Tag: vascular disorders

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Prospective untreated outcomes in patients with cerebral cavernous malformation

J Neurosurg 144:1344–1352, 2026

This prospective cohort study quantifies long-term functional outcomes in 332 untreated patients with cerebral cavernous malformation (CCM), using modified Rankin Scale (mRS) scores to evaluate disability over a mean 6.6-year follow-up. It reports incidence of symptomatic hemorrhage (SH), temporal patterns of recovery after a first SH, and external validation of published predictive nomograms.

Key findings identify brainstem location, a history of self-reported psychiatric disorder, and two or more SHs as independent predictors of long-term disability; most patients improved within one year after a first hemorrhage, and ten-year disability risk for nonbrainstem CCM was under 8%.

Objective Elucidate long-term morbidity and disability risk in adults with untreated cerebral cavernous malformation (CCM).

Methods Prospectively followed registry cohort; functional outcome tracked using mRS, with disability defined as mRS ≥ 3; time-to-disability analyzed via Kaplan–Meier and risk factors via Cox models; previously published morbidity nomograms were externally validated.

Cohort 332 patients (58.4% female; mean age 44.5); 19.8% familial CCM; 28.0% brainstem location; 38.3% presented with symptomatic hemorrhage (SH).

Recovery after first SH Among patients with SH who had no further SH and no surgery (n=48), disability (mRS ≥ 3) was 27.1% at diagnosis, improving to 6.2% at 1 year and 4.7% at 5 years, with most improvement in year 1.

Hemorrhage burden Over mean 6.6 years, 31.0% had ≥1 prospective SH and 14.5% had multiple prospective SHs; disability rose sharply with each SH (mRS ≥ 3: 2.3% with 0 SH up to 100% after 5 SHs in untreated follow-up).

Location risk Brainstem CCM carried substantially higher disability risk (18.8% at 5 years; 35.4% at 10 years) versus nonbrainstem locations (4.1% at 5 years; 7.5% at 10 years).

Predictors Multivariate predictors of disability included brainstem location, self-reported psychiatric disorder, and ≥2 SHs.

Nomogram validation Prior nomograms showed high specificity but limited sensitivity; AUC 0.687 for predicting mRS ≥ 2 and 0.783 for predicting mRS ≥ 3.

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Basilar artery perforator rupture as the cause of perimesencephalic subarachnoid hemorrhage

J Neurosurg 144:1271–1277, 2026

This clinical study evaluates the etiology of perimesencephalic subarachnoid hemorrhage (pmSAH) by applying high-resolution cone-beam CT (CBCT) during catheter angiography to detect basilar artery perforator outpouchings. The retrospective analysis of 22 pmSAH patients found that CBCT identified basilar perforator pseudoaneurysms in a substantial subset, with conservative management yielding excellent outcomes.

The authors argue that many pmSAHs may be arterial rather than venous in origin when imaged with modern high-resolution CBCT protocols. They recommend heightened suspicion for an arterial source and detailed angiographic CBCT acquisition, while acknowledging limits of retrospective design, variable imaging quality, and unresolved management questions.

Objective High-resolution CBCT performed during catheter angiography was used to better identify the etiology of perimesencephalic SAH (pmSAH), challenging the historical assumption of a venous source.

Methods Retrospective review of pmSAH cases (Jan 2023–Dec 2024) requiring catheter angiography with available, diagnostic-quality CBCT; images were interpreted by two experienced neuroangiographers to consensus.

Cohort Of 152 spontaneous SAH presentations, 22 met Rinkel criteria for pmSAH; after exclusions (alternative causes found, missing/low-quality CBCT), 13 patients remained for CBCT-based imaging analysis.

Key finding In 8/13 (61.5%) analyzed pmSAH cases, CBCT showed a basilar artery perforator focal outpouching consistent with a rupture site (submillimeter, 0.4–0.8 mm).

Anatomy distribution Among the 8 identified perforator lesions, 6 were rostral basilar perforators, with 1 midbasilar and 1 caudal perforator involvement.

Outcomes All pmSAH patients—including those with identified basilar perforator outpouchings—had excellent recovery, with no re-rupture events and no clinically significant vasospasm reported in the series.

Follow-up imaging In patients who underwent follow-up DSA with CBCT, the basilar perforator finding resolved on follow-up imaging.

Conclusion/implication pmSAH should be approached with high suspicion for an arterial etiology (basilar perforator pseudoaneurysm frequently detectable with high-resolution CBCT), and conservative management was associated with excellent outcomes in this cohort.

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The role of surveillance MRI scans in patients with sporadic cerebral cavernous malformations

J Neurosurg 144:1017–1023, 2026

This clinical study assesses the diagnostic value of routine versus symptom-driven MRI follow-up in patients with sporadic cerebral cavernous malformations (CCMs), analyzing radiographic changes at the first postdiagnosis scan in a prospective single-center cohort. Results show that new or worsening focal neurological deficit (FND) strongly predicts symptomatic hemorrhage, while routine surveillance rarely detects acute hemorrhage.

Imaging progression—including lesion growth, Zabramski classification changes, T1 hyperintensity, and edema—occurred across indications but had limited impact on management when patients were asymptomatic. The authors recommend symptom-driven MRI, reserving routine surveillance for select cases and early posthemorrhage confirmation.

Objective Evaluate whether routine surveillance MRI vs symptom-driven MRI better detects hemorrhage in patients with sporadic, brain-only cerebral cavernous malformations (CCMs), and what radiographic changes appear at first follow-up.

Cohort/Design Prospective single-center registry analysis of 236 sporadic brain-only CCM patients who had ≥1 follow-up MRI after diagnosis; MRI indications categorized as routine vs symptom-driven (e.g., new/worsening focal neurological deficit [FND], headache, seizure).

Hemorrhage yield Radiographic hemorrhage at first follow-up occurred in 19.1% (13/68) of symptom-driven MRIs vs 1.2% (2/168) of routine/non–CCM-related surveillance MRIs.

Routine progression In routine/non–CCM-related surveillance (n=168), 10.1% showed radiologic progression (growth ≥3 mm, more aggressive Zabramski type, or hemorrhage), but acute hemorrhage was only 1.2%; 88.2% of progression events occurred within 2 years.

Imaging correlates of SH Symptomatic hemorrhage (SH) was associated with lesion growth, moderate-to-severe T1-hyperintensity, and edema at follow-up; baseline lesion size and location did not predict hemorrhage.

Symptom predictors New or worsening FND predicted hemorrhage, while seizure or headache alone did not; in multivariate analysis, only new/worsening FND remained independently associated with hemorrhage (OR 13.73, p<0.001).

Clinical implication Follow-up MRI is most justified when there is new or worsening FND; routine surveillance in asymptomatic patients has limited diagnostic yield but may be reasonable in select situations.

Special cases MRI may still be considered for atypical, prolonged headaches distinct from baseline and not responsive to over-the-counter medication, or for changing/new seizure patterns based on clinical judgment.

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Long-term outcomes of microvascular decompression for trigeminal neuralgia in multiple sclerosis

J Neurosurg 144:1122–1133, 2026

This systematic review and meta-analysis evaluates microvascular decompression (MVD) outcomes for trigeminal neuralgia in patients with multiple sclerosis (TN-MS). The authors pooled 30 studies (265 unique TN-MS patients), finding neurovascular compression in 96.6% and a pooled long-term pain-free (BNI I) success rate of about 30%, with low heterogeneity and primarily transient sensory complications.

The report discusses limited, mostly retrospective evidence, methodological limitations, and potential dual mechanisms of TN in MS. Authors conclude MVD yields lower success than in classic TN but remains a reasonable option for selected TN-MS patients with demonstrable neurovascular compression; they call for prospective studies and refined patient selection.

Objective Evaluate long-term pain relief and complications of microvascular decompression (MVD) for trigeminal neuralgia in patients with multiple sclerosis (TN-MS), a group traditionally considered poor candidates for MVD.

Methods Systematic review/meta-analysis (PRISMA) of PubMed, Embase, Scopus, and Web of Science (search June 2024); primary endpoint was long-term pain-free status BNI I at final follow-up using random-effects meta-analysis of proportions.

Evidence base 30 studies were included, covering 429 TN-MS patients treated with MVD, representing 265 unique patients.

Neurovascular compression Compression was identified in 96.6% of reported TN-MS cases (via MRI and/or intraoperative findings).

Long-term efficacy Pooled long-term pain-free outcome (BNI I) after MVD was 30.2% (95% CI 24.2%–36.9%), with low heterogeneity across analyses.

Complications The most commonly reported complication after MVD was transient facial numbness (with other complications variably reported).

Interpretation MVD is less effective in TN-MS than in classic TN, but can still provide meaningful benefit, particularly when neurovascular compression is present.

Conclusion/implication MVD should not be categorically excluded for TN-MS; further prospective studies are needed to improve selection and outcomes.

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Neuropsychological profile and risk factors for poor cognitive outcomes in survivors of aneurysmal subarachnoid hemorrhage

J Neurosurg 144:517–525, 2026

This clinical study characterizes long-term neuropsychological outcomes in 156 survivors of aneurysmal subarachnoid hemorrhage (aSAH), using MoCA-22, digit span, and verbal fluency tests. Findings show that 34% scored below the 25th percentile despite largely favorable functional recovery, with deficits concentrated in executive function, working memory, and language.

Multivariable analysis identified modified Fisher grade 4 on admission and new radiological infarction during hospitalization as independent predictors of poor cognitive outcomes. Secondary assessments revealed frequent depressive symptoms and acquired personality disturbances, implicating impacts on work productivity and social relationships.

Objective Characterize neuropsychological deficits in aneurysmal subarachnoid hemorrhage (aSAH) survivors and identify clinical variables linked to poor cognitive outcomes.

Design/assessments Retrospective cohort (2009–2024) with cognitive testing ≥6 months post-aSAH using MoCA-22, Digit Span Forward/Backward, and Verbal Fluency; poor outcome defined as MoCA-22 <25th percentile (norm-adjusted).

Prevalence 34% (53/156) had MoCA-22 <25th percentile despite most having good functional recovery at discharge (mRS ≤2 in 79% of those with poor MoCA-22).

Cognitive profile Moderate/severe deficits (z-score >1 SD below norms) occurred in 11% on DST-F, 27% on DST-B, and 9% on VFT, highlighting prominent working-memory/executive-function vulnerability.

Key risk factors Modified Fisher grade 4 on admission and new radiological infarction during hospitalization were independently associated with poor MoCA-22 outcomes (aOR 2.43 and 2.71, respectively).

Quality of life impact Radiological infarction was associated with worse work productivity (OR 0.69) and social relationships (OR 0.72).

Behavioral sequelae Among those assessed, 27% reported at least mild depressive symptoms and 64% showed acquired personality disturbance.

Bottom line Cognitive/behavioral deficits can persist long after aSAH even with favorable mRS; higher hemorrhage burden (modified Fisher 4) and in-hospital infarction signal higher risk.

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Artificial intelligence–based deep learning model for evaluating procedural consistency in microvascular anastomosis

J Neurosurg 144:1–10, 2026

This study presents an LSTM-based deep learning model that objectively evaluates microvascular anastomosis performance by predicting hand-motion trajectories from MediaPipe-derived hand landmarks. It quantifies consistency using Kullback-Leibler divergence and validates complementary metrics—economy and flow of motion—comparing two expert neurosurgeons (repeat sessions) and one trainee in simulated end-to-side anastomoses.

Results show low KL divergence for experts versus higher divergence for the trainee, reflecting greater consistency and efficiency. The authors discuss methodology, model architecture choices, limitations in generalizability, and potential integration into microsurgical training workflows for objective skill assessment.

Deep Learning Model: An LSTM-based neural network was developed to objectively assess consistency and precision in microvascular anastomosis by predicting and comparing suturing hand movements using video-based hand landmark tracking, eliminating the need for physical sensors.

Hand Tracking Technology: The model utilized MediaPipe Hand Landmarker, a CNN-based system that detects 21 hand landmarks from standard video, enabling detailed, sensor-free motion analysis during microsurgical simulation.

Performance Metrics: Three primary metrics were used: Kullback-Leibler (KL) divergence for consistency, economy of motion (mean Euclidean distance of hand movement), and flow of motion (median time per suture), providing quantitative, objective evaluation of surgical skill.

Experimental Setup: Two expert neurosurgeons performed microanastomosis simulations (interrupted and continuous suturing) in two sessions one year apart, and a trainee performed the same task for comparison; all sessions were recorded and analyzed using the AI pipeline.

Results and Interpretation: Experts showed low KL divergence (high consistency) and efficient, rhythmic motion, while the trainee had higher KL divergence, longer suture intervals, and more variable motion, reflecting less developed skill.

Model Application: The approach enables rapid, automated assessment of multiple trainees using standard video equipment, supporting objective tracking of skill progression and facilitating feedback in training environments.

Model Rationale: LSTM architecture was chosen for its ability to model long-term temporal dependencies in sequential hand movement data, making it suitable for predicting surgical motion patterns over extended timeframes.

Limitations and Future Directions: Current findings are based on a small sample of experts and one trainee in a simulated environment; broader validation, metric standardization (especially for KL divergence), and extension to real operative settings are needed for generalizability.

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Recurrence of initial angiographic occlusion in intracranial dural arteriovenous fistulas

J Neurosurg 143:1530–1538, 2025

This clinical study analyzes recurrence after angiographic cure of intracranial dural arteriovenous fistulas (DAVFs) using a single-center DREAM-INI cohort of 510 patients. It reports an overall recurrence rate of 8.0%, estimated cumulative recurrence of 13.9% at 36 months and 24.1% at 105 months, and an annual recurrence risk of 6.2%, with most recurrences occurring within 15 months but some delayed beyond 10 years.

The paper identifies independent risk factors including age <45 years, transverse–sigmoid sinus location, multiple fistulae, pial arterial supply, and venous congestion, distinguishes in situ versus remote-site recurrence, explores pathophysiologic mechanisms (venous hypertension, incomplete embolization, angiogenesis), and recommends angiographic follow-up beyond one year for high-risk cured patients.

Recurrence Rate: The overall recurrence rate of intracranial dural arteriovenous fistulas (DAVFs) after initial angiographic cure was 8.0%, with estimated recurrence rates of 13.9% at 36 months and 24.1% at 105 months; the annual recurrence risk was 6.2%.

Types of Recurrence: DAVF recurrence can be classified as in situ recurrence (at the original site) or remote site recurrence (at a different location); both are closely linked to unresolved venous hypertension and previously masked portions of the fistula.

Timing of Recurrence: Most recurrence events (76.6%) occurred within 15 months after initial cure, but delayed recurrences were observed, including cases more than 3 years and up to 10 years later.

Risk Factors: Key risk factors for recurrence included age younger than 45 years, transverse–sigmoid sinus location, multiple fistulae, pial arterial supply, and venous congestion.

Borden Classification: Recurrence was more frequently observed in Borden type II DAVFs, whereas Borden type III DAVFs had a lower recurrence rate when complete occlusion of the proximal draining vein was achieved.

Treatment Implications: Almost all recurrences occurred after endovascular therapy, highlighting the importance of ensuring complete occlusion of the draining vein to minimize recurrence risk.

Clinical Symptoms: There was no clear correlation between clinical symptoms and DAVF recurrence; many recurrences were asymptomatic, emphasizing the need for routine angiographic follow-up.

Follow-Up Recommendation: All patients with cured DAVFs, especially those with identified risk factors, should undergo angiographic follow-up beyond 1 year to detect and manage possible recurrences.

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Optimal imaging follow-up strategies for conservatively managed cerebral cavernous malformations: a cost-effectiveness analysis

J Neurosurg 143:1555–1566, 2025

This study evaluates cost-effectiveness of MRI surveillance intervals for conservatively managed cerebral cavernous malformations (CCMs) using a Markov model and Monte Carlo simulations. It compares 0.5-, 1-, 2-, and 3-year follow-up strategies for brainstem versus nonbrainstem CCMs, calculating lifetime costs, QALYs, and net monetary benefit from a US societal perspective.

Results indicate annual MRI is most cost-effective for brainstem CCMs, while a 3-year MRI interval is preferred for nonbrainstem CCMs, with findings robust to sensitivity analyses that varied hemorrhage rates, mortality, and MRI costs. The authors emphasize individualized follow-up based on symptoms, Zabramski grade, family history, and lesion multiplicity, and note model limitations and US-centric cost data.

Optimal MRI Follow-up for Brainstem CCM: Annual MRI follow-up (every 1 year) is the most cost-effective strategy for conservatively managed, unruptured brainstem cerebral cavernous malformations (CCM), balancing cost and quality-adjusted life years (QALYs).

Optimal MRI Follow-up for Nonbrainstem CCM: MRI follow-up every 3 years is the most cost-effective approach for nonbrainstem CCM, with less frequent imaging justified by lower rupture and rehemorrhage rates.

Markov Model and Monte Carlo Simulation: A decision-analytic Markov model with Monte Carlo simulations was used to compare different MRI follow-up intervals (0.5, 1, 2, and 3 years) for both brainstem and nonbrainstem CCM, incorporating costs, effectiveness (QALYs), and net monetary benefit (NMB).

Key Drivers of Cost-effectiveness: The cost-effectiveness of follow-up strategies is highly sensitive to annual rates of CCM rupture, mortality after rupture, and the cost of MRI; higher hemorrhage or mortality rates favor more frequent imaging.

Individualization of Follow-up: Follow-up intervals should be tailored based on lesion location, symptoms, prior hemorrhage, Zabramski grade, family history, and multiplicity, as higher-risk patients may benefit from closer surveillance.

Brainstem Lesion Risks: Brainstem CCMs have higher annual rupture (2.8%) and rehemorrhage rates (32.3%) compared to nonbrainstem lesions, resulting in greater disability and loss of quality of life, justifying more vigilant follow-up.

MRI Cost Thresholds: As the annual MRI cost increases above $6,581 for brainstem CCM and $8,995 for nonbrainstem CCM, less frequent MRI follow-up (every 2 years) becomes more cost-effective than the previously optimal intervals.

Limitations: The model does not distinguish between cerebellar and supratentorial nonbrainstem lesions, does not account for comorbidities or detailed imaging findings (e.g., Zabramski grade), and uses US-based cost data, which may limit generalizability to other healthcare settings.

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Institutional experience using the endoscopic endonasal approach for the treatment of 40 intracranial aneurysms: indications, outcomes, and technical considerations

J Neurosurg 143:1575–1587, 2025

This clinical series reviews 40 intracranial aneurysms treated via the endoscopic endonasal approach (EEA) over 20 years, outlining patient selection, operative techniques, reconstruction evolution, and outcomes. It emphasizes indications where EEA provides superior ventral access for paraclinoid and selected posterior circulation aneurysms, especially when endovascular therapy is unsuitable.

The report details complication rates—notably CSF leaks—and their temporal improvement, intraoperative adjuncts, follow-up imaging, illustrative cases, and statistical correlations identifying posterior location, age, and SAH as risk factors.

Endoscopic Endonasal Approach (EEA) Indications: EEA is reserved for carefully selected intracranial aneurysms—primarily medially projecting paraclinoidal/cavernous internal carotid artery (ICA) and posterior circulation aneurysms—especially when endovascular treatment is unsuitable and open surgery would risk cranial nerve or brain injury.

Advantages of EEA: Provides a direct ventral surgical corridor, enabling superior proximal/distal vascular control, avoiding brain retraction and cranial nerve manipulation, and facilitating treatment of concomitant sellar pathologies or multiple lesions in a single procedure.

Patient Selection and Outcomes: Out of 34 patients (40 aneurysms) over 20 years, most aneurysms treated were in the paraclinoid/cavernous ICA or posterior circulation; EEA was only used if it was considered safer than open or endovascular approaches, with less than 1% of aneurysm patients treated annually by EEA.

Complication Profile: The main complication was cerebrospinal fluid (CSF) leak (8 cases), particularly in posterior circulation or post-subarachnoid hemorrhage (SAH) cases; other complications included meningitis, clip exposure, lacunar infarcts, and transient cranial nerve palsies. No permanent cranial nerve deficits, visual loss, or procedure-related mortalities occurred since 2019.

Technical Evolution: Advancements in reconstruction techniques and instrumentation (e.g., dedicated endonasal clip appliers, multilayer closure) have reduced complications such as clip exposure and improved overall safety and outcomes over time.

Limitations of EEA: Not suitable for most anterior communicating artery (AcomA) aneurysms due to limited exposure and control; not feasible for revascularization procedures; requires a highly experienced, multidisciplinary team for optimal results.

Comparative Morbidity: EEA appears to reduce the risk of cranial nerve deficits and parenchymal injury compared to lateral (open) approaches, especially for midline lesions, but CSF leak remains the main limitation.

Clinical Recommendation: EEA should be considered only for selected cases where endovascular and open approaches are suboptimal, and only by experienced teams aware of the risks and reconstruction challenges, with all treatment options discussed in a multidisciplinary setting.

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Minimally invasive surgical evacuation confers a mortality benefit in patients with moderate-sized putaminal hemorrhages

J Neurosurg 143:1514–1521, 2025

Minimally invasive surgical (MIS) evacuation of moderate-sized putaminal intracerebral hemorrhages (pICH, 10–50 mL) was retrospectively compared with matched maximal medical management in a single-center cohort. The study found similar utility-weighted functional outcomes but a marked reduction in 1-year mortality (3% surgical vs 24% medical) and shorter ICU length of stay for surgically treated patients, with an incremental cost-effectiveness ratio of ~$68,463 per QALY.

Detailed stereotactic volumetric mapping revealed that hemorrhage spatial distribution predicts outcome differently by treatment: anteromedial extension (caudate/anterior limb internal capsule) associated with worse surgical outcomes, while posterior/superior extension (corona radiata/frontal lobe) predicted worse medical outcomes. The authors propose imaging-based selection criteria for MIS candidacy and recommend validation in larger, multicenter studies.

• Mortality Benefit: Minimally invasive surgical (MIS) evacuation of moderate-sized putaminal intracerebral hemorrhages (pICHs, 10–50 mL) significantly reduced 1-year mortality compared to medical management (3% vs 24%, p = 0.010).

• Functional Outcome: Functional outcomes (utility-weighted modified Rankin Scale) were statistically similar between surgical and medical cohorts, with no significant difference detected (mean uw-mRS 0.44 vs 0.33, p = 0.174), possibly due to limited sample size.

• ICU Stay: MIS evacuation resulted in a shorter median ICU length of stay by 3 days compared to medical management (4 vs 7 days, p = 0.045).

• Cost-Effectiveness: Surgical evacuation was cost-effective with an incremental cost-effectiveness ratio of $68,462.55 per quality-adjusted life year (QALY), under the commonly accepted $100,000/QALY threshold.

• Anatomical Predictors: Poor functional outcomes after MIS were associated with anteromedial hemorrhage extension (anterior limb of internal capsule/caudate), while poor outcomes after medical management were linked to posterior/superior extension (frontal lobe/corona radiata).

• Patient Selection: Imaging-based spatial distribution of pICH can help predict which patients may benefit most from surgical versus medical management, suggesting a role for CT-based anatomical biomarkers in clinical decision-making.

• Study Limitations: Retrospective, single-center design, small sample size, and potential selection bias limit generalizability and statistical power, especially regarding functional outcome differences.

• Guideline Context: Current evidence and guidelines do not define optimal selection criteria for surgery in basal ganglia ICH, highlighting the need for further prospective, multicenter research to refine indications for MIS evacuation

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Decreasing delayed cerebral infarction after aneurysmal subarachnoid hemorrhage using active blood clearance and prevention of delayed cerebral ischemia: results of a 16-year patient registry

J Neurosurg 143:928–938, 2025

Active blood clearance and prevention of delayed cerebral ischemia (ABCD) after aneurysmal subarachnoid hemorrhage significantly reduced delayed cerebral infarction rates and improved outcomes in high-risk patients, using methods like intrathecal irrigation, urokinase, and nimodipine, according to a 16-year registry study.

Active blood clearance and prevention of delayed cerebral ischemia (ABCD) was introduced for patients with aneurysmal subarachnoid hemorrhage (aSAH) to reduce delayed cerebral infarction (DCI) using methods like intrathecal irrigation, fibrinolysis with urokinase, and intrathecal nimodipine.

• Four ABCD methods were developed: stereotactic catheter ventriculocisternostomy (STX-VCS), intraoperative cisternoventricular catheter (CVC), ventriculolumbar irrigation (VLI), and lumbo-lumbar irrigation (LLI).

• Implementation of ABCD in high-risk patients led to a significant reduction in DCI rates from 21.2% to 7.7% and a 70% decrease in per-patient DCI burden.

• Patients selected for ABCD had higher initial blood load and worse clinical status, but still showed improved outcomes, especially those with high Hijdra scores (≥30).

• Pressure-controlled VLI and intraoperative CVC emerged as the most practical and widely applicable ABCD techniques.

• Complication rates were low and ABCD was considered safe, with rare adverse events and no increase in infection rates.

• The study suggests ABCD outperforms previous DCI prevention strategies and recommends multicenter trials for further validation.

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Microsurgical management of 883 previously coiled intracranial aneurysms

J Neurosurg 143:654–667, 2025

This systematic review and meta-analysis found that microsurgical management of previously coiled intracranial aneurysms is effective and safe in well-selected patients, achieving high complete occlusion and good functional outcomes, especially with delayed direct clipping, small aneurysm size, and anterior location.

• Microsurgical management of previously coiled intracranial aneurysms (IAs) is effective and safe in well-selected patients.

• Meta-analysis included 874 patients with 883 previously coiled IAs; most underwent direct clipping.

• Complete occlusion rate was 97.2%, good functional outcome 82.9%, and perioperative mortality 3.7%.

• Direct clipping had the best safety and efficacy, with the lowest rates of complications and highest rates of good outcomes.

• Smaller, anteriorly located, and unruptured aneurysms were associated with the most favorable outcomes.

• Early microsurgery (within 1 month of coiling) and Gurian group C IAs had higher perioperative death rates.

• Key management factors: IA size, location, rupture status, indication, and timing/type of microsurgery.

• Most studies were retrospective case series, limiting subgroup analysis and introducing some heterogeneity.

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Predictive models for assessing the risk of brain aneurysm rupture

J Neurosurg 143:607–614, 2025

This study evaluated predictive models for brain aneurysm rupture risk using clinical, morphological, and advanced MRI radiomics data. Models combining these factors, especially radiomics, significantly improved accuracy in identifying symptomatic aneurysms, supporting a comprehensive, personalized approach for aneurysm risk stratification and treatment decisions.

• The study evaluated predictive models for assessing the risk of brain aneurysm rupture using high-resolution MRI, clinical, morphological, and radiomic data.

• 129 intracranial aneurysms were analyzed; 26% were symptomatic (ruptured or with warning symptoms).

• The PHASES score alone had low predictive ability (AUC 0.61–0.62) for symptomatic aneurysms.

• Adding morphological metrics (especially size ratio) and smoking status improved prediction (AUC up to 0.79).

• Incorporating aneurysm wall enhancement (AWE) metrics further increased model performance (AUC 0.82).

• The best model included age and radiomics features, achieving the highest predictive accuracy (AUC 0.87, 88% sensitivity).

• Younger age, current smoking, larger size ratio, and higher wall enhancement were associated with symptomatic aneurysms.

• A comprehensive approach using clinical, morphological, and advanced imaging/radiomics data improves aneurysm risk stratification.

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Conservative management of 661 patients with unruptured intracranial aneurysms: an observational study over 4 decades

J Neurosurg 143:641–653, 2025

This retrospective study of 661 patients with unruptured intracranial aneurysms found a 4.4% aneurysm-related mortality and 0.6% annual rupture rate. No ruptures occurred with PHASES <8 or ELAPSS <15, highlighting these thresholds for risk stratification and the importance of close follow-up, especially in the first 10 years.

• A retrospective study analyzed 661 patients with 767 unruptured intracranial aneurysms (UIAs) managed conservatively over 4 decades.

• The overall aneurysm-related mortality rate was 4.4%, with 3.5% of patients experiencing rupture; annual hemorrhage rate was 0.6%.

• Most ruptures (87%) occurred within the first 5 years after diagnosis; no ruptures were observed after 10 years.

• No ruptures or aneurysm-related deaths occurred in patients with PHASES score <8 or ELAPSS score <15.

• Independent predictors of rupture included aneurysm size, PHASES and ELAPSS scores, posterior circulation location, and age ≥70 years.

• Aneurysms <7 mm in diameter did not rupture in this cohort, but this may reflect selection bias.

• Lifelong regular follow-up is recommended for conservatively managed UIAs, especially in the first 10 years.

• PHASES and ELAPSS score thresholds can help identify high-risk patients who may benefit from treatment.

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Predictors of dural venous sinus pressure gradient in patients with idiopathic intracranial hypertension

J Neurosurg 143:543–549, 2025

• Venous sinus stenosis (VSS) may cause raised intracranial pressure (ICP) in idiopathic intracranial hypertension (IIH) via impaired venous outflow.

• This study identified predictors of elevated cerebral venous pressure gradient (CVPG) in IIH patients using venous manometry (VM).

• Key predictors of elevated CVPG include: childbearing age, African American race, obesity (BMI ≥ 30), papilledema, pulsatile tinnitus, focal VSS with unilateral dominance on MRV, and opening pressure on lumbar puncture (LP) ≥ 25 cm H₂O.

• Papilledema and pulsatile tinnitus showed the highest sensitivity and specificity among symptoms for predicting elevated CVPG.

• MRV is a useful noninvasive screening tool for VSS, but confirmation by VM is needed.

• An LP opening pressure ≥ 25 cm H₂O is an optimal threshold to refer IIH patients for VM.

• Obesity and younger age are strongly associated with elevated CVPG.

• Venous sinus stenting is a promising therapy for medically refractory IIH with elevated CVPG.

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Relationship of blood flow, angioarchitecture, and rupture in cerebral arteriovenous malformations

J Neurosurg 143:499–504, 2025

Patients with ruptured cerebral AVMs were more likely to have deep location, deep venous drainage, lower flow, smaller nidal volume, smaller arterial feeders, and fewer draining veins than unruptured AVMs. These findings highlight the complex interplay between angioarchitecture, hemodynamics, and rupture risk.

• Lower AVM flow, smaller nidus volume, deep location, deep venous drainage, smaller arterial feeders, and fewer draining veins are associated with ruptured AVMs compared to unruptured ones.

• Male sex and deep AVM location significantly increase the risk of hemorrhagic presentation.

• AVM size and flow are not independent predictors when other variables are considered.

• Fewer draining veins, but not venous stenosis, are linked to rupture, suggesting venous outflow restriction may play a role.

• Findings support previous smaller QMRA-based studies showing lower flow is associated with rupture, despite some conflicting literature.

• Prerupture flow data are lacking; rupture itself may alter measured hemodynamics.

• Further research is needed to clarify the role of hemodynamics and venous occlusion in AVM rupture risk.

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Predicting the natural history of unruptured brain arteriovenous malformations: external validation of rupture risk scores

J Neurosurg 143:490–498, 2025

This retrospective study externally validated four rupture risk scoring systems for unruptured brain arteriovenous malformations (bAVMs) and found their predictive performance ranged from nondiscriminatory to poor. The R2eD AVM scale performed best but still showed limited accuracy, highlighting the need for improved predictive models.

• The study externally validated four rupture risk scoring systems for unruptured brain arteriovenous malformations (bAVMs): Nataf, R2eD AVM, ARI, and VALE.

• Current rupture risk scores showed nondiscriminatory to poor performance in predicting ruptured presentation in a Peruvian single-center population.

• The R2eD AVM scale had the best performance among evaluated scores, but its discrimination was still poor (AUROC 0.664).

• A logistic regression model using size, location, venous tortuosity, and ventricular involvement showed only fair discrimination (AUROC 0.709).

• Key risk factors for rupture included smaller size, periventricular/infratentorial location, absence of venous tortuosity, and ventricular involvement.

• Some variables in published scores, such as venous tortuosity and venous drainage features, were not predictive in this cohort.

• Further research and better predictive factors are needed to improve rupture risk assessment in bAVMs.

• The R2eD AVM score can be used preferentially in clinical practice, but with caution due to its limited performance.

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Competing pathways of intracranial aneurysm growth: linking regional growth distribution and hemodynamics

J Neurosurg 142:1741–1750, 2025

This study analyzes intracranial aneurysm growth, revealing two main mechanisms: high-flow impingement causing wall thinning (mainly in ACom aneurysms) and slow, oscillatory flow leading to wall thickening (mainly in MCA aneurysms). Findings support personalized monitoring and interventions based on regional hemodynamic environments.

• Intracranial aneurysm growth is driven by complex interactions of hemodynamic forces and wall remodeling mechanisms.

• Growth most commonly occurs in the aneurysm body and central flow regions, with patterns varying by location and morphology.

• Two main growth pathways are identified: high-flow impingement (causing wall thinning/degeneration, mainly in ACom aneurysms) and low-flow oscillatory conditions (causing wall thickening/remodeling, mainly in MCA aneurysms).

• High-flow impingement regions (neck, body, inflow) show higher wall shear stress (WSS) and are linked to wall degeneration and rupture risk.

• Low-flow regions (dome, central) have low WSS, high oscillatory shear index, and promote wall remodeling and thickening.

• Distinct growth patterns by aneurysm type suggest targeted monitoring and interventions could reduce rupture risk.

• Findings challenge the simplistic view that only one flow condition drives growth or rupture, emphasizing the need for personalized treatment strategies.

• Study limitations include model assumptions (rigid walls, Newtonian blood), subjective region labeling, and exclusion of nonhemodynamic factors.

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Clinical and radiological presentation of cavernomas according to the Zabramski classification

J Neurosurg 142:1751–1762, 2025

Most cerebral cavernous malformations (CCMs) are asymptomatic, especially Zabramski type IV. Symptoms, mainly seizures or neurological deficits, are primarily linked to Zabramski type I. Type I CCMs often regress to types II/III, but up to one-quarter develop new symptoms over time.

• Most cerebral cavernous malformations (CCMs) are asymptomatic and found incidentally on MRI.

• Zabramski classification is widely used to describe CCMs’ radiological features, but its correlation with clinical symptoms was not well established before this study.

• Zabramski type I CCMs are mostly symptomatic and associated with an unstable clinical course; types II and III are usually asymptomatic or have mild symptoms; type IV CCMs are always asymptomatic.

• Epileptic seizures are the most common presenting symptom, especially for supratentorial CCMs; infratentorial CCMs more often cause balance problems and cranial nerve deficits.

• Most Zabramski type I CCMs regress over time to type II or III; very few type II or III CCMs change to type I.

• Age is associated with Zabramski type: type I CCMs occur in younger patients, type III in older.

• Nearly all Zabramski type IV CCMs appear in patients with multiple CCMs and remain stable and asymptomatic over time.

• The Zabramski type at diagnosis can help predict the future clinical course of CCMs.

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Natural history of dolichoectatic vertebrobasilar aneurysms: a multinational study

J Neurosurg 142:1376–1386, 2025

This multinational study of 382 patients reveals dolichoectatic vertebrobasilar aneurysms (DVBAs) have a high annual mortality (10.8%) and morbidity (1.6%). Advanced age (>50 years), basilar artery location, and large aneurysm size predict worse outcomes, supporting early invasive treatment when feasible to improve prognosis.

• Dolichoectatic vertebrobasilar aneurysms (DVBAs) are rare, malignant vascular lesions with high morbidity and mortality.

• Largest multinational study to date analyzed 382 patients with DVBAs from 11 centers in Europe, US, and Japan.

• Most patients were male (68.6%), median age at diagnosis was 58.8 years.

• Annual adverse event, mortality, and morbidity rates were 12.4%, 10.8%, and 1.6% respectively.

• Older age (>50 years), basilar artery location, larger aneurysm size (>25 mm), and type II (dolichoectatic) morphology were key risk factors for poor outcomes.

• Highest risk of adverse events and death occurred within the first year after diagnosis, especially in older patients and those with basilar artery involvement.

• Early invasive treatment is encouraged when feasible, based on age and radiological characteristics.

• Study highlights urgent need for new, safer therapeutic options for DVBAs.

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