Ítalo Emmanuel Lima Ferreira

The persistence of the primitive trigeminal artery (PTA) is the most common embryological anatomical variation connecting the posterior circulation to the internal carotid artery (ICA). Aneurysms associated with this artery are rare, especially when located on the lateral wall of the persistent artery rather than at the junction with the ICA. Lateral wall aneurysms of the PTA are infrequent, and their management should be individualized. The utilization of flow diverters in these cases presents an effective and safe treatment option, particularly when preservation of the persistent artery is essential.

The middle meningeal artery (MMA) supplies over two-thirds of the cranial dura mater, making its anatomical knowledge crucial for surgery. Rarely, the MMA may originate from the basilar artery. Typically, it arises between the superior cerebellar artery and anterior inferior cerebellar artery, following a course near the trigeminal nerve to reach the petrous branch of the MMA. An embryological origin involves anastomosis between persistent stapedial and trigeminal arteries. The image illustrates an unusual case of a patient with right MMA originating from the posterior circulation via the basilar artery.

Background and purpose: Flow diverters (FDs) have become one of the primary treatments for intracranial aneurysms (IAs). However, their use in distal IA has been associated with higher complication rates compared with other techniques. The development of coated FDs, in combination with novel antiplatelet regimens, offers promising strategies to improve the safety profile of FDs in this context. This trial aimed to compare mono antiplatelet therapy (MAPT) using prasugrel versus dual antiplatelet therapy (DAPT) with aspirin and prasugrel for the treatment of distal IA using the p48 MW HPC FD (WallabyPhenox). Methods: This was a multicenter, prospective, parallel-group, single-blind, non-inferiority randomized trial. Between February 2021 and February 2025, 140 patients were enrolled. After excluding 11 patients, 129 were included in the final analysis. The primary endpoint was the absence of new neurological deficits, defined as no shift in the modified Rankin Scale (mRS) score. The secondary endpoint was the incidence of any stroke. Results: At the 30-day follow-up, 66 patients (98.5%) in the MAPT group and 59 patients (95.2%) in the DAPT group showed no new neurological deficits. With a predefined non-inferiority margin of 5%, the difference of 3.35% confirmed the non-inferiority of MAPT compared with DAPT (p=0.002). The incidence of any stroke was 4/67 (5.9%) in the MAPT group and 6/62 (9.6%) in the DAPT group (p=0.431). Conclusion: Prasugrel monotherapy for the treatment of distal IAs using the p48 MW HPC was non-inferior to DAPT within the first 30 days following treatment. Clinical trial registration: https://ensaiosclinicos.gov.br/rg/RBR-3q9zb73. UTN code: U1111-1290-2489. Research Ethics Committee of the Hospital das Clínicas de Ribeirão Preto - Universidade de São Paulo. CAAE number: 29848720.0.1001.5440.

Letter to the Editor Telencephalic variant of the anterior choroidal artery: clinical significance and management considerations Lívio Pereira de Macêdo, Ítalo Emmanuel Lima Ferreira, Marcos Alcino Soares Siqueira Marques-Júnior, Renata Raizza Monterazzo-Cysneiros, Ubiratan Alves Viturino da Silva, Marcos Antonio Barbosa da Silva, Bruno Anderson Araújo da Mota, Romero Marques, José Laercio Júnior-Silva, Carlos Gustavo Coutinho Abath, Hildo Rocha Cirne Azevedo-Filho

Dissecção aórtica tipo B de Stanford: achado angiotomográfico atípico da arterite de Takayasu

O Lúpus Eritematoso Sistêmico (LES) é uma doença inflamatória crônica, sistêmica, de causa desconhecida e de natureza autoimune. Apresenta prognóstico variável, dependente do órgão ou sistema acometido, sendo o comprometimento renal uma das condições mais frequentemente relacionadas à morbimortalidade. O presente manuscrito propõe-se a contribuir como mais um indício de que o diagnóstico precoce e a terapia agressiva inicial, no lúpus, elevam sobremaneira o índice de sucesso clinico. Falhas no tratamento devem ser reconhecidas de imediato, com rápida mudança de estratégia, quando necessário. Neste sentido, uma nova opção terapêutica parece ser o agente biológico rituximab, descrito neste estudo e para o qual é dada ênfase devido à sua possível e ainda suposta capacidade de atuar como agente de resgate para a nefrite e para a anemia hemolítica lúpicas, simultaneamente, com efetividade e segurança. Apresenta-se o caso de paciente lúpica com acometimento renal e hematológico grave e refratário, que evoluiu simultaneamente com restabelecimento do débito urinário e melhora clínico-laboratorial da anemia autoimune após administração de rituximab, resposta considerada parcial, posto que a existência de dano renal persistente não pode ser descartada