conditions. For bow hunter’s syndrome, pediatric cases primarily involve the upper cervical spine (C1-C2) with vertebral artery dissection, while adults more commonly have lower cervical disease related to spondylosis. 

– Recognition that bow hunter’s syndrome is a major cause of posterior circulation stroke in children is critically important. Appropriate diagnosis with catheter angiography and head rotations is needed to guide surgical management and prevent recurrence.

– The high rate of recurrent stroke with medical management alone found by Rollins et al (80% recurrence) highlights the need for definitive surgical treatment in pediatric bow hunter’s syndrome. This differs from the lower recurrence rates with medical therapy in adults.

– For Eagle’s syndrome, the review highlights that symptomatic internal carotid artery compression or dissection is very rare in children compared to adults. However, diagnosis with provocative vascular imaging and surgical treatment principles are similar.

– Growing evidence indicates symptomatic jugular venous compression can occur in children, causing headaches or cognitive issues. The entity is likely underdiagnosed currently.

– Dynamic venography showing reversible flow changes or elevated gradients with head positioning is key to definitively diagnosing jugular compression syndromes. This differs from traditional thinking that venous drainage should not be posture-dependent.

– The provided examples demonstrate how bony anatomical variants in children likely increase their risk for developing these disorders compared to adults. Recognition of high-risk anatomy on CT or MRI is important.

– The review emphasizes that catheter angiography remains the gold standard for diagnosis of these disorders, as it provides the best combination of dynamic information and anatomical detail with head provocation maneuvers.

Overall, the paper greatly improves understanding of how pediatric mechanical circulatory disturbances differ from adults. This will support prompt recognition and appropriate diagnosis and management in children presenting with concerning symptoms or posterior circulation events.

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