bluuebunny/crossref_metadata_2025_split huggingface dataset:
693 Treatment Differences of Ruptured Versus Unruptured Wide Neck Aneurysms: Insights From the EVERRUN Registry
Authors: Hardigan Trevor , Hendricks Benjamin K. , Yoon James Seungwon , Kellner Christopher P. , Lawton Michael T. , Mocco J. D. , Mascitelli Justin Robert 
Published: March 2024

INTRODUCTION:
Wide neck aneurysms (WNAs) are more challenging to treat compared to narrow neck aneurysms, requiring more advanced techniques. The Wide Neck / EVERRUN Registry compared endovascular versus microsurgical techniques for unruptured and ruptured aneurysms.

METHODS:
Saccular and not previously treated WNA were examined. WNA definition was aneurysm neck=4mm or dome-to-neck-ratio (DTNR)<2. Differences in treatment strategy (EVT vs. MS) and angiographic results were the primary outcomes. Angiographic outcome was assessed immediately following treatment and at last follow-up using the Raymond-Roy scale (core lab review, adequate occlusion: RR 1-2). Statistical significance set at p<0.05. All analysis performed using R(v.4.2.1).

RESULTS:
310 WNA were included (87 ruptured (R) aneurysms vs. 223 unruptured (U)). There were no significant differences in the rate of EVT vs. MS between ruptured (R) vs. unruptured (U) aneurysms (Clipping, R: 36.8%, U: 37.7%). Amongst EVT, ruptured WNA were treated more with stand-alone coiling (R: 27.6%, U: 5.8%) and balloon-assisted coiling (R: 32.2%, U: 10.8%). Unruptured aneurysms were more commonly treated with flow diversion (R: 1.1%, U: 22.9%) and stent-assisted coiling (R: 2.3%, U: 21.5%) (p < 0.05 for all). Ruptured aneurysms had higher rates of adequate angiographic occlusion after initial treatment (R: 88.5%, U: 74.3%) (p < 0.05). There was no difference in final adequate occlusion at follow-up (R: 90.1%, U: 90.7%). Ruptured WNA had higher retreatment rates (R: 14.3%, U: 3.1%) (p < 0.05). Ruptured WNA had more procedural complications (R: 28.7%, U: 17%) (p < 0.05). Rates of good mRS (0-2) at one year were higher in unruptured WNA patients (R: 72.8%, U: 90.3%) (p < 0.05).

CONCLUSIONS:
WNA rupture status significantly influences the EVT choice, likely based on the need for DAPT. The lower initial adequate occlusion in the unruptured cohort is likely due to more flow diverter use. Ruptured WNAs were more difficult to treat as evidenced by higher rates of retreatment and procedural complications, however this did not impact the final angiographic outcomes.
694 Morphological Differences of Ruptured Versus Unruptured Wide Neck Aneurysms: Insights From the EVERRUN Registry
Authors: Hardigan Trevor , Hendricks Benjamin K. , Yoon James Seungwon , Kellner Christopher P. , Lawton Michael T. , Mocco J D. , Mascitelli Justin Robert 
Published: March 2024

INTRODUCTION:
Wide neck aneurysms (WNAs) have been defined as having a neck width >4 mm (N > 4) and/or dome-to-neck ratio <2 (DTNR < 2). Despite literature detailing treatment options for WNAs, there has been less study on the natural history of WNAs.

METHODS:
Ruptured and unruptured, saccular, not previously treated WNAs (N > 4, DTNR < 2, or both) were included. Differences in WNA morphology and patient demographics were compared between ruptured (R) and unruptured (U) cohorts. Statistical significance set at p < 0.05. All analysis performed using R(v.4.2.1).

RESULTS:
There were 310 WNA (87 R vs. 223 U). There were more females in both groups (R: 80.5%, U: 75.8%). Ruptured WNA were smaller (neck size R: 3.72 ± 1.39 mm, U: 4.5 ± 1.78 mm; dome width R: 5.04 ± 2.39 mm, U: 6.29 ± 3.37 mm, p < 0.05) with a trend towards reduced height (R: 5.04 ± 2.16 mm, U: 5.74 ± 3.01 mm) (p = 0.05). Ruptured aneurysms had higher rates of DTNR<2 alone (R: 60.9%, U: 42.2%) and unruptured aneurysms had higher rates of combined DTNR <2 and N >4 (R: 34.5%, U: 50.7%, p < 0.05). N > 4 alone was more prevalent in the unruptured cohort (R: 4.6%, U: 7.2%). ICA-Pcomm location (R: 21.1%, U: 9.4%) and AComm (R: 24.1%, U: 15.2%) were more common in the ruptured cohort. ICA-Oph location was more common in the unruptured cohort (R: 2.3%, U: 17.0%) (p < 0.05). Higher percentages of Asian (A), African American (AA), and Hispanic (H) patients were in the ruptured cohort compared to Caucasian (C) patients (A, R: 6.9%, U:0.9%; AA, R: 12.6%, U: 7.2%; H,R: 35.5%, U: 29.6%; C,R: 42.5%,U: 60.1%) (p < 0.05).

CONCLUSIONS:
Ruptured WNAs tend to be smaller with unfavorable DTNR whereas unruptured WNAs tend to be larger with a favorable DTNR. Higher rates of Pcomm/Acomm location in ruptured WNA are consistent with previous studies of all aneurysms. The significant racial disparity in ruptured vs. unruptured WNAs highlights the need to examine the biological and societal risks underlying these results.
696 Optimal Management Strategy for Carotid Cavernous Aneurysm From Cost-effectiveness Perspective
Authors: Salih Mira , Young Michael , Ramapriyan Rishab , Shutran Max , Taussky Philipp , Ogilvy Christopher S. 
Published: March 2024

INTRODUCTION:
Most cavernous carotid aneurysms (CCAs) are asymptomatic benign lesions; therefore, they are frequently detected during routine clinical diagnostic processes. Most providers recommend routine surveillance instead of immediate management for CCAs given a natural history with a low risk of life-threatening complications. However, the cost-effectiveness of such care and the optimal follow-up interval remains unknown.

METHODS:
A decision analysis study was performed utilizing a Markov model with Monte Carlo simulations to simulate patients undergoing treatment or routine surveillance at different time intervals (half, 1-,2-,3-, 5-and 7-year intervals) for different size of CCAs (=<12 mm, 13- 24 mm, >=25 mm ). Input data for the model was extracted from the current literature. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the Model.

RESULTS:
On base case analysis, following-up every 2 years with noninvasive imaging is the most cost-effective strategy for CCAs =< 12 mm, while annual follow up is cost-effective for large/giant (13-24 mm, >=25 mm) CCAs. The conclusions remain robust in probabilistic sensitivity and deterministic sensitivity analyses. As the risk of thrombo-embolic event gets higher and annual growth risk and annual rupture risk of CCAs increases, immediate treatment for large/giant (13- 24 mm, >=25 mm ) CCAs and annual follow up even prompt treatment for CCAs =< 12 mm is optimal.

CONCLUSIONS:
The most cost-effective management strategy for CCAs=< 12 mm and large/giant CCAs are following up every 2 years and following up every year, respectively. More frequent follow-up strategies or prompt preventive treatment for CCAs =< 12 mm and immediate treatment for large/giant CCAs would be more appropriate in patients with higher risk factors for cerebral ischemia, aneurysm growth and aneurysm rupture.
699 Immune Activation on Stroke Thrombus Proteome Associated With Failed First Pass Recanalization by Thrombectomy
Authors: Akkipeddi Sajal Medha , Rahmani Redi , Ellens Nathaniel R. , Kohli Gurkirat S. , Houk Clifton , Schartz Derrek , Chittaranjan Siddharth , Jalal Muhammad Ibrahim , Worley Logan , Bhalla Tarun , Mattingly Thomas , Morrell Craig , Bender Matthew T. 
Published: March 2024

INTRODUCTION:
Endovascular thrombectomy remains one of the most potent tools in the treatment kit for acute ischemic stroke. Prior cursory histopathological studies have demonstrated relationships between cellular composition of the thrombus and successful endovascular treatment.

METHODS:
Quantitative proteomes were generated using mass spectrometry from thromboembolic material from 59 stroke patients retrieved by mechanical thrombectomy. Clinical data, including whether or not Thrombolysis In Cerebral Infarction (TICI) score of 2b or greater was achieved on the first pass (FP±), was gathered by retrospective chart review. FP effect was related to the clinical variables, as well as the abundances of proteins identified by mass spectrometry. Finally, gene ontology and KEGG pathway analysis was used to examine the functional implications of proteins significantly associated with FP±.

RESULTS:
Both discharge and 90-day follow-up mRS were significantly greater in greater in patients who were FP- (Wilcoxon; Z = -1.84, -2.32; p = 0.03, 0.01). Additionally, mortality was significantly associated with FP effect (Fisher’s; p = 0.04). Numerous proteins were negatively and positively associated with FP± (Wilcoxon; 1.6 < |Z| < 2.8, p < 0.05). Notably, several neutrophil and histone proteins were associated with FP- thrombectomy (Wilcoxon; |Z| > 1.9, p < 0.05). GO tags represented in the proteins FP- thrombectomy included, among others, immune activation and granule secretion (padj < 0.001). KEGG pathways significantly represented in the FP- group also include immune activation, in particular neutrophil degranulation (padj < 1E-13).

CONCLUSIONS:
This study suggests that not only is angiographic FP effect significantly associated with short and long-term functional outcomes, but it is also associated with significant proteome-level differences in the composition of retrieved stroke thrombi. Specifically, immune activation may be related to failure to achieve FP recanalization.
704 Different Therapeutic Effects on the Ipsilateral Retinal-choroidal Blood Flow and the Visual Acuity Between Carotid Endarterectomy and Carotid Artery Stentinga
Authors: Oya Soichi , Yoshida Shinsuke , Saito Akira , Iihoshi Satoshi , Shojima Masaaki , Obata Hiroto , Yamazaki Atsushi , Ooigawa Hidetoshi , Kohyama Shinya , Kikkawa Yuichiro , Kurita Hiroki 
Published: March 2024

INTRODUCTION:
We previously reported that ipsilateral retinal-choroidal blood flow increased, and ipsilateral visual acuity improved after carotid endarterectomy (CEA) for internal carotid artery stenosis.

METHODS:
Twenty-eight patients who underwent CAS at participating centers were enrolled for this prospective observational study. Retinal-choroidal blood flow was evaluated by Mean Blur Ratio (MBR) with Laser Speckled Flowgraphy before and after CAS. In addition, visual acuity was measured precisely with the CSV-1000 before and after surgery. The MBR was defined as an increase in retinal blood flow above 1.14 based on the results of measurements in normal subjects.

RESULTS:
MBR significantly increased after CAS (MBR 34.2 vs 34.3, p = 0.02), but there was no improvement in the CSV-1000 score observed after CEA as shown in our previous CEA study (4.8 vs 4.9, p = 0.57). Furthermore, the CSV-1000 score did not improve after CAS even when the evaluation was limited to the group with a significant increase in MBR.

CONCLUSIONS:
The improvement in visual function after CEA that we have shown in the past was not observed after CAS. One reason for this is that postoperative MRI showed scattered microembolic infarctions after CAS in 17.9% (5 patients), whereas 7.3% after CEA in our previous study, which may have caused micro-occlusion of the retinal arteries. Although a direct comparison cannot be conducted, postoperative microembolism occurred in only 7.3% (3/41 patients) in our previous study that demonstrated improved vision after CEA. We also cannot rule out the possibility that intraoperative microemboli caused the deterioration of higher brain functions such as visual cognition, leading to the decreased score of the CSV-1000. This study might provide details on the therapeutic effects of carotid revascularization other than stroke prevention and may contribute to optimizing treatment choices for individual patients.
705 Urgent or Emergent Endovascular Intervention for Neurological Deficits Post-carotid Endarterectomy: A Single-institutional Case Series and Systematic Review of the Literature
Authors: Porto Carl Michael , Sastry Rahul , Moldovan Krisztina , Torabi Radmehr 
Published: March 2024

INTRODUCTION:
Historically the management of acute neurological deficit following carotid endarterectomy (CEA) has been operative re-exploration; however, given the proliferation of endovascular techniques, and utilization of CT angiography, endovascular intervention is an alternative to redo-CEA.

METHODS:
All patients undergoing CEA in the Department of Neurosurgery at Rhode Island Hospital (Providence, RI) were reviewed. A systematic literature review was conducted in PubMed according to PRISMA guidelines to identify papers relevant to endovascular procedures addressing acute neurological deficits following CEA, which yielded 2499 unique articles. Review by 2 investigators revealed 12 relevant articles.

RESULTS:
Four patients from our institutional cohort met inclusion criteria. Among these, stenting was technically successful in 3 patients, 2 of which achieved near-full recovery. One patient underwent successful carotid stenting and ipsilateral M2 thrombectomy for tandem occlusion. Stent placement was unsuccessful in the remaining patient due to mechanical constriction. Articles obtained through the literature review revealed 57 further relevant cases. Of those with sufficiently complete data, 30/39 (76.9%) were male with an age range of 43 - 78 years old. Twenty-eight of 32 (87.5%) patients underwent CEA for symptomatic carotid stenosis. Post-CEA angiographic evaluation was most commonly conducted for routine completion imaging (21/57, 36.8%), non-specific stroke symptoms (15/57, 26.3%), and extremity weakness (7/57, 12.3%). Thrombotic stenosis (23/43, 53.4%) and arterial dissection (15/43, 34.9%) were the most common angiography findings. Two (3.5%) stent procedures were unsuccessful, and in the immediate postoperative period 8 patients (14.0%) had significant neurological deficits and only 3 deaths (5.3%) were reported.

CONCLUSIONS:
Endovascular intervention may be considered in situations where patients have neurological deficit after CEA. Direct comparison of outcomes in patients who have endovascular intervention vs. redo CEA may help identify the optimal management strategy.
709 Establishment of an Early ICU De-escalation Pathway Using the Modified Frailty Index Among Angiogram-Negative Subarachnoid Hemorrhage Patients
Authors: McIntyre Matthew , Cheaney Barry , Jia-Xin Liu Jesse , Dogan Aclan , Sanusi Olabisi 
Published: March 2024

INTRODUCTION:
Angiogram-negative subarachnoid hemorrhage (ANSAH) may have a benign clinical course. Our standard practice is to observe ANSAH patients for a prolonged period in the ICU. Previous work has established frailty as a strong predictor of ANSAH outcomes.

METHODS:
A retrospective cohort analysis was performed among patients admitted between 2011 and 2022 with non-traumatic subarachnoid hemorrhage and initial angiogram (DCA) negative for source. Primary endpoints were in-hospital complications, discharge home, and length-of-stay (LOS). Cost analysis was performed using hospital charges.

RESULTS:
101 patients were included with an average age of 59.7 ±1.2 years, Hunt and Hess score of 2.0 ± 0.1, and 51 (50.5%) with a perimesencephalic hemorrhage distribution. 2 patients had a subsequent DCA showing aneurysmal etiology, both of whom would have been considered high risk. 38 (37.6%) were frail, 38 (37.6%) required an EVD, and 68 (67.3%) were intact on arrival. Multivariate analysis showed that frailty but not age or perimesencephalic distribution predicted the 3 primary endpoints (p < 0.039) while lack of EVD predicted LOS (p = 0.004) and intact neurologic exam predicted discharge home (p = 0.043). Low-risk patients (40/101, 39.6%) had no deaths, significantly reduced odds of any complication (OR 0.14, 95%CI: 0.04-0.44, p < 0.001), increased odds of discharge home (OR 9.98; 95%CI: 2.19-45.46, p < 0.001), and shorter LOS (7.8 ± 0.4 v. 14.7 ± 1.1 days, p < 0.001). Assuming a 6-day ward stay after 1-day of ICU observation, early de-escalation of low-risk ANSAH patients would, on average, save $20,177.70 per patient.

CONCLUSIONS:
Non-frail ANSAH patients who are neurologically intact and without an EVD are likely to have a benign clinical course and may benefit from early ICU de-escalation.
767 Racial and Gender Disparities in Traumatic Brain Injury Clinical Trial Enrollment
Authors: Bah Momodou G. , Naik Anant , Barrie Umaru , Dharnipragada Rajiv Sai , Eden Sonia Veronica , Cramer Samuel , Arnold Paul M. 
Published: March 2024

INTRODUCTION:
Despite the increasing number of women and racial/ethnic minorities sustaining Traumatic Brain Injuries (TBI), they are underrepresented in TBI clinical trials.

METHODS:
The authors conducted a review of TBI clinical trials with reported results registered in ClinicalTrials.gov between 2008 and 2022. The studies were assessed for the proportion of women and racial/ethnic minorities enrolled as well as their reporting of race and gender-specific characteristics such as Gender Ratio (GR) and Racial Diversity Index (RDI). Furthermore, study parameters including year and duration, phase, trial design, type of funding, and trial completion were included.

RESULTS:
135 clinical trials met inclusion criteria, of which 65 and 134 reported race and gender, respectively. 25 trials were found to have existing racial disparity (RDI < 1). Comparatively, industry-funded trials had a 26% more likelihood of racial disparities (p = 0.026), whereas federally-funded trials were 30% less likely (p = 0.031). 66 trials had gender disparities (GR < 0.4) present, with federally-funded trials having 37.1% greater rates of gender disparity (p < 0.001, aOR: 5.47, 95% CI: 2.26-14.25). The impact of funding source on race and gender remained significant despite adjusting for other covariates in the multivariate analyses. Racial disparity was negatively correlated with trial completion rate (p < 0.001). Disparities were not found to improve over the 14-year span.

CONCLUSIONS:
Racial and gender disparities in TBI clinical trial enrollment persist, and the lack of diversity may lead to biased evidence-based medicine. Efforts should be made to increase the representation of women and racial/ethnic minorities in TBI clinical trials to ensure equitable access to effective treatments for all populations.
784 Effects of Optimal Versus Suboptimal Median Household Income on the Operative Traumatic Brain Injury Population: A Propensity Score-matched Analysis
Authors: Ravina Kristine , Safransky Michelle , Sconzo Daniel , Binello Emanuela 
Published: March 2024

INTRODUCTION:
Median household income is a useful metric for healthcare disparity assessment. New England holds a highly diverse, densely populated metropolitan area with one of the highest living wages in the US. To our knowledge, there is no published data on the effects of optimal vs. suboptimal median household income on the operative traumatic brain injury (TBI) patients.

METHODS:
Demographic, clinical and outcome data of operative TBI patients between 2015 and 2021 were collected and stratified based on optimal (80 000$ or more) and suboptimal (less than 80 000$) median residential household income. 1:1 tight caliper (0.01) propensity score matching was performed to balance the groups for comparative analysis.

RESULTS:
From the initial 91 patients in the optimal and 102 patients in the suboptimal income groups, 62 patients were included in each group after propensity matching. There were significantly more ethnic minority patients in the suboptimal as compared to the optimal income group (66.1% and 35.7%, respectively; p=0.002). Optimal income group patients presented as transfers from other hospitals significantly more frequently than the suboptimal group (52.5% and 30.7%, respectively; p = 0.02). There were no significant differences in post-operative Glasgow coma scale scores (p = 0.15), modified Rankin scale scores at discharge (p = 0.92) and upon follow-up (p = 0.1), mortality (p > 0.999) or disposition destination distribution (p = 0.3).

CONCLUSIONS:
While the suboptimal income group is significantly more ethnically diverse, optimal versus suboptimal median household income does not seem to affect TBI outcomes and disposition. Optimal income group patients are more frequently presenting as transfers from other facilities indicating fair high-level care at a specialized high safety-net burden trauma center adapted to an ethnically diverse population.
785 Variability in Withdrawal of Life Sustaining Treatment Decision for Patients With Severe Traumatic Brain Injury: An Analysis of 510 North American Trauma Centers
Authors: Malhotra Armaan K. , Shakil Husain , Smith Christopher , Wijeysundera Duminda , Kulkarni Abhaya Vivek , Ladha Karim , Wilson Jefferson , Nathens Avery , Witiw Christopher 
Published: March 2024

INTRODUCTION:
Withdrawal of life sustaining treatment (WLST) in severe traumatic brain injury (TBI) is complex with a paucity of standardized guidelines to inform practice patterns. We hypothesized presence of variability in WLST decision-making across centers, which could have important implications for equitable trauma care provision.

METHODS:
This retrospective study utilized data from adult severe TBI patients treated at trauma centers participating in the Trauma Quality Improvement Program between 2017-2020. Multivariable hierarchical logistic regression was used to adjust for patient, injury and hospital attributes influencing WLST. Residual between-center variability was characterized using the median odds ratio. Disparate WLST practices were further assessed by ranking centers' tendencies for WLST and assessing mortality between quartiles.

RESULTS:
We identified a total of 85511 subjects with severe TBI treated across 510 trauma centers, of which 20,300 (24%) had WLST. Patient-level factors associated with increased likelihood of WLST were advanced age, white race, treatment in a non-profit trauma center or self-pay/ Medicare insurance status (compared to private insurance). Black race was associated with reduced tendency for WLST. Higher severity intracranial and extracranial injuries also increased likelihood for WLST.After adjustment for patient and hospital attributes, the median odds ratio was 1.44 (1.40-1.48 95%CI), suggesting substantial residual variation in WLST between centers. When centers were grouped into quartiles by their propensity for WLST, there was a 1.37 (1.30-1.42 95%CI) increased adjusted odds of mortality between fourth versus first quartile centers.

CONCLUSIONS:
We highlighted the presence of disparate WLST practice patterns between trauma centers after adjustment for case-mix and hospital attributes. These findings highlight a strong need for examination of center-level factors contributing to heterogenous WLST practices to ultimately improve equity of care provision for severe TBI patients.