Category: Vascular

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Natural history, management, and outcomes of cerebellar cavernous malformations: A retrospective study of 130 patients

Neurosurgical Review (2025) 48:381

This study on cerebellar cavernous malformations (CMs) examines their natural history, management, and outcomes. It concludes that conservative management is generally effective for incidental lesions, while surgery is recommended for symptomatic cases, especially in accessible regions, due to the associated hemorrhage risks.

• This study investigates cerebellar cavernous malformations (CMs), focusing on natural history, management, and outcomes in 130 patients from 1990 to 2023.

• Hemorrhage risk for incidental lesions is 1.19%, while rehemorrhage risk for initially hemorrhagic lesions is 8.35%.

• Conservative management is recommended for incidental lesions, with surgery reserved for symptomatic, accessible cases.

• Surgery was performed on 31 patients, primarily for hemorrhage or cerebellar symptoms, with postoperative complications in three patients.

• Lesion location and size significantly influence hemorrhage risk and clinical outcomes, with eloquent regions posing higher risks.

• Long-term outcomes were generally favorable, with most patients experiencing improved or stable functional status.

• Psychological support is important due to potential cognitive and emotional impacts associated with cerebellar dysfunction.

• The study emphasizes the need for risk stratification based on lesion size and subregional anatomy within the cerebellum.

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Comparative Efficacy and Safety of Endovascular Versus Surgical Treatment in Spinal Dural Arteriovenous Fistulas A Systematic Review and Meta-analysis

Spine 2025;50:562–574

This systematic review and meta-analysis reveal that surgical treatment for spinal dural arteriovenous fistulas (SDAVFs) achieves higher rates of complete occlusion and successful treatment compared to endovascular approaches, with lower recurrence and retreatment rates, despite similar neurological improvements and periprocedural complications.

• Objective: Compare the efficacy and safety of surgical vs. endovascular treatments for spinal dural arteriovenous fistulas (SDAVFs) through a systematic review and meta-analysis.

• Methods: Searched PubMed, Scopus, and Web of Science databases until July 2024, identifying 1192 articles, with 40 studies meeting inclusion criteria, involving 1818 patients.

• Results: Surgical treatment showed higher rates of complete occlusion (96.8%) and successful treatment (97.5%) compared to endovascular treatment (72.5% and 66.7%, respectively).

• Recurrence and Retreatment: Lower rates in the surgical group, with endovascular treatment showing higher initial treatment failure.

• Neurological Improvement: Both treatments had similar improvements in neurological status and periprocedural complications, but surgery showed greater improvement in the ALS score.

• Conclusion: Surgical treatment is preferred for definitive results in SDAVFs, but decisions should be individualized based on patient-specific factors. Further research is needed.

• Limitations: Potential publication bias and heterogeneity among included studies.

• Key Insight: This study is the most updated and comprehensive meta-analysis on SDAVF treatments, providing valuable insights for clinical and policy decisions.

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Management of intracavitary bleeding during ultra-early minimally invasive intracerebral hemorrhage evacuation

J Neurosurg 142:1003–1013, 2025

Ultra-early minimally invasive endoscopic evacuation of intracerebral hemorrhage within 5 hours increases intraoperative bleeding but does not elevate risks of postoperative rebleeding or worsen long-term outcomes, suggesting safe exploration of its clinical benefits with proper techniques.

• Objective: The study examines the management of intracavitary bleeding during ultra-early minimally invasive intracerebral hemorrhage evacuation.

• Methodology: Patients with spontaneous supratentorial ICH were triaged for surgical evacuation using a 5-point intraoperative bleeding scale.

• Findings: Ultra-early evacuation within 5 hours is associated with increased intraoperative bleeding but not with postoperative rebleeding or worse long-term outcomes.

• Bleeding Scale: A score of 1 indicates no active bleeding, while a score of 5 indicates severe bleeding requiring extensive irrigation and cauterization.

• Results: Ultra-early evacuation had a mean bleeding score of 4.9, compared to 2.3 for evacuations conducted 5 to 10 hours after ictus.

• Conclusion: The benefits of ultra-early evacuation can be explored without increased risk of postoperative rebleeding using minimally invasive endoscopic techniques.

• Significance: The study supports the safety and feasibility of early evacuation strategies in improving functional outcomes for ICH patients.

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Has a fast treatment transition from surgical to endovascular operations improved the survival of aneurysmal subarachnoid hemorrhage?

Acta Neurochirurgica (2025) 167:34

The study examines the impact of transitioning from surgical to endovascular treatment for aneurysmal subarachnoid hemorrhage (aSAH) at Helsinki University Hospital. Findings suggest that case fatality rate (CFR) reductions may be more attributable to other factors than the treatment shift.

• The study investigates the effects of a rapid transition from surgical to endovascular treatment on case fatality rates (CFRs) of aneurysmal subarachnoid hemorrhage (aSAH) at Helsinki University Hospital (HUH).

• The transition to endovascular treatment occurred in 2015, with two treatment eras defined: surgical (2012–2014) and endovascular (2015–2017).

• Results showed a significant increase in endovascular treatment for non-MCA cases and a consistent surgical treatment for MCA cases, with similar decreases in 1-year CFRs for both groups.

• The study concludes that the independent effect of endovascular treatment on decreasing CFRs is small, suggesting improvements in other factors such as diagnostic modalities and acute care may have contributed more.

• The study highlights the need for a case-specific approach in treating aSAH, as different aneurysm locations may benefit differently from surgical or endovascular treatments.

• The research emphasizes the importance of considering other outcome-related factors in addition to treatment modality when analyzing CFR trends.

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Laser interstitial thermal therapy for cavernous malformations: a meta-analysis of individual patient-level data

J Neurosurg 142:1014–1024, 2025

Laser interstitial thermal therapy (LITT) shows promise for treating cavernous malformations, offering high seizure freedom rates and significant CM volume reduction. Immediate neurological deficits are a risk but often transient. Further research is needed for long-term outcomes and safety validation.

• Study Objective: Evaluate laser interstitial thermal therapy (LITT) for cavernous malformations (CMs).

• Methodology: PRISMA-compliant systematic review and patient-level data meta-analysis.

• Patient Demographics: 39 patients, 28 with epilepsy, treated at six centers.

• Seizure Freedom Rate: 88% at last follow-up for epilepsy patients.

• Immediate Postoperative Deficits: 15.4% experienced transient neurological deficits.

• CM Volume Reduction: 73.7% for epileptogenic, 53.8% for nonepileptogenic CMs.

• No Perioperative Hemorrhage: No reported hemorrhages during or after procedures.

• Study Limitations: Small patient cohort, limited follow-up time.

• Predictors of Seizure Freedom: No significant predictors identified.

• Adverse Events Analysis: No significant predictors for adverse events post-LITT.

• Radiographic Outcomes: No significant differences based on CM location.

• Pooled Effect Size Analysis: Frequentist and Bayesian models used for volume reduction estimates.

• Future Research Needs: Larger cohorts and longer follow-up required for validation.

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Implementation of high-definition fiber tractography for preoperative evaluation and surgical planning of brainstem cavernous malformation

J Neurosurg 142:968–976, 2025

The study discusses the use of high-definition fiber tractography (HDFT) in the surgical planning and resection of brainstem cavernous malformations, highlighting its role in reducing postoperative deficits and improving patient outcomes by accurately delineating white matter tracts and optimizing surgical approaches.

• High-definition fiber tractography (HDFT) is implemented for preoperative planning in brainstem cavernous malformations (BSCM) to improve surgical outcomes.

• Study Objective: Evaluate the role and long-term outcomes of HDFT in the surgical management of BSCMs.

• Methods: Retrospective evaluation of 11 patients who underwent HDFT and microsurgical resection.

• Results: Gross-total resection achieved in 72.7% of patients; no new permanent neurological deficits reported.

• HDFT Benefits: Provides critical anatomical information, decreases morbidity, and aids in defining eloquent perilesional boundaries.

• Challenges: Unpredictable displacement of white matter tracts by cavernomas necessitates tailored surgical approaches.

• Limitations: Small sample size, single-center study, and restricted MRI compatibility.

• Conclusion: HDFT is a pivotal tool for safer, more effective resection of BSCMs, warranting further prospective studies.

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Working Status in Patients With Untreated Unruptured Intracranial Aneurysms: A Descriptive Longitudinal Study

Neurosurgery 96:660–666, 2025

The study assessed the working status of Norwegian patients with untreated unruptured intracranial aneurysms (UIAs) from 2008 to 2018. It found that these patients had significantly lower work participation pre- and post-diagnosis compared to the general population, highlighting potential psychological and health burdens.

Study Overview

• Objective: Assess working status in patients with untreated unruptured intracranial aneurysms (UIAs).

• Design: Retrospective nationwide registry-based descriptive longitudinal study.

Key Findings

• Working Status Decline: From 62.1% prediagnosis to 51.3% postdiagnosis in patients.

• Comparison with Controls: Controls decreased from 77.9% to 73.4% in the same period.

• Odds of Working: 86.7% lower in patients than controls postdiagnosis.

• Death Rate: 2.4% of patients died during the 1-year follow-up.

Statistical Analysis

• Predictive Factors: Older age and sickness absence prediagnosis reduce postdiagnosis working status.

• Regression Model: Controlled for age, sex, and baseline working status.

Discussion Points

• Psychological Impact: UIA diagnosis causes stress, anxiety, and reduced work-life participation.

• Comorbidities: Patients may have additional health issues affecting working status.

Limitations

• Data Limitations: Lack of comorbidity and aneurysm characteristic data.

• Country-Specific Factors: Results may not apply to countries outside Norway.

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Natural history and management outcomes of patients with ruptured Spetzler-Martin grade IV and V brain arteriovenous malformations

J Neurosurg 142:667–675, 2025

Study Objective: To explore the natural history and management outcomes of patients with ruptured Spetzler-Martin grade IV and V brain arteriovenous malformations (bAVMs).

• Patient Selection: The study involved 84 patients with ruptured high-grade bAVMs, identified from a database spanning 1990 to 2020.

• Hemorrhagic Risk: Annual hemorrhagic risk was 2.68% for cortical bAVMs and 8.37% for deep-seated bAVMs during natural history.

• Treatment Outcomes: Surgery reduced hemorrhagic risk significantly in cortical bAVMs, while radiosurgery was effective for deep-seated bAVMs. Embolization alone increased hemorrhagic risk.

• Predictors of Success: Surgery and radiosurgery were significant predictors of bAVM obliteration for cortical and deep-seated bAVMs, respectively.

• Management Strategies: Conservative management was compared to surgical interventions, showing similar functional outcomes but differing in obliteration rates.

• Conclusion: Surgery and radiosurgery may be viable options for certain patients, while embolization alone should be avoided

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Idiopathic cerebellar hemorrhage in a patient with isolated developmental venous anomaly: A case report

Surg Neurol Int. 2025;16:82.

A 33-year-old female with severe headaches and vertigo was diagnosed with cerebellar hemorrhage due to an isolated developmental venous anomaly (DVA). Conservative treatment led to full recovery, highlighting the importance of considering DVA in cerebellar hemorrhage etiology and recommending non-surgical management to avoid complications.

• Case Report: Idiopathic cerebellar hemorrhage with isolated developmental venous anomaly in a 33-year-old female.

• Symptoms: Severe headaches, vertigo, left oculomotor nerve palsy, left-sided hemidysmetria.

• Initial Misdiagnosis: Meniere’s disease.

• Imaging Findings: Acute hemorrhage in cerebellar vermis, isolated DVA with “caput medusae” sign.

• Management: Conservative treatment with steroids and analgesics, full recovery.

• DVA Characteristics: Benign anatomical variation, low-flow malformation, rarely causes hemorrhage.

• Hemorrhage Risk Factors: Coexisting cavernous malformation or arteriovenous malformation increase risk.

• Study Findings: Hemorrhage risk 0.22–0.68%/year, higher in infratentorial DVAs.

• Surgical Intervention: Reserved for life-threatening mass effects or raised intracranial pressure.

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Conservative management of brain arteriovenous malformations: results of the prospective observation registry of a pragmatic trial

J Neurosurg 142:637–646, 2025

• Study Overview: TOBAS study on conservative management of brain AVMs.

• Objective: Monitor outcomes of patients with brain AVMs managed conservatively.

• Primary Outcome: Death or dependency (mRS score > 2) at 10 years.

• Patient Recruitment: 1010 patients recruited, 498 in observation registry.

• Follow-up Results: Low incidence of death or disability, 1.7% per year.

• Risk Factors: History of rupture, infratentorial location, age ≥ 55 years increase poor outcomes.

• SAEs Incidence: 3.6 per 100 patient-years, higher in ruptured AVMs.

• Methodology: Kaplan-Meier curves, Cox log-rank tests used for analysis.

• Study Design: Multicenter, includes randomized trials and prospective registries.

• Data Collection: Simple electronic forms, Good Clinical Practice compliance.

• Patient Characteristics: Majority with unruptured, low-grade AVMs.

• Statistical Analysis: Cox models and hazard ratios used.

• Conclusions: Observed patients had low rates of adverse neurological events

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From conservative to interventional management in unruptured intracranial aneurysms

J Neurosurg 142:619–625, 2025

• Study Focus: Management of unruptured intracranial aneurysms (UIAs) from conservative to interventional.

• Objective: Identify patterns and predictors for revising UIA management strategy.

• Methodology: Retrospective review of cases diagnosed between 2006-2022 with conservative management.

• Results: 10 of 144 cases shifted to interventional treatment due to aneurysm growth.

• UIA Growth: Most frequent reason for changing treatment strategy.

• Size Threshold: UIAs > 3 mm at diagnosis more likely to require intervention.

• Conservative Management: Regular radiographic follow-ups recommended, especially for UIAs > 3 mm.

• Guidelines: ESO and American Heart Association guidelines emphasize monitoring UIA growth.

• Statistical Analysis: Cox regression and Kaplan-Meier curves used for data analysis.

• Risk Factors: No significant effect of potential risk factors on treatment change.

• Imaging: DSA as confirmative modality for revising conservative management.

• Study Limitations: Low statistical power due to limited cases of treatment change.

• Conclusion: Regular monitoring crucial for conservatively managed UIAs, especially > 3 mm.

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Aneurysm Wall Enhancement Can Predict Rupture Point in Intracranial Aneurysms With Multiple Blebs

Neurosurgery 96:593–599, 2025

• Aneurysm Wall Enhancement (AWE) can predict rupture points in intracranial aneurysms with multiple blebs.

• Vessel Wall MRI (VW-MRI) is used to visualize ruptured aneurysms, showing characteristic AWE.

• Higher AWE is associated with ruptured blebs, while lower wall shear stress (WSS) is observed in ruptured versus unruptured blebs.

• CRstalk (contrast ratio of the aneurysm wall against the stalk) is a significant predictor of rupture status, with higher values indicating ruptured blebs.

• AWE is independent of WSS in predicting rupture status and can guide treatment strategies.

• Study limitations include its retrospective nature and small sample size; future studies with high-resolution MRI are suggested.

• Clinical value: AWE helps determine which aneurysm to treat first, especially in cases with multiple aneurysms, improving surgical safety.

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Association of Global Ultraviolet Radiation With the Incidence of Aneurysmal Subarachnoid Hemorrhage

Neurosurgery 96:396–401, 2025

• Study Focus: The research investigates the association between global ultraviolet (UV) radiation and the incidence of aneurysmal subarachnoid hemorrhage (SAH).

• Inverse Correlation: A significant inverse correlation between UV radiation and SAH incidence was found, suggesting higher UV exposure is linked to lower SAH rates.

• Methodology: Data from 32 countries were analyzed using UV indices from the Tropospheric Emission Monitoring Internet Service, with statistical analyses performed using R and Excel.

• Geographic Variations: The study found significant regional differences, with higher UV indices in Europe associated with lower SAH incidences, but this was not significant in non-European countries.

• Biological Implications: UV radiation may reduce inflammation, potentially decreasing the risk of aneurysm rupture, and may also boost vitamin D synthesis, which is linked to improved immune response.

• Limitations: The study faced limitations, including lack of data from some countries and inability to assess seasonal influences due to variability in study periods.

• Conclusion: The findings suggest that environmental factors like UV exposure may influence SAH incidence, warranting further investigation into potential therapeutic implications.

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A taxonomy for cerebellar cavernous malformations: subtypes of cerebellar lesions

J Neurosurg 142:380–393, 2025

• A novel taxonomy for cerebellar cavernous malformations (CMs) is proposed, introducing six distinct subtypes based on anatomical location.

• The study was conducted over a 25-year period and involved 143 cerebellar CMs treated microsurgically.

• The subtypes include suboccipital, tentorial, petrosal, vermian, tonsillar, and deep nuclear lesions.

• Favorable neurological outcomes were achieved in 91% of cases, with a mean follow-up of 37.4 months.

• Surgical approaches were guided by the CM subtypes, aiming to minimize tissue transgression and preserve function.

• Complete resection was achieved in 94% of cases, with no significant differences in outcomes between subtypes.

• The taxonomy aids in selecting craniotomy and approach to enhance patient safety and optimize outcomes.

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Intracranial Arteriovenous Malformations During Pregnancy and Puerperium

Neurosurgery 96:346–355, 2025

Study Overview

• Focus: Brain AVM during pregnancy and puerperium.

• Method: Retrospective cohort study in Finland from 1987 to 2016.

• Data Sources: National Hospital Discharge Register, Medical Birth Register, and AVM registry.

Key Findings

• AVM Rupture: Occurred mostly in the second and third trimesters.

• Previous Pregnancies: Most women with AVM rupture had previous pregnancies.

• Treatment Timing: 35.7% received treatment during pregnancy or puerperium.

• Outcomes: No significant difference between treated and conservatively managed mothers.

Maternal and Fetal Outcomes

• Maternal Mortality: Last AVM-related fatality during pregnancy was in 1988.

• Newborn Health: Most had favorable outcomes, with Apgar scores similar between groups.

• Delivery: Average gestation at delivery was 38 weeks.

Clinical Implications

• Management: Multidisciplinary approach recommended for AVM treatment during pregnancy.

• Research Needs: More studies needed on AVM rupture risk related to delivery method.

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Multistaged Stereotactic Radiosurgery for Complex Large Lobar Arteriovenous Malformations

Neurosurgery 96:223–232, 2025

Although stereotactic radiosurgery (SRS) has well defined outcomes in the management of smaller-volume arteriovenous malformations (AVM), this report evaluates the outcomes when SRS is used for large-volume (≥10 cc) lobar AVMs.

METHODS: Between 1990 and 2022, a cohort of 1325 patients underwent Leksell Gamma Knife SRS for brain AVMs. Among these, 40 patients (25 women; median age: 37 years) with large lobar AVMs underwent volume-staged SRS followed by additional SRS procedures if needed (2-5 procedures). The patients presented with diverse AVM locations and Spetzler-Martin Grades. Before SRS, 16 patients underwent a total of 43 embolization procedures.

RESULTS: Over a median follow-up of 73 months, 20 patients achieved AVM obliteration. The 3, 5, and 10-year obliteration rates were 9.3%, 15.3%, and 53.3%, respectively. During the latency interval between the first SRS procedure and the last follow-up, 11 patients had intracerebral hemorrhages (ICH) and 6 developed new neurological deficits unrelated to ICH. The postoperative hemorrhage risk after the first SRS was 13.8% at 3 years, 16.6% at 5 years, and 36.2% at 10 years. No hemorrhagic event was documented after confirmed obliteration. Compared with the modified Rankin Scale (mRS) scores before SRS, the mRS improved or remained stable in 28 patients. Nine patients died during the observation interval. Five were related to ICH.

CONCLUSION: These outcomes underscore both the potential effectiveness and the limitations of multistage SRS procedures for complex high-risk large volume AVMs in critical brain lobar locations. Most patients retained either stable or improved long-term mRS scores. During the latency interval from the first SRS until obliteration, achieved after two or more procedures, the risk of hemorrhage and treatment-related complications persists.

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Anterior choroidal artery aneurysms: a systematic review and meta-analysis of outcomes and ischemic complications following surgical and endovascular treatment

J Neurosurg 142:127–137, 2025

Anterior choroidal artery (AChA) aneurysms account for 2%–5% of all intracranial aneurysms. Treatment considerations include microsurgical clipping, flow diversion, or coiling with or without adjunctive devices. AChA aneurysms pose challenges in treatment due to the origination of the aneurysm from the origin or proximal segment of the AChA. The AChA is particularly susceptible to vasospasm and occlusion during treatment with devastating neurological deficits, including hemiparesis, hemianesthesia, lethargy, neglect, and hemianopia. In this study, the authors performed a meta-analysis to quantify the outcomes and complication rates across treatment modalities for AChA aneurysms and to identify risk factors reported in the literature.

METHODS The authors performed a systematic review of AChA aneurysms treated with surgical clipping, endovascular coiling, or flow diversion and reported in the PubMed, Embase, Scopus, and Cochrane search databases. Single-arm meta-analyses of the selected outcomes were performed in RStudio.

RESULTS Literature review yielded 25 studies that met the inclusion criteria. In total, 1627 patients were included in the analysis, with 554 males, 1009 females, and 64 unspecified. The rate of any complication in the full cohort was 11.6%, with a rate of ischemic complications of 5.5% and a favorable recovery rate of 90.3% of all patients treated. In total, 1064 patients underwent surgical clipping, 443 were treated with coiling, and 120 patients with flow diversion. In clipped patients, the rate of total surgical complications was 17.6%, with an ischemic complication rate of 9.4%. The rate of good functional recovery, defined on the basis of a Glasgow Outcome Scale score of 4–5 or modified Rankin Scale score of 0–2, was 88.0%, and complete obliteration was achieved in 84.5% of surgically clipped aneurysms. The complication rate in coiled patients was 10.3%, with an ischemic complication rate of 3.0%. Good functional recovery was achieved in 88.6% of coiled patients and complete aneurysm obliteration in 74.1%. Flow diversion resulted in a complication rate of 1.3%, with 0.7% rate of ischemic complications. Good functional recovery was achieved in 98.4% of patients and complete aneurysm obliteration in 79.0% in the flow diversion group. Aneurysm morphological features that impacted the complication rate were also identified to augment quantitative data and to help guide treatment selection for AChA aneurysms.

CONCLUSIONS Flow diversion showed significantly lower total and ischemic complications and improved outcomes compared to clipping and coiling. There may be differences in outcomes between treatment types, especially when considering the varied patient presentations that guide treatment selection.

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Nighttime Treatment of Ruptured Intracranial Aneurysms Are Associated With Poor Outcomes

Neurosurgery 96:78–86, 2025

Rebleeding of ruptured intracranial aneurysms (RIA) is associated with poor outcomes. Although immediate treatment of RIAs is preferred, optimal treatment timing is multifactorial and may be a complicating factor for achieving the best outcomes. The objective of this study was to compare outcomes for patients with RIAs as a function of treatment time of day. To the best of our knowledge, this is the first study that examines how treatment time of day influences treatment outcomes.

METHODS: This retrospective single-center study included all patients who were treated, either surgically or endovascularly, for RIAs within 24 hours after admission. Exclusion criteria were blister, mycotic or giant aneurysms, or incomplete records. The modified Rankin Scale was used to evaluate treatment outcomes using multivariate analysis. Nighttime treatment was defined when greater than 50% of the procedure was performed between 10 PM and 7 AM, with other times classified as daytime treatment. Off-hours treatment was defined when more than 50% of the procedure was performed between 7 PM and 7 AM, with other times classified as on-hours.

RESULTS: This study included 493 patients, with 84.2% (415) treated during the daytime, 15.8% (78) during the nighttime, 67.5% (333) during on-hours, and 32.5% (160) during off-hours. These groups did not differ according to age, sex, World Federation of Neurosurgical Societies and Fisher scales, aneurysm size, location, and surgical or endovascular treatment. Outcomes were favorable (modified Rankin Scale 0-2) for 72.0% (299) of patients treated during the daytime and 60.0% (46) of patients treated during the nighttime. Aneurysm treatment during the nighttime (OR: 0.50 [95% CI: 0.28-0.91], P = .023) but not during off-hours (OR: 0.76 [0.50-1.14], P = .18) was independently associated with unfavorable outcomes.

CONCLUSION: Nighttime treatment was associated with poorer outcomes. Further studies are needed to evaluate outcomes if treatment is postponed to daytime hours.

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Comparing surgical clipping with endovascular treatment for unruptured middle cerebral artery aneurysms: a systematic review and updated meta-analysis

J Neurosurg 142:116–126, 2025

Unruptured middle cerebral artery aneurysm (uMCAA) has traditionally been treated with open surgical clipping (SC). Endovascular treatments (EVTs) were designed to reduce surgical risks in these cases. Nevertheless, despite its potential benefits, many surgeons favor SC for uMCAA. This updated meta-analysis aimed to compare the safety, efficacy, and clinical outcomes of SC and EVT for uMCAA.

METHODS The authors searched the Medline, Embase, and Cochrane Library databases according to the Cochrane and PRISMA guidelines. Eligible studies included those with ≥ 4 patients with uMCAA reporting comparative data of SC and EVT. The endpoints were the complete occlusion rate (Raymond class I and II), good clinical outcomes (modified Rankin Scale score ≤ 2 or Glasgow Outcome Scale score ≥ 4), procedure-related complications (further divided into major and minor), and mortality. The authors pooled OR with 95% CI values with a random-effects model. I 2 statistics were used to assess heterogeneity, and sensitivity analysis was conducted to address high heterogeneity. Publication bias was assessed with funnel plot analysis and the Egger’s test.

RESULTS The analysis included data from 10 studies. Regarding the complete occlusion assessment, the comparative analysis revealed OR 0.17 (95% CI 0.08–0.40, p < 0.01), favoring SC. In terms of achieving good clinical outcomes, OR 0.44 (95% CI 0.20–0.97, p < 0.05) was determined, favoring SC. No differences regarding total procedure-related complications, major complications, or mortality were identified. However, a higher likelihood of minor complications was identified for EVT, with OR 4.68 (95% CI 2.01–10.92, p < 0.01).

CONCLUSIONS This systematic review and meta-analysis identified a lower likelihood of complete occlusion at last follow-up and lower likelihood of good clinical outcomes in patients treated with EVT when compared with SC. Furthermore, a higher likelihood of minor complications was identified in patients who underwent EVT when compared with SC. The findings reinforce that, based on the currently available data, SC should be considered the primary approach for treating uMCAA. However, EVT is an evolving approach, and this study’s findings represent a synthesis of observational studies. Randomized trials are warranted to elucidate which approach should be the mainstay for uMCAA and to identify the nuances that determine whether SC or EVT is more or less indicated for addressing uMCAA with consideration of the individuality of each patient and aneurysm.

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Optimal Timing of Microsurgical Treatment for Ruptured Arteriovenous Malformations: A Systematic Review and Meta-Analysis

Neurosurgery 96:18–28, 2025

The timing of microsurgical treatment (MST) for ruptured brain arteriovenous malformations (bAVM) is a contentious issue in the literature. This study aimed to investigate the impact of MST timing on outcomes in patients with ruptured bAVMs, considering MST with and without preoperative endovascular treatment (EVT).

METHOD: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a comprehensive search was conducted across multiple databases, yielding 15 studies meeting the inclusion criteria. The timing was defined as the duration from the rupture of bAVM to the MST. The patients were divided into 4 different groups based on MST timing: <48 hours, <1 week, <2 weeks, and <1 month. The primary outcome was favorable outcome defined as a modified Rankin Scale score of 0 to 2 or a Glasgow Outcome Scale score of 4 to 5 in the last clinical follow-up. Secondary outcomes included periprocedural mortality and complete excision.

RESULTS: MST time >48 hours were associated with a significantly higher favorable outcome rate (odds ratio: 9.71, 95% Cl: 3.09-30.57, P < .01) and a lower mortality rate (OR: 0.15, 95% Cl: 0.02-0.88, P = .04) compared with MST timing ≤48 hours. After exclusion of patients who underwent MST with preoperative EVT, MST time >48 hours had a significantly higher rate of favorable outcome (OR: 9.39, 95% CI: 2.53-34.89, P < .01).

CONCLUSION: This meta-analysis suggests that delayed surgical intervention beyond 48 hours may be associated with improved favorable outcomes in patients who underwent MST with and without preoperative EVT for ruptured bAVMs.

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