Cerebrovascular

ENRICH is the strongest recent surgical ICH trial signal, but it is not a blanket green light for every hemorrhage. The benefit appears to come mainly from early minimally invasive evacuation of lobar bleeds, so the right takeaway is targeted adoption, not indiscriminate surgery.

This TOBAS registry report highlights that AVM embolization often did not achieve complete cure and carried substantial hemorrhagic risk. It supports careful case selection and preference for trial-based care when available.

Hemorrhagic stroke J NeuroIntervent Surg: first published as 10.1136/jnis-2023-020650 on 30 October 2023. Downloaded from http://jnis.bmj.com/ on November 5, 2023 at Eskind Biomedical Library Serials Original research Re-­rupture in ruptured brain arteriovenous malformations: a retrospective cohort study based on a nationwide multicenter prospective registry Kexin Yuan ‍ ‍,1 Yu Chen ‍ ‍,1 Debin Yan,1 Ruinan Li,1 Zhipeng Li ‍ ‍,1 Haibin Zhang ‍ ‍,1 Ke Wang

In TOBAS surgical registry patients, microsurgery delivered high cure rates, especially for low-grade AVMs, with nontrivial complication burden that was partly linked to adjunct embolization. Use this as supportive but nondefinitive evidence pending stronger randomized data.

POISE-3 showed that tranexamic acid cuts major bleeding in noncardiac surgery, but the trial stopped short of proving cardiovascular safety noninferiority. The practical read is not 'never use it' or 'use it on everyone' - it is most persuasive when a patient has meaningful bleeding risk and only modest thrombotic concern.

BASICS was a randomized trial of thrombectomy for basilar-artery occlusion, but it came out neutral: the endovascular group did a bit better numerically, yet the confidence interval still included no real benefit. The clean read is not that thrombectomy failed, but that this particular trial could not settle the question on its own.

This individual patient meta-analysis of randomized trials supports decompressive surgery for malignant hemispheric infarction, with large mortality benefit and better chances of mRS <=3 at 1 year. Apply caution for late presenters and elderly subgroup extrapolation.

The POST trial was a retrospective, seven-center, real-world check on the early Penumbra thrombectomy experience. Revascularization was high at 87%, serious procedural events were uncommon at 5.7%, and 41% of patients reached mRS 2 or less at 90 days, which looked better than the historical Pivotal trial. The catch is that this was not a randomized comparison, so it is a useful reassurance study, not a definitive practice-changing trial.

DEFUSE 3 extends thrombectomy window to 6-16 hours using perfusion imaging selection. In 182 patients with proximal occlusion and favorable imaging mismatch, thrombectomy increased functional independence from 17% to 45% with mortality benefit. This supports changing practice for selected late-presenting patients.

BRAT is important because it shows that aneurysm treatment is not just a clipping-versus-coiling popularity contest. Coiling looked better for posterior circulation functional outcomes, but clipping was far more durable and required fewer retreatments. The mature lesson is to choose the modality that fits the aneurysm and circulation territory, not to force every case into one camp.

This 18-year follow-up of ISAT's UK cohort shows endovascular coiling leads to better independent survival at 10 years compared to clipping for ruptured aneurysms suitable for either treatment. Coiling had higher survival (83% vs 79%) and similar independence rates (82% vs 78%), with a small increased rebleeding risk. The evidence supports coiling as first-line for eligible patients, though individual aneurysm anatomy and patient factors remain crucial.

ARUBA randomized 223 adults with unruptured brain AVMs to medical management alone versus medical management plus intervention (surgery, embolization, or radiotherapy). At mean 33-month follow-up, the intervention group had significantly higher rates of death or stroke (30.7% vs 10.1%, HR 0.27). This challenges the practice of preventive intervention for unruptured AVMs, though longer-term data are needed.

This large Japanese cohort study found a 0.95% annual rupture rate for unruptured cerebral aneurysms. Risk increases with size ≥7mm, anterior/posterior communicating artery location, and daughter sac morphology. Consider these factors when counseling Japanese patients, but be cautious generalizing to other populations.

COSS randomized 195 patients with symptomatic carotid occlusion and PET-confirmed hemodynamic ischemia to EC-IC bypass plus medical therapy vs medical therapy alone. The trial was stopped early for futility with no difference in the primary composite endpoint (21.0% vs 22.7% at 2 years). Bypass surgery carried a significant 30-day stroke risk (14.4% vs 2.0%). This provides high-quality evidence against routine EC-IC bypass for this population.

This paper is a biologic review, not a treatment trial. Its main message is that inflammatory cell infiltration, fibrosis, complement activation, and wall degeneration travel together in intracranial aneurysms, which makes inflammation a plausible marker of instability but not yet a standalone reason to change management.

This was not a sedation trial. It was a post-hoc IMS II analysis showing that patients treated with lighter sedation had better reperfusion, lower mortality, and better 3-month outcomes than patients treated with heavy sedation or paralysis. Because deeper sedation was used more often in sicker patients, you should read this as a strong caution signal rather than clean proof of causality.

CREST trial: 2502 patients randomized to carotid stenting vs endarterectomy. No difference in 4-year composite of stroke/MI/death (7.2% vs 6.8%). Stenting had higher periprocedural stroke (4.1% vs 2.3%), endarterectomy had higher MI (1.1% vs 2.3%). Age matters: stenting better for <70, endarterectomy for >70. Both require highly skilled operators.

This paper argues that flow diversion with Pipeline can solve a problem that coiling often does not: durable reconstruction of the diseased parent artery in large or wide-necked aneurysms. The early results are promising, especially for sidewall internal carotid aneurysms, but the evidence in this article is still mostly early series and proof-of-concept work.

ISAT long-term follow-up shows coiling reduces 5-year mortality compared to clipping for ruptured aneurysms (RR 0.77). Rebleeding from treated aneurysms was higher with coiling (10 vs 3 events) but absolute risk small. No difference in independence among survivors at 5 years. Overall mortality remains elevated compared to general population (SMR 1.57).

NASCET is the landmark proof that carotid endarterectomy benefits patients with recently symptomatic high-grade carotid stenosis. The core teaching point is not just that surgery helps, but that it helps when stenosis is severe, symptoms are recent, and perioperative complication rates stay low.