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Introduction Extracranial internal carotid artery (ICA) aneurysms are rare (<1% of arterial aneurysms) yet clinically significant due to risks of distal embolization, local compressive symptoms, and, less commonly, rupture. High-quality evidence is limited, and no consensus guidelines exist, management is therefore individualized to aneurysm morphology, cervical segment involvement, vessel tortuosity, and operator expertise. Flow diversion with Pipeline Embolization Device (PED) achieves aneurysm exclusion while reconstructing the parent artery and is especially useful in tortuous cervical segments. Clinical Summary A 60-year-old woman with incidentally discovered bilateral cervical ICA aneurysms (left 2.3 cm mid-ICA; right 0.5 cm) and a type III bovine arch underwent PED diversion of the lesion. Via femoral access, a long 6-F Fubuki sheath (Asahi Intecc, Irvine, USA) with Sofia catheter (Micro-Vention, Tustin, USA) support and systemic heparinization (ACT >250 s) enabled deployment of a 5.0 × 25 mm Pipeline Flex (Medtronic Neurovascular, Irvine, USA) across the aneurysm neck. Immediate angiography showed intra-aneurysmal stasis while preserving parent-artery flow . At 12 months, she is asymptomatic with a 70% reduction in the contrast-opacified aneurysm component to 7 mm, and the contralateral small aneurysm remains stable. Conclusion Flow diversion with a PED provided an effective, artery-preserving solution for a mid-cervical ICA aneurysm in tortuous anatomy, achieving immediate flow stasis with parent-artery patency. At 12 months, the patient is asymptomatic with a contrast-opacified component reduced to 7 mm. This case supports using flow diversion for extracranial ICA aneurysms when anatomy is favorable, alongside careful antiplatelet therapy and planned imaging follow-up.

Abstract Oncogenic BRAF alterations occur in a subset of diffuse gliomas across WHO grades and are increasingly identified through modern molecular diagnostics. In addition to standard glioma therapies, targeted treatments are available for patients with BRAF-altered glioma supported by variable evidence spanning randomized trials, single-arm studies, and real-world evidence. This joint consensus review from the Society for Neuro-Oncology (SNO) and the European Association of Neuro-Oncology (EANO) synthesizes current knowledge on the diagnosis and management of BRAF-altered gliomas across age groups, tumor grades, and lines of therapy. Particular emphasis is placed on expert consensus in clinical scenarios where high-quality trial evidence remains limited. The review addresses rationale testing for BRAF alterations, selection, and monitoring of targeted therapies, management of treatment-related toxicities, approaches to resistance, and priorities for future research. It aims to provide practical, evidence-based guidance for clinicians while highlighting gaps to inform prospective studies.

INTRODUCTION: Online patient education materials are essential in improving access to and understanding of clinical information. Artificial intelligence (AI), specifically ChatGPT, offers a novel way to synthesize complex information and is increasingly being used for patient education, including in obstetrics and gynecology. This study compares the understandability and actionability of patient education materials about hysterectomy and uterine fibroids generated by ChatGPT with those published by the American College of Obstetricians & Gynecologists (ACOG). METHODS: In a randomized cross-sectional study, participants were allocated to one of four groups: ACOG–Fibroids, ChatGPT–Fibroids, ACOG–Hysterectomy, or ChatGPT–Hysterectomy. The ACOG groups reviewed the corresponding ACOG FAQ webpage, while the ChatGPT groups reviewed responses generated by ChatGPT to the same FAQs. Participants then completed demographic questions and the Patient Education Materials Assessment Tool (PEMAT). The primary outcome was the equivalence of PEMAT scores between ACOG and ChatGPT. RESULTS: Equivalence was not demonstrated between ChatGPT and ACOG for either topic. For fibroid material, ACOG was rated higher on both understandability (86.3 versus 82.6 points, P =.039) and actionability (65.4 versus 53.2 points, P =.003) on superiority testing. For hysterectomy content, no significant difference was observed. No interaction was found between material type and either education level or personal history of fibroids/hysterectomy. CONCLUSIONS/IMPLICATIONS: PEMAT scores for ACOG were superior to ChatGPT for fibroid content, but neither equivalent nor superior for hysterectomy content. While ChatGPT offers a responsive, iterative source of information, its understandability and actionability may depend on topic-specific factors, highlighting both the promise and limitations of AI for patient education.

Background/Objectives: Pancreatic ductal adenocarcinoma (PDAC) arises predominantly from activating KRAS mutations, yet individual genetic variants differ markedly in signaling output and clinical impact. G12D, the most prevalent variant, strongly drives oncogenic programs, whereas G12R signals less efficiently through the AKT and ERK pathways and is associated with longer patient survival than G12D-driven PDAC. Methods: To elucidate how these differences influence early cellular transformation, we expressed a panel of KRAS mutants in non-cancerous pancreatic ductal epithelial cells as a model of early PDAC initiation and profiled transcriptional and phospho-proteomic responses. We next examined whether epigenetic differences translate into mutation-specific changes in nuclear organization using quantitative imaging of G12D- and G12R-expressing nuclei at 24 and 48 h. Results: Each variant established a unique regulatory program enriched for chromatin remodelers, histone modifiers, and nuclear structural factors, indicating that variant-specific KRAS signaling rapidly develops divergent epigenetic states. Integrated transcriptomic and phospho-proteomic analyses identified G12D and G12R as the most divergent variants. G12D induced pronounced nuclear remodeling, including increased nuclear size, irregular morphology, and reorganization of the nucleolus and spliceosome, consistent with extensive chromatin and transcriptional reprogramming. In contrast, G12R elicited a weaker response, with minimal or delayed structural changes. Conclusions: Together, these findings demonstrate that KRAS mutational context in pancreatic ductal epithelial cells shapes early transcriptional reprogramming that actively remodels nuclear architecture and nuclear sub-compartments. This work establishes nuclear structural remodeling as a structural state of KRAS-driven epigenetic dysregulation during PDAC initiation.

Background: The management of asymptomatic high-grade carotid stenosis remains challenging, particularly in identifying individuals at highest risk for hypoperfusion-related stroke. Impaired cerebrovascular reactivity (CVR) has emerged as a potential predictor of future cerebrovascular events. Objective: To perform a systematic review and meta-analysis to quantify the association between impaired CVR and the risk of ipsilateral ischemic stroke or TIA in patients with asymptomatic high-grade carotid stenosis/occlusion. Methods: A systematic literature search of PubMed, Embase and Scopus was conducted from inception till July 2025. Eligible studies included asymptomatic patients with ≥70% carotid stenosis or occlusion who underwent CVR assessment and reported ipsilateral ischemic stroke or TIA outcomes. Pooled relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random-effects model. Forest plots were generated, and heterogeneity was assessed using the chi-square test and the I 2 statistic. Results: Six prospective observational studies including a total of 361 patients with asymptomatic high-grade carotid stenosis/occlusion (mean age 70.4 years; 73.6% male; 71.2% with hypertension; 28.6% with diabetes; 29.6% current or former smokers) were included in the analysis. Of these, 120 patients had impaired CVR and 241 had preserved CVR. Transcranial Doppler (TCD) was the most frequently used modality to assess CVR, with acetazolamide or CO 2 as the vasodilatory stimulus. Following CVR assessment, patients were monitored for a weighted mean follow-up of 26.2 months (range: 21.5 to 42.5 months). The incidence of ipsilateral ischemic stroke or TIA was 14.2% in patients with impaired CVR versus 2.1% in those with preserved CVR (RR 3.98; 95% CI 1.62–9.76; P = 0.003; Figure 1). When limited to ipsilateral ischemic stroke alone, the incidence was 21.4% in the impaired CVR group compared to 4.3% in the preserved CVR group (RR 3.35; 95% CI 1.54–7.25; P = 0.002; Figure 2). Conclusions: Impaired CVR is associated with a 3- to 4-fold increased risk of ipsilateral ischemic stroke or TIA in patients with high-grade carotid stenosis/occlusion. CVR assessment may help stratify risk and guide individualized management in this population.

Introduction: AI-driven software has been recommended as a means of triaging suspected large vessel occlusions (LVOs) on CT angiography (CTA), and different solutions are now commercially available. This study compared the performance of two software packages, Brainomix 360 Triage LVO and Rapid LVO, in prospective, real-world use. Methods: Consecutive patients scanned for suspected stroke at 3 comprehensive stroke centres from May to July 2024 (3 months) were included in the study. CTA, where available, was processed in real time by both Rapid and Brainomix software. Ground truth on vessel occlusion was ascertained using clinical review of electronic medical records. Occlusion location was coded as intracranial internal carotid artery terminus (ICA-T), middle cerebral artery (MCA) M1 or MCA M2. If more than one occlusion was observed, the most proximal of these was taken as the primary vessel affected. Results: There were 561 suspected stroke patients scanned during the study period across the three sites. Of these, CTA was sent for processing by both Rapid LVO and Brainomix 360 Triage LVO for 359 cases. Cases were excluded if no contrast was detected (n=17), leaving 342 cases (Table 1). Of these, proximal LVO (ICA-T or MCA M1) was confirmed in 14 cases and MCA M2 occlusions were present in 6 cases. Table 2 shows the LVO detection results for all cases from the two software packages. For both devices, sensitivity was higher when considering only proximal occlusions (ICA-T or M1). Performance was similar overall, but there was a trend towards differing sensitivity for more distal occlusions. As a composite measure, area under the curve (AUC) was higher for Brainomix than Rapid (Figure 1) but this difference was not significant. The positive predictive value (PPV) was low for both software packages due to the low incidence of LVO in the patient population. Conclusions: This study demonstrated consistent performance of two AI software devices, Brainomix 360 Triage LVO and Rapid LVO, for detection of LVO on CTA imaging, in prospective, real-world use. The low number of positive cases in the dataset (N=21) is a limitation of the study. There was a trend towards different performance for more distal vessel occlusion locations. Overall, the sensitivity observed in this dataset was in line with reports from previous retrospective studies for both software packages and underlines the importance of prospective evaluation to understand real-world performance.

Background: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) can be misdiagnosed as multiple sclerosis (MS). This study aims to contrast demographic, clinical, neuroimaging, and genetic features of CADASIL patients with vs. without prior MS misdiagnosis. Methods: We conducted a retrospective cohort study to compare genetically or histopathologically confirmed CADASIL patients with and without a prior MS misdiagnosis across Mayo Clinic. Patients were classified into high-, medium-, low-, or unknown-risk by location of NOTCH3 mutation. Disease severity was assessed using NOTCH3 Small-Vessel Disease (N3SVD) scale. Between-group comparisons used independent t-test for age, chi-square or Fisher’s exact test for categorical variables, and Mann–Whitney U test for quantitative variables. Within the misdiagnosed subgroup, neuroimaging changes between MS to CADASIL diagnosis were assessed using Wilcoxon signed-rank test for quantitative data and Stuart–Maxwell test for categorical data. Significance was set at p<0.05 (two-sided). Results: Among 107 patients (mean age 57.5±13.4 yrs) with CADASIL, 12 (11.2%) had a prior MS misdiagnosis (Table 1). Compared to patients without misdiagnosis (n=95), those misdiagnosed were younger, more frequently Asian, more likely to undergo lumbar puncture (83.3% vs 26.3%, p <0.001), and less likely to have had stroke (33.3% vs 65.3%, p =0.031). There were no significant differences in deep white matter hyperintensity scores or lacune counts. However, the misdiagnosed group had a higher median modified Rankin Scale ( p =0.008) and a different distribution of N3SVD stages ( p =0.017), with a higher proportion in stage 3A (33.3% vs 5.3%). There was no significant difference in genetic risk categories (Figure), but 5 of 12 misdiagnosed cases clustered in the medium risk EGFR 13, 13.5, and 14 domains. Among the misdiagnosed, 41.7% received MS-specific treatment during a median of 10.2 months (range 0.4–138.1) before diagnostic correction (Table 2). Over this period, there were no significant changes in DWMH score, lacune count, mRS, or N3SVD stage (all p >0.05). Conclusions: About one in nine CADASIL patients had a prior MS diagnosis. Atypical presentations in younger individuals without a clear stroke history may prompt consideration of MS over CADASIL, leading to diagnostic delays and unnecessary treatments. EGFR domain risk category did not correlate with misdiagnosis.

Background/Objectives: Pelvic exenteration is a radical procedure performed for recurrent gynecologic cancers. The goal of exenteration is to prolong survival, but this procedure also results in extensive tissue loss and consequently high morbidity. Reconstruction using vascularized flaps, particularly the VRAM flap, is crucial to restoring pelvic integrity and decreasing complications resulting from extensive tissue loss. With the rise of minimally invasive surgery, the traditionally open abdominal approach to exenteration and reconstruction can now be performed with the assistance of robotic platforms. This review aims to summarize available evidence, describe techniques, and propose future directions for robotic rectus flap reconstruction after pelvic exenteration. Methods: This narrative review was conducted following the SANRA guidelines for narrative synthesis. A comprehensive search of PubMed, Embase, Scopus, and Web of Science was conducted for studies published between January 2000 and November 2025 on pelvic exenteration followed by robotic rectus abdominis flap reconstruction in gynecologic oncology. Eligible studies were retrospective or prospective reports, technical descriptions, case series, or comparative analyses. Non-robotic techniques and animal studies were excluded. Although the primary focus was gynecologic oncology, technically relevant studies from other oncologic disciplines were included when the reconstructive approach was directly applicable to pelvic exenteration. Extracted data included patient demographics, surgical details, and perioperative and oncologic outcomes. Results: The literature search identified primarily case reports and small single-center series describing robot-assisted rectus muscle-based flap reconstruction after pelvic exenteration. Reported cases demonstrated technical feasibility and successful flap harvest using robotic platforms, with adequate pelvic defect coverage. Potential benefits, such as reduced wound morbidity and preservation of a minimally invasive workflow, have been described. However, patient numbers were small, techniques varied, and standardized outcome measures or comparative data with open approaches were lacking. Conclusions: Robotic rectus flap reconstruction represents a promising advancement in pelvic exenteration surgery, potentially reducing morbidity and improving recovery. Further research, including multicenter prospective studies, is needed to validate these findings and establish standardized protocols.

Introduction Software packages for quantification of CT perfusion parameters allow quick visualization of perfusion deficits to support clinical decision making in acute ischemic stroke (AIS). Several packages are now commercially available for automated quantification of ischemic core, penumbra volumes, and mismatch ratios to indicate eligibility for reperfusion therapies. This study explored the agreement between two software packages, Brainomix 360 e‐CTP and Rapid CTP, in prospective, real‐world use. Methods Consecutive patients scanned for suspected stroke at three comprehensive stroke centers over 90 days from May to July 2024 were included in the study. Eligibility for the current analysis was limited to discharge diagnosis of AIS and CTP imaging processed by both Brainomix and Rapid software. Software processing was conducted in real time after image acquisition. The presence of large vessel occlusion (LVO) was determined from review of electronic medical records. CTP core (CBF<30%) and penumbra (Tmax>6s) volumes from Brainomix and Rapid were recorded for each case. Mismatch ratios were calculated (penumbra÷core volume); positive mismatch was defined according to DEFUSE‐3 criteria (core<70ml, penumbra>15ml, mismatch ratio > 1.8). The correlations and linear regressions between Brainomix and Rapid were computed for core, penumbra and mismatch ratios, and their concordance for mismatch positivity was assessed. Results 137 patients were scanned and received a final diagnosis of AIS. Of these, only 38 had imaging processed by both Brainomix and Rapid. Median age was 69 years (interquartile range: 57‐77.5y); 16 (42%) were female; 13 (34%) had LVO. Linear models between Brainomix and Rapid's outputs for CBF and Tmax volumes are shown in Figure 1a and 1b. The correlation between software outputs for CBF volume was r=0.70 (p<.001), and for Tmax volume was r=0.72 (p<.001). Mismatch ratios were calculated for the 13 cases with LVO (Figure 1c). The linear model between mismatch ratios was not significant, with four Rapid outputs showing infinite mismatch ratios (due to having CBF volumes of 0ml). Concordance between software for mismatch positivity was good; 8/13 cases showed mismatch on both softwares; 1 case showed mismatch on Brainomix only; 1 for Rapid only; and 3 cases showed mismatch on neither software. Conclusion This prospective study, despite limited sample size (N=38), showed good correlations between Brainomix 360 e‐CTP and Rapid CTP for calculation of both core and penumbra volumes. Although mismatch ratios showed less agreement, the categorization of mismatch positivity showed good concordance between software platforms. image