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Abstract Background Traumatic brain injury (TBI) in older adults is associated with high mortality and poor functional outcomes. However, optimal management remains uncertain, as evidence comparing surgical and medical strategies is limited, heterogeneous, and extrapolated from younger populations. We conducted a systematic review and meta-analysis to compare outcomes between surgical and medical management in this population. Methods PubMed, Embase, and Web of Science were searched from database inception to December 8, 2025. Studies including adults aged ≥60 years with TBI comparing surgical versus medical management were included. The primary outcome was favorable neurological outcome, while secondary outcomes included hospital length of stay (LOS) and mortality. Pooled estimates were calculated as risk ratios (RR) and mean differences (MD) using random-effects models with restricted maximum likelihood and Hartung–Knapp adjustment. Results Sixteen cohort studies comprising 132,823 patients were included. Surgical management was not associated with improved favorable neurological outcomes at discharge, 3, 6, or 12 months. However, it was associated with longer LOS (MD = 6.35 days, 95% CI: 2.55 to 10.14; p < 0.01). No differences were observed in in-hospital, 30-day, 3-month, 12-month, or 24-month mortality. Notably, surgical management was associated with a reduction in 6-month mortality (RR = 0.68, 95% CI: 0.51–0.92; p = 0.02). Conclusions In older adults with TBI, surgical management was associated with reduced 6-month mortality and longer hospital LOS, but not with improved functional outcomes, highlighting a dissociation between survival and recovery. This dissociation has implications for clinical decision-making and patient and family counseling. Individualized decision-making that incorporates frailty, comorbidities, and potential reversibility of injury is essential, rather than relying solely on age. While this study represents the best available comparative evidence to date on surgical versus non-surgical management in older adults with TBI, findings should be interpreted with caution due to heterogeneity and low to very low certainty of the evidence. High-quality randomized controlled trials are needed to better define the role of surgery in this population.

OBJECTIVE Open resective surgery (ORS) has become the standard of care for focal drug-resistant epilepsy (DRE). However, minimally invasive surgical alternatives, such as laser interstitial thermal therapy (LITT), have also been shown to be safe and effective. A meta-analysis comparing both treatments is warranted to assess the benefits of each modality for focal DRE. METHODS A literature search was conducted until March 14, 2024, to identify studies comparing LITT and ORS in patients with DRE. The primary outcomes included seizure freedom (SF), length of hospital stay (LHS), and complication rate (CR). Subgroup analyses were performed based on age, epilepsy etiology, and propensity score–matched (PSM) studies. RESULTS Of 558 articles, 15 cohort studies met the authors’ inclusion criteria, encompassing 3873 patients for analysis. The rate of SF in the LITT group was 52.5% (95% CI 0.453–0.597, I 2 = 47.4%) and 67.1% (95% CI 0.602–0.739, I 2 = 57.4%) for the ORS group. LITT showed a significantly lower rate of SF compared to ORS (risk ratio [RR] 0.78, 95% CI 0.70–0.88, p ≤ 0.0001). However, when PSM studies (RR 0.85, 95% CI 0.63–1.15, p = 0.30) and studies on patients with temporal lobe epilepsy (TLE) (RR 0.88, 95% CI 0.67–1.14, p = 0.34) were analyzed, the SF rates were similar. Patients who underwent LITT had a significantly shorter LHS (mean difference 2.95 days, 95% CI 1.12–4.78, p < 0.00001), lower CR (RR 0.54, 95% CI 0.37–0.79, p < 0.002, I 2 = 32%), lower rate of ischemic stroke (RR 0.15, 95% CI 0.04–0.65, p = 0.01), and lower rate of permanent neurological deficits (RR 0.13, 95% CI 0.05–0.36, p < 0.0001). CONCLUSIONS Across unmatched studies evaluating focal DRE, ORS showed a higher rate of SF. However, pooled matched-cohort analyses showed no difference between interventions in achieving SF, a trend also noted in the authors’ PSM TLE sample. LITT, however, offered significantly shorter LHS and lower CRs. Future prospective studies should match patient populations to control for confounding factors and assess key outcomes, such as postoperative neurocognitive follow-up and quality of life measurements, in order to fully evaluate the risks and benefits of each approach.

Abstract BACKGROUND There is a paucity of literature regarding treatment options for extracranial pseudoaneurysms of the internal carotid artery (ICA). To date, Pipeline Embolization Device (PED; Medtronic Inc) use for the treatment of extracranial pseudoaneurysms of the ICA has only been reported from single-center case series. OBJECTIVE To evaluate the safety and efficacy of PED for the treatment of extracranial ICA pseudoaneurysms. METHODS This is a multicenter retrospective study involving 6 high-volume tertiary academic institutions in the United States. We analyzed patients with extracranial ICA pseudoaneurysms treated with PED between January 1, 2011, and January 1, 2019. Clinical assessment was performed pre- and postintervention using the modified Rankin Scale (mRS) and National Institution of Health Stroke Scale (NIHSS) at a minimum of 4-mo follow-up. RESULTS A total of 28 pseudoaneurysms with a mean diameter of 17.7 mm (range: 4.1-52.5 mm) were treated with PED in 24 patients at 6 participating centers. The mean age was 52.1 yr (17-73) ± 14.3 with 14 females and 10 males. At a mean of 21-mo (range 4-66 mo) follow-up, complete occlusion was achieved in 89% (n = 25/28), with near-complete occlusion (>90% occlusion) in the remainder. There were no periprocedural complications. Postprocedure NIHSS was 0 in 88% (n = 21/24) and 1 in 12% (n = 3/24) of patients, and mRS was 0 in 83% (n = 20/24) and 1 in 17% (n = 4/24) of patients. CONCLUSION The treatment of extracranial ICA pseudoaneurysms with PED is safe and effective in selected patients. Randomized controlled trials and prospective cohort studies are needed to establish the role of flow diversion for ICA pseudoaneurysms.

OBJECTIVE The impact of FDA approval of flow-diversion technology for the treatment of supraclinoid internal carotid artery aneurysms and the publication of the Carotid Occlusion Surgery Study, both of which occurred in 2011, on the utilization of extracranial-intracranial (EC-IC) bypasses is not known. METHODS The National Inpatient Sample (NIS) was queried for hospitalizations for EC-IC bypass performed from 2008 to 2016. Diagnoses of interest included an unruptured intracranial aneurysm (UIA), subarachnoid hemorrhage (SAH), carotid occlusive disease (COD), and moyamoya disease. The authors assessed trends in EC-IC bypass utilization for these diagnoses and the incidence of adverse discharges, defined as discharge to locations other than home, and the rate of mortality. RESULTS A total of 1640 EC-IC bypass procedures were performed at 558 hospitals during the study period, with 1148 procedures at 448 hospitals performed for a diagnosis of interest. The most frequent surgical indication was moyamoya disease (65.7%, n = 754), followed by COD (23.2%, n = 266), SAH (3.2%, n = 37), and a UIA (7.9%, n = 91). EC-IC bypass utilization for COD decreased from 0.21 per 100 admissions of COD in 2010 to 0.09 per 100 admissions in 2016 (p = 0.023). The frequency of adverse discharges increased during the study period from 22.3% of annual admissions in 2008 to 31.2% in 2016 (p = 0.030) when analysis was limited to procedures performed for a diagnosis of interest. Per volume, the top 5th percentile of hospitals, on average, performed 18.4 procedures (SD 13.2) per hospital during the study period, compared to 1.3 procedures (SD 1.3) that were performed in hospitals within the bottom 95th percentile. The rate of adverse discharges was higher at low-volume institutions when compared to that at high-volume institutions (33.8% vs 28.7%; p = 0.029). Over the study period, the authors noted a trend toward a reduced percentage of total surgical volume performed at high-volume hospitals (p < 0.001). CONCLUSIONS The authors observed a decrease in the utilization of EC-IC bypass for COD during the study period. An increase in the rate of adverse discharges was also noted, coinciding with more procedures being performed at lower-volume centers.

OBJECTIVE Traditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device. METHODS This study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications. RESULTS A total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A 1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2. CONCLUSIONS PulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist’s armamentarium, especially with regard to its off-label use.

Abstract Endovascular therapy is the primary treatment for the majority of tentorial dural arteriovenous fistulas (dAVF). Surgical occlusion is an effective alternative when embolization is not possible. This video demonstrates microsugical occlusion of a right-sided tentorial dAVF in a symptomatic 45-yr-old male. The dAVF was fed directly by meningohypophyseal trunk. Venous drainage was retrograde through the sphenoparietal sinus, superficial sylvian vein, vein of Labee, and transverse sinus. The patient underwent a right-sided pterional craniotomy; the sylvian fissure was widely opened. Subarachoid dissection was performed until a large arterialized draining vein was identified exiting dura subtemporally. Intraoperative indocyanine green angiography confirmed the fistulous site and the draining vein was occluded and divided. The patient remained neurologically intact after surgery. Immediate angiography demonstrates complete occlusion of the dAVF. This video demonstrates the surgical access obtained through a transylvian approach for this tentorial dAVF. Occlusion of the draining vein, with or without resection of the fistula, is enough to permanently treat these lesions.

OBJECTIVEDelayed cerebral ischemia (DCI) and aneurysm rebleeding contribute to morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH); however, the relationship between their impacts on overall functional outcome is incompletely understood.METHODSThe authors conducted a cohort study of all aSAH during the study period from 2001 to 2016. Primary end points were overall functional outcome and ischemic aSAH sequelae, defined as delayed cerebral ischemia (DCI), DCI with infarction, symptomatic vasospasm (SV), and global cerebral edema (GCE). Outcomes were compared between the rebleed and nonrebleed cohorts overall and after propensity-score matching (PSM) for risk factors and treatment modality. Univariate and multivariate ordered logistic regression analyses for functional outcomes were performed in the PSM cohort to identify predictors of poor outcome.RESULTSFour hundred fifty-five aSAH cases admitted within 24 hours of aneurysm rupture were included, of which 411 (90%) experienced initial aneurysm ruptures only, while 44 (10%) had clinically confirmed rebleeding. In the overall cohort, rebleeding was associated with significantly worse functional outcome, longer intensive care unit length of stay (LOS), and GCE (all p < 0.01); treatment modality, overall LOS, DCI, DCI with infarction, and SV were nonsignificant. In the PSM analysis of 43 matched rebleed and 43 matched nonrebleed cases, only poor functional outcome and GCE remained significantly associated with rebleeding (p < 0.01 and p = 0.02, respectively). Multivariate regression identified that both rebleeding (HR 21.5, p < 0.01) and DCI (HR 10.1, p = 0.01) independently predicted poor functional outcome.CONCLUSIONSRebleeding and DCI after aSAH are highly morbid and potentially deadly events after aSAH, which appear to have independent negative impacts on overall functional outcome. Early rebleeding did not significantly affect the risk of delayed ischemic complications.

Abstract Fusiform aneurysms involving the M2 branches of the middle cerebral artery are often dissecting, identified by a characteristic diseased adjacent segment, and location not at a branch point. Herein, we present the case of a 38-yr-old man with a symptomatic, dissecting M2 aneurysm that was previously incompletely treated with stent-assisted coiling. In our experience, symptomatic fusiform aneurysms in this location tend to recur unless the involved segment is completely trapped or reconstructed with flow diversion. We successfully treated this patient with a vessel reconstruction using a Pipeline Flex Embolization Device (Medtronic). Deployment of a flow diverter inside a previously placed stent can pose potential challenges, as the original stent may constrain complete expansion of the flow diverter and prevent perfect apposition against the parent vessel wall. In this operative video, we demonstrate this technique and provide a brief discussion of the potential pitfalls.

Background and Purpose— Racial and ethnic disparities in the access to mechanical thrombectomy (MT) for treatment of acute ischemic stroke (AIS) secondary to large vessel occlusion have been previously described. The effect of recent randomized trials validating MT as an effective therapy for AIS secondary to large vessel occlusion on such disparities has not been investigated. Methods— Information on admissions for AIS to endovascular centers occurring between January 2016 and September 2018 was obtained from a national database. The number of patients receiving IV-tPA (intravenous tissue-type plasminogen activator) and MT at each institution was determined, and patient demographics were characterized according to age, sex, race/ethnicity, and insurance status. Comparisons of patients who did and did not undergo MT and between patients of different racial and ethnic backgrounds were performed. Demographic variables independently associated with the utilization of MT were identified using multivariate linear regression analysis. Results— There were 206 853 admissions to 173 endovascular centers during the time period of interest. The overall utilization of MT was 8.4%. The utilization of MT for black/Hispanic patients was lower than that among white/non-Hispanic patients (7.0% versus 9.8%; P <0.001). Black/Hispanic patients were also less likely to receive IV-tPA (16.2% versus 20.5%; P <0.001) and to be admitted to the endovascular center after transfer from a different hospital (20.0% versus 30.1%; P <0.001). On multivariate linear regression analysis, increasing institutional proportions of patients with female sex (β=−0.601; P <0.001), insurance with Medicaid or uninsured status (β=−0.153; P =0.029), and black/Hispanic race/ethnicity (β=−0.062; P =0.046) were independently associated with lower institutional utilization of MT. Conclusions— Despite the mainstream acceptance of MT for the treatment of AIS secondary to large vessel occlusion, racial and ethnic disparities in the utilization of MT persist.