Search Results (107)

Posterior cerebral artery (PCA) aneurysms are rare, accounting for less than 2% of intracranial aneurysms. Among them, dissecting aneurysms frequently occur in the P2 segment. Traumatic PCA aneurysms are extremely uncommon and usually reported in pediatric or young adults following high-energy injuries. We report the case of a 43-year-old woman who sustained a ruptured left PCA P2 dissecting aneurysm with subarachnoid hemorrhage, accompanied by an L2 unstable burst fracture after a high-speed motor vehicle collision. Initial neuroimaging revealed diffuse basal cistern hemorrhage with more predominance at the left side ambient cistern and a fusiform aneurysm with a superimposed saccular component along its anterior portion of left PCA P2 segment. The patient underwent endovascular treatment with a flow-diverting stent and stent-assisted coiling, achieving complete obliteration, followed by lumbar minimally invasive spinal surgery (MISS). The patient recovered without neurological deficits and remained fully independence at a one-year follow-up. Traumatic PCA dissecting aneurysms pose a diagnostic challenge due to their rarity and potential for delayed clinical manifestation, yet they carry a substantial risk of morbidity and rebleeding if untreated. Early recognition through detailed vascular imaging and timely reconstructive endovascular intervention are essential to preventing secondary hemorrhage and optimizing clinical outcomes. This case underscores the need for heightened suspicion for vascular injury in patients with significant craniovertebral trauma. Full article

Background and Objectives: Minimally invasive surgery (MIS) has emerged as a less invasive alternative to medical management (MM) in intracerebral hemorrhage (ICH), but its comparative effectiveness remains uncertain. Materials and Methods: We searched PubMed, Web of Science, Scopus, and Cochrane Library for RCTs and prospective matched studies comparing MIS with MM in supratentorial spontaneous ICH. Primary outcomes were functional recovery and mortality; secondary outcomes were adverse events, rebleeding, and ICU stay. Meta-analysis was performed using RevMan 5.4 with 95% confidence intervals (CI). Results: Thirteen studies (11 RCTs, 2 cohorts; 1503 MIS, 1401 MM) were included. MIS significantly improved functional outcomes (Risk Ratio, RR 1.18, 95% CI 1.01 to 1.38), driven mainly by studies including both deep and lobar hematomas, whereas deep-only studies showed inconsistent effects. The benefit was largely attributable to stereotactic aspiration with local thrombolytics (RR 1.23, 95% CI 1.07 to 1.41), while other MIS techniques showed no significant advantage. Early intervention (<24 h) demonstrated better outcomes (RR 1.16, 95% CI 1.07–1.26). Thirty-day mortality was lower with MIS (RR 0.63, 95% CI 0.49–0.80). No significant differences were observed for ICU stay (Mean Difference, MD –0.15 days, 95% CI −1.34 to 1.05) or rebleeding (RR 1.57, 95% CI 0.84–2.97). Severe adverse events were lower in MIS (RR 0.80, 95% CI 0.71–0.89). Conclusions: MIS may reduce mortality and improve functional outcomes in supratentorial ICH, particularly using stereotactic aspiration with thrombolytics. The benefit in deep hematomas remains uncertain. Early intervention and careful patient selection are essential. Further high-quality RCTs are warranted. Full article

Subarachnoid hemorrhage (SAH) is a life-threatening cerebrovascular event with high mortality and long-term morbidity. While clinical grading scales such as Hunt and Hess or the World Federation of Neurological Surgeons (WFNS) score aid in prognosis, their accuracy implies a neurological assessment that can be confounded in sedated patients, highlighting the need for objective biomarkers. Biomarkers offer an alternative approach for risk stratification. This review examines the prognostic value of the glucose/potassium ratio (GPR) in patients with aneurysmal SAH and its potential integration into future predictive models. A literature review of retrospective studies assessing the association between GPR and clinical outcomes in SAH was conducted. Evidence on the pathophysiological basis of stress-induced hyperglycemia and hypokalemia in SAH is presented, along with findings from five key clinical studies evaluating GPR in relation to mortality, vasospasm, delayed cerebral ischemia, and functional outcomes. Elevated GPR levels were consistently associated with poor short- and long-term outcomes in SAH patients. Studies reported significant correlations between GPR and 30-day mortality, poor Glasgow Outcome Scale (GOS) scores, increased incidence of cerebral vasospasm, and higher rates of rebleeding. The optimal GPR cutoff for predicting adverse outcomes was greater than 37 mg/dL, with multivariate analyses confirming GPR as an independent prognostic factor. GPR is a promising, cost-effective biomarker that integrates two stress-response parameters (glucose and potassium), both of which are independently associated with SAH prognosis. Its incorporation into future predictive models may enhance early risk stratification and guide clinical decision-making. Further prospective studies are warranted to validate its utility and standardize its clinical application. Full article

Background: Chronic subdural hematoma (cSDH) is a common condition, particularly in individuals over 65 years of age. Its pathophysiology involves traumatic and inflammatory processes, culminating in hematoma formation. Although surgical drainage is the primary treatment of choice, its significant recurrence rates have prompted exploration of non-surgical options. This study evaluates the effectiveness of middle meningeal artery (MMA) embolization as an alternative or adjunctive treatment in asymptomatic or paucisymptomatic cSDH patients. Methods: This two-center retrospective study analyzed 93 patients treated with MMA embolization at two hospitals between 2020 and 2024. Patients exhibited either asymptomatic or mild symptomatic cSDH (Markwalder score 0 or 1), with hematoma thickness >10 mm. Pre- and post-treatment CT scans were compared to assess hematoma thickness, with follow-ups conducted at three months. Statistical analysis included ANCOVA and Mann–Whitney U tests for outcome evaluation. Results: Of the 93 patients, 44 underwent bilateral embolization, and 49 underwent unilateral embolization. Treatment reduced hematoma thickness by an average of 59% at three months follow-up. The trabecular subtype showed the greatest thickness reduction compared to other subtypes (p < 0.05). No significant differences were found between embolization materials. Only 3.2% of patients experienced technical complications, and three patients experienced rebleeding during follow-up. Conclusions: MMA embolization appears to be a safe and effective treatment for cSDH, providing a minimally invasive alternative to surgery. The technique shows promise in reducing hematoma size, especially in the trabecular subtype. Further research is needed to confirm these findings and establish their role in routine clinical practice. Full article

Dural arteriovenous fistulas (dAVFs) are a heterogeneous group of intracranial vascular anomalies characterized by abnormal arteriovenous shunting within the dura mater. While they are often considered acquired lesions—associated with trauma, surgery, venous sinus stenosis, or thrombosis—their precise etiology remains unclear in many cases. The clinical presentation of dAVFs varies widely depending on location and venous drainage patterns. Benign forms may manifest as pulsatile tinnitus or headache, whereas lesions with retrograde venous drainage and cortical venous reflux are considered aggressive and carry a heightened risk of hemorrhage and progressive neurological decline. Multiple classification systems, primarily based on angioarchitecture and venous outflow characteristics, have been developed to stratify risk and guide treatment strategies, as these features largely determine the natural history and clinical course of dAVFs. Endovascular embolization, microsurgical disconnection, and stereotactic radiosurgery (SRS) represent the mainstays of treatment, aiming to prevent hemorrhage or rebleeding and to alleviate symptoms related to venous congestion. Over the past two decades, advances in endovascular techniques have driven a paradigm shift in management, positioning embolization as the first-line therapy for most dAVFs. This review begins with a comprehensive overview of dAVF pathogenesis, classification systems, and angioarchitecture. It then focuses on the endovascular management of dAVFs, offering a detailed appraisal of current and emerging techniques, key technical considerations, and lesion-specific treatment strategies. Finally, we discuss the role of microsurgery and SRS. Full article

Background/Objectives: Cerebral infarction significantly worsens outcomes after aneurysmal subarachnoid hemorrhage (SAH). This retrospective study analyzed early predictors of infarct-free survival and the impact of infarct timing on clinical outcomes. Methods: We reviewed 988 consecutive SAH patients treated from 2003 to 2016, all with follow-up CT scans. Baseline clinical and SAH characteristics were recorded to identify predictors of infarct-free survival and assess the relationship between infarct timing and outcomes. Results: Cerebral infarctions occurred in 475 patients (48.1%) at a median of 3.4 days post-SAH; 70.9% happened within the first week. Earlier infarctions were associated with higher in-hospital mortality (odds ratio [OR] = 0.91 per day increase, p < 0.0001) and poor 6-month outcomes (modified Rankin Scale > 3; OR = 0.96 per day increase, p = 0.012), especially within 48 h. Independent predictors of infarct-free survival included poor initial condition (WFNS ≥ 4, adjusted hazard ratio [aHR] = 1.82, p < 0.0001), intraventricular hemorrhage (aHR = 1.25, p = 0.041), aneurysm rebleeding (aHR = 1.76, p < 0.0001), acute hydrocephalus (aHR = 1.38, p = 0.020), and daily aspirin intake (aHR = 0.68, p = 0.002). The number of baseline risk factors (0–5) strongly influenced both infarction likelihood and timing (p < 0.0001). Conclusions: Cerebral infarctions predominantly occur within the first week after SAH, with earlier infarctions having a more severe impact on outcomes. Initial risk factor-adapted SAH management may improve functional outcomes. Full article

Background: Splenic artery embolization (SAE) has emerged as a key adjunct to non-operative management (NOM) in hemodynamically stable patients with blunt splenic trauma, yet variability in its application persists across centers. Objectives: The aim was to evaluate real-life clinical practices, techniques, and outcomes of SAE in blunt splenic trauma across multiple Italian trauma centers. Materials and Methods: This retrospective multicenter study analyzed data from 281 patients undergoing emergency SAE for blunt splenic trauma between January 2019 and December 2021. Demographics, imaging findings, embolization techniques, complications, and outcomes were collected and analyzed. Multivariate logistic regression was used to assess predictors of splenectomy. Results: The technical success rate was 100%, with a 9.6% rate of post-embolization splenectomy and a complication rate of 24.9% (including 5.7% splenic infarction and 3.2% rebleeding). Embolization was performed proximally (46.6%), distally (28.8%), or with a combined approach (24.6%). No significant correlation was found between embolization technique and splenectomy rate. Patients with AAST grade III injuries benefited from SAE with high technical success and low failure rates. Notably, 14.2% of patients underwent angiography despite negative CT, with a splenectomy rate of 10% in this subgroup. Multivariate analysis identified no independent predictors of splenectomy. Conclusions: SAE is a reliable and effective tool in the management of blunt splenic trauma, achieving high splenic salvage rates even in selected grade III injuries and CT-negative patients. In an era of precision medicine, interventional radiology should be regarded as a distinct and specific treatment modality, comparable to surgery, rather than being merely included within non-operative management (NOM). Full article

Background: The COVID-19 pandemic disrupted healthcare systems globally, raising concerns about its negative impact on patients with chronic liver diseases by contributing to hepatic decompensations such as acute variceal bleeding (AVB). This study aimed to evaluate the impact of the COVID-19 pandemic on clinical outcomes in cirrhotic patients with AVB in Germany. Methods: This retrospective national multicenter study compared patients with cirrhosis and AVB treated at four tertiary care centers in Germany before (2016–2020) and during the pandemic (2020–2022). The primary endpoint was 6-week mortality, and secondary outcomes included infections, transfusion requirement and rebleeding. Results: The baseline characteristics of the 247 patients were largely comparable between the two groups, however metabolic dysfunction-associated steatotic liver disease was more prevalent during the pandemic compared to the pre-pandemic period (12.5% vs. 4.8%, p = 0.048). Only one patient tested positive for SARS-CoV-2. Six-week mortality (32.2% vs. 30.1%; p = 0.767) and rebleeding rates (22.8% vs. 22.3%; p = 1.000) did not differ significantly between groups. Interestingly, intubation rates, length of stay on the intensive care unit, post AVB infection rates and types of infection were also comparable (all p > 0.05), while transjugular intrahepatic portosystemic shunt placement (TIPS) after bleeding was performed more frequently during the pandemic (23.2% vs. 11.3%, p = 0.019). Conclusions: Relevant patient-related AVB outcomes were unaffected during the COVID-19 pandemic. These findings suggest the resilience of critical AVB management practices in German tertiary centers. The increased use of TIPS and MASLD prevalence during the pandemic may reflect evolving clinical practice and patient profiles warranting further investigation. Full article

Chronic subdural hematoma (cSDH) is a common neurosurgical condition in the elderly, often resulting from minor head trauma. Traditional surgical treatments such as burr-hole drainage carry recurrence rates of 10–20% and significant risks in older patients, especially those on anticoagulation therapy. Middle meningeal artery (MMA) embolization has emerged as a minimally invasive alternative, aiming to reduce blood flow to the dura and thereby promote hematoma resolution and lower recurrence. We conducted a bibliometric analysis of publications on MMA embolization for cSDH up to December 2023. The analysis shows a sharp increase in research activity over the past decade. North America, Japan, and Europe are leading contributors, with collaborative networks forming among major institutions. Key journals in neurosurgery and neurointervention have published much of this research, and author collaborations are extensive. Frequently used keywords such as “recurrence” and “treatment outcome” reflect an emphasis on reducing rebleeding and improving patient outcomes. In conclusion, MMA embolization is rapidly gaining attention as a promising treatment for cSDH. While early results are favorable and multi-center efforts are expanding the evidence base, further research is needed to establish long-term efficacy, optimize patient selection, and standardize techniques. Full article

Background: Non-variceal upper gastrointestinal bleeding (NVUGIB) remains a critical medical–surgical emergency associated with significant morbidity, mortality, and healthcare burden worldwide. Despite advances in diagnostic and therapeutic modalities, NVUGIB continues to pose complex clinical challenges, particularly in resource-limited settings. Methods: This retrospective observational study analyzed 364 consecutive adult patients diagnosed with NVUGIB and hospitalized at the First Surgical Clinic of the County Emergency Clinical Hospital Craiova between January 2009 and December 2014. Inclusion criteria required a confirmed diagnosis based on clinical presentation, laboratory findings, and upper gastrointestinal endoscopy (UGIE). Demographic variables, etiology, comorbidities, drug-induced triggers, laboratory parameters, onset-to-admission and onset-to-surgery intervals, endoscopic findings, therapeutic interventions (medical, endoscopic, surgical), rebleeding rates, and mortality were recorded and analyzed. Results were descriptively compared with historical data from the national and international literature. Due to the retrospective and aggregate nature of the data, survival analysis (Kaplan–Meier) was not applicable. Results: Peptic ulcers, erosive gastritis, Mallory–Weiss syndrome, and gastric neoplasms were the predominant etiologies. NSAID use, oral anticoagulation, and alcohol consumption emerged as major risk factors. Endoscopic hemostasis was achieved in the majority of cases; surgical intervention was required in 11.5% of patients, mainly for refractory or recurrent bleeding. The overall mortality rate was 10.9%, consistent with historical benchmarks. Comparative analysis revealed trends in etiology and management reflecting evolving clinical practice standards. Conclusions: NVUGIB remains a significant clinical challenge with persistent mortality and rebleeding risks. This cohort highlights the need for timely diagnosis, risk stratification, and an evidence-based therapeutic strategy integrating modern endoscopic and surgical options. An updated diagnostic and management algorithm is proposed to guide practical decision-making and optimize outcomes in similar tertiary care settings. Full article

(1) Background: Acute variceal bleeding (AVB) represents an important cause of upper gastrointestinal bleeding (UGIB). Several prognostic scores may be useful for assessing mortality and rebleeding risk, with the Glasgow-Blatchford score (GBS) and Rockall score being the most commonly used for non-variceal bleeding. Scores assessing liver failure (MELD and Child) do not reflect bleeding severity. The neutrophil-to-lymphocyte ratio (NLR) increases in UGIB and can predict survival and rebleeding. (2) Methods: We analyzed the predictive role of NLR, GBS, Rockall, AIMS65, Child, and MELD for mortality (48 h, 5-day, in-hospital, and 6-week) and rebleeding in AVB patients admitted to our hospital from 2017 to 2021. ROC analysis was performed, and a multivariate analysis with logistic regression was used to construct a simplified model. (3) Results: A total of 415 patients were admitted. NLR exhibited fair accuracy for 48-h mortality (AUC 0.718, 95% CI 0.597–0.839, p < 0.0001), with limited predictive value for medium-term mortality. The NLR accuracy was better than that of the GBS and Rockall score, similar to that of the AIMS65 and Child scores, but inferior to that of MELD. The value for all scores in predicting rebleeding was poor, with the highest AUC for the NLR. (4) Conclusions: The NLR exhibited reasonable accuracy in predicting short-term mortality in AVB. Our model (including NLR, age, creatinine, bilirubin, albumin, INR, platelet count, HCC, and etiology) demonstrated 80.72% accuracy in predicting 6-week mortality. Full article

Background/Objectives: An aberrant internal carotid artery (aICA) in the middle ear is a rare vascular anomaly with potentially catastrophic consequences if injured during otologic procedures. Given its rarity, standardized treatment recommendations are lacking. This study aims to present four cases of aICA bleeding, systematically review the literature, and evaluate the outcomes of conservative and interventional management. Methods: A retrospective review of four patients treated for intraoperative aICA hemorrhage at two tertiary referral centers was performed. A systematic review was conducted following PRISMA guidelines. Neurologic and otologic outcomes, hemostasis, and complications were analyzed. Results: Two patients were treated conservatively with external auditory canal packing, while two required endovascular coil embolization due to pseudoaneurysm formation or persistent bleeding. One patient suffered a stroke due to traumatic ICA occlusion. The systematic review identified 20 additional cases. Conservative treatment alone sufficed in 37.5% of cases, whereas 62.5% required vessel occlusion via coiling, balloon occlusion, or stenting. Neurologic complications occurred in 25% of patients, while otologic outcomes varied widely and were inconsistently reported. Conclusions: Initial external auditory canal packing and a CT angiogram should be recommended for all patients. Initial conservative management may be appropriate for cases with early hemostasis if close monitoring is ensured. Endovascular treatment is often necessary, particularly in cases of pseudoaneurysm or rebleeding. Full article

Objectives: Epistaxis is a common condition affecting up to 60% of the population, with approximately 6% requiring medical intervention. Posterior epistaxis is particularly challenging, often necessitating endoscopic or endovascular treatment. Sphenopalatine artery (SPA) embolization is an effective treatment option, though concerns remain about the risks associated with nonselective or bilateral approaches. This study evaluates the efficacy and safety of unilateral superselective SPA embolization in managing severe posterior epistaxis. Methods: A prospective study of patients undergoing unilateral superselective SPA embolization for refractory posterior epistaxis over a four-year period was conducted. Demographic data, clinical history, prior treatments, and procedural characteristics were analyzed. The primary endpoint was clinical success, defined as the absence of recurrent bleeding within 24 h post-procedure. Secondary outcomes included recurrence at one month and complication rates. Results: Thirty-two patients with severe posterior epistaxis were included. All required nasal packing prior to embolization. Half had undergone previous endoscopic cauterization. Hypertension was present in 69%, and 56% were receiving anticoagulant or antiplatelet therapy. Clinical success was achieved in 100% of cases, with no rebleeding in the first 24 h. Two patients (6%) experienced early recurrence within seven days, requiring readmission. Minor complications included nasal dryness in two cases (6%); no major complications occurred. Mean fluoroscopy time was 19.9 ± 11 min. Conclusions: Unilateral superselective SPA embolization is a safe and highly effective treatment for severe posterior epistaxis, offering high initial success and low complication rates. Its adoption may reduce the need for bilateral procedures and surgical interventions. Full article

Lower gastrointestinal bleeding (LGIB) is a frequent and potentially life-threatening clinical condition. Over the past two decades, several prognostic scoring systems have been developed to stratify risk and guide the management of patients with LGIB. This comprehensive review aims to summarize and compare the current evidence on the utility, accuracy, and limitations of key LGIB scoring systems, including the Glasgow-Blatchford Score (GBS), AIMS65, ABC score, Oakland score, SALGIB, CHAMPS, and Rockall score. We conducted a structured literature review of studies evaluating these scores in adult patients with LGIB. For each scoring system, we analyzed its origin, components, intended use, and predictive performance regarding clinical outcomes such as severe bleeding, transfusion requirement, in-hospital mortality, rebleeding, and safe discharge. Comparative analyses of diagnostic accuracy were extracted where available. Our findings indicate that while no single score offers comprehensive predictive accuracy across all outcomes, certain tools are particularly effective for specific endpoints. The Oakland and GBS scores are useful for identifying patients at low risk who may be managed safely as outpatients. The ABC and CHAMPS scores demonstrate superior performance in predicting mortality, especially in elderly or comorbid populations. SALGIB, a newer score developed in Vietnam, shows promising performance for early triage but requires further validation. The Rockall score, although historically valuable in upper GI bleeding, offers limited applicability in LGIB due to its reliance on post-endoscopic findings. In conclusion, multiple prognostic tools are now available to support early decision-making in LGIB. Their optimal use requires understanding their strengths, limitations, and appropriate clinical contexts. Integrating these scores into routine practice, along with clinical judgment, can enhance patient outcomes and resource allocation. Full article

Background and Aims: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common cause of hospitalizations, with proton pump inhibitors (PPIs) being the mainstay treatment. However, there is a lack of high-level evidence to show if adjunctive medical therapy (somatostatin and its analogs) can improve outcomes. This systematic review and meta-analysis aim to evaluate the outcomes of PPIs with adjunctive therapy versus PPI monotherapy in treating NVUGIB in an in-patient setting. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, major databases were systematically searched to retrieve English-only, original studies, published from 1 January 2000 to 31 December 2023, investigating NVUGIB only. The primary outcomes included the mortality rate within 7 days of therapy, rebleeding rate within 7 days of therapy, and length of hospital stay. Results: Seven studies with 789 patients had a pooled mortality rate of 2.0% (95% CI, 0–4.0%), and the pooled risk ratio was 1.11 (95% CI, 0.50–2.48; p = 0.79) between PPI monotherapy and PPIs with adjunctive medical therapy. The pooled rebleeding rate was 13% (95% CI, 6–20%) and the risk ratio was 1.04 (95% CI, 0.73–1.48; p = 0.83). The pooled average length of stay in the hospital was 5.47 days (95% CI, 3.72–7.21 days), with insignificant weighted differences between the two groups. No statistically significant differences were noted in surgical management risk ratios or amount of blood transfusion. Conclusions: Among patients with NVUGIB, adjunctive medical therapy offered no clinical benefits given the statistically insignificant differences in the primary outcomes. However, this conclusion is limited by the considerable variability in treatment protocols, weak control of confounding variables, and missing clinical information in the original studies. Therefore, better-quality, large-scale randomized controlled trials are needed, ideally using standardized somatostatin dosing, timing, delivery routes, and clearly defined inclusion criteria to more accurately evaluate the role of somatostatin in NVUGIB management. Full article