Jhon E. Bocanegra-Becerra

OBJECTIVES: Intracerebral hemorrhage carries high mortality and long-term disability. The optimal blood pressure (BP) management strategy—aggressive vs. conservative lowering—remains uncertain. This review compares both strategies. DATA SOURCES: Articles from PubMed, Web of Science, Embase, and Cochrane were screened to August 2025. STUDY SELECTION: Only randomized open-label blinded-endpoint trials were included. DATA EXTRACTION: Patient characteristics, inclusion criteria, interventions, and outcomes were independently extracted by two authors; conflicts were resolved by a third. DATA SYNTHESIS: Eight randomized controlled trials (12,669 patients; median age 63 yr; 60% male) met inclusion. No significant differences emerged between aggressive and conservative strategies for excellent functional outcome (risk ratio [RR], 1.07; 95% CI, 0.99–1.16; p = 0.94; I ² = 33%), good functional outcome (RR, 1.09; 95% CI, 0.99–1.20; p = 0.07; I ² = 51%), 90-day mortality (RR, 0.90; 95% CI, 0.77–1.05; p = 0.18; I ² = 0%), or hematoma growth (RR, 0.85; 95% CI, 0.66–1.10; p = 0.22; I ² = 48%). Aggressive BP lowering was associated with fewer adverse events (RR, 0.87; 95% CI, 0.76–0.99; p = 0.03; I ² = 59%). Sensitivity analyses showed significant benefits of the aggressive approach for good recovery (RR, 1.05; 95% CI, 1.01–1.10; p = 0.02; I ² = 0%), although not confirmed in the subgroup analyses (RR, 1.09; 95% CI, 0.97–1.23; p = 0.14; I ² = 61%). For adverse events, subgroup analyses consistently favored the aggressive strategy (RR, 0.81; 95% CI, 0.74–0.88; p < 0.01; I ² = 0%). No clear association with hematoma growth emerged, largely due to heterogeneity. CONCLUSIONS: Aggressive and conservative BP lowering yielded similar outcomes for functional recovery, mortality, and hematoma growth. Aggressive BP lowering was linked to fewer adverse events, with some subgroup analyses suggesting modest functional benefits.

To compare the outcomes of flow diversion treatment with Pipeline Embolization Device (PED) and Tubridge Flow Diverter (TFD) in unruptured intracranial aneurysms. A systematic review and meta-analysis were conducted in accordance with PRISMA 2020 guidelines. The primary outcome was complete aneurysm occlusion. Secondary outcomes included favorable functional outcomes (modified Rankin Scale 0-2), perioperative ischemic and hemorrhagic complications, and in-stent stenosis. Risk ratios (RR) with 95% confidence intervals (CI) were pooled using the Mantel-Haenszel method under a random-effects model. Heterogeneity was assessed using the I² statistic. Statistical analyses were performed using R software (version 4.4.0). Four studies including 913 patients were analyzed; 462 underwent treatment with TFD and 451 with PED. Complete aneurysm occlusion was achieved in 75.96% of TFD cases and 81.64% of PED cases (RR: 0.93; 95% CI: 0.87-1.00; I² = 0%). Favorable functional outcomes occurred in 97.07% (TFD) and 96.84% (PED) (RR: 1.00; 95% CI: 0.98-1.02; I² = 0%). Ischemic complications were slightly higher in TFD (4.11%) than in PED (2.44%) (RR: 1.67; 95% CI: 0.39-7.10; I² = 53.7%). Hemorrhagic complications were low in both groups (0.26% vs. 0.54%; RR: 0.55; 95% CI: 0.07-4.39; I² = 0%). In-stent stenosis occurred in 15.06% (TFD) and 16.08% (PED) (RR: 0.94; 95% CI: 0.66-1.33; I² = 0%). PED and TFD demonstrate comparable efficacy and safety profiles for the treatment of unruptured intracranial aneurysms. Both devices are effective options for endovascular therapy.

Facial nerve palsy (FNP) is a result of facial and temporal trauma, often requiring surgery. Endoscopic or microscopic nerve decompression is one of the main surgical treatments. However, robust evidence on the safety and efficacy of these techniques remains scarce in the literature. This systematic review and meta-analysis aimed to synthesize current data on the outcomes of these surgical techniques for traumatic FNP (tFNP).Following PRISMA guidelines, we searched PubMed, Embase, Web of Science, and the Cochrane Library. Studies included patients who underwent endoscopic or microscopic surgical treatment for tFNP. Outcomes were classified by the House–Brackmann (HB) score: complications after surgery, normal facial function to recovery from mild dysfunction, moderate to moderately severe dysfunction, and severe dysfunction to total paralysis after surgery. Analyses were conducted separately, with subanalyses for the transmastoid (TM), middle cranial fossa (MCF), and combined TM + MCF routes in studies reporting.A total of 26 studies with 597 patients were included. The overall complication rate was 2% for endoscopic and 3% for microscopic. Endoscopic outcomes showed HB I–II 88, HB III–IV 6, and HB V–VI 3%. Microscopy revealed HB I–II 66, HB III–IV 29, and HB V–VI 2%. The complication rates for the TM approach were 0, MCF, and TM + MCF combined were 3 and 2%. Furthermore, the HB I–II score rates were 66 (TM), 70 (MCF), and 58% (TM + MCF).Both techniques are safe and effective; better efficacy was analyzed with the endoscopic. Further studies with standardized populations are needed.

BACKGROUND: Flow diverters (FDs) are increasingly used off-label for the treatment of distal anterior cerebral artery aneurysms (DACAAs), located at or beyond the A2 segment of the anterior cerebral artery (ACA). However, data on safety and efficacy remain limited. PURPOSE: To evaluate the safety and efficacy of FDs for the treatment of DACAAs through a systematic review and meta-analysis. DATA SOURCES: PubMed, Scopus, and Web of Science were systematically searched according to PRISMA guidelines. STUDY SELECTION: Studies were eligible if they reported on ≥5 patients treated with FDs for DACAAs and provided angiographic and clinical outcome data. DATA ANALYSIS: Efficacy outcomes included adequate and complete aneurysm occlusion rates and retreatment rates. Safety outcomes included good functional outcome (mRS 0–2), procedure-related morbidity and mortality, procedure-related complications, in-stent stenosis, and covered branch occlusion. Pooled estimates with 95% confidence intervals (CIs) were calculated using a random-effects model. DATA SYNTHESIS: Eleven retrospective studies comprising 326 patients (71% female; mean age, 59.4 ± 4.4 years) with 328 DACAAs were included. Most aneurysms were unruptured (95.7%) and located in the A2 or A2–A3 segments (89%). Adequate and complete occlusion at last follow-up were 89% (95% CI, 82–96) and 77% (95% CI, 69–85), respectively. The retreatment rate was 1% (95% CI, 0– 3). Good functional outcome was reported in 97% (95% CI, 95–100). Procedure-related complications occurred in 7% (95% CI, 1–12), resulting in 1% morbidity (95% CI, 0–3) and no procedure-related deaths. In-stent stenosis and covered branch occlusion were observed in 4% (95% CI, 0–10) and 10% (95% CI, 6–13), respectively. Clinically symptomatic covered branch occlusion was rare (1.1%), possibly reflecting the adequacy of collateral circulation in distal ACA territory. LIMITATIONS: The analysis is based on retrospective studies that lacked centralized adjudication of angiographic outcomes, potentially introducing methodological biases intrinsic to such study designs, including selection bias, confounding, and publication bias. CONCLUSIONS: FDs appear to be a safe and effective treatment option for DACAAs, with high rates of occlusion and favorable clinical outcomes, and low rates of retreatment and procedure-related complications. ABBREVIATIONS: ACA＝ anterior cerebral artery; DACAAs＝ distal anterior cerebral artery aneurysms; FDs＝ flow diverters.

Background The Woven EndoBridge (WEB; Terumo) device has gained increasing recognition for treating ruptured intracranial aneurysms (RIAs) due to its ability to disrupt flow with a single implant, avoiding long-term dual antiplatelet therapy. Despite multiple studies, a comprehensive synthesis of recent evidence remains lacking. This study addresses this gap through a systematic review and meta-analysis evaluating the WEB device’s safety and efficacy in RIA management. Methods A systematic search of EMBASE, MEDLINE, Scopus, Cochrane, and the Web of Science identified studies on WEB treatment for RIAs up to January 2025. Key outcomes included implantation success, rebleeding, occlusion, retreatment, good functional outcomes (mRS 0–2) at 90 days, morbidity, mortality, and complications. A single-arm proportion analysis was conducted under a random-effects model. Results Twenty-five studies with 1,065 patients (1,077 aneurysms) were included. The implantation success rate was 98.04%, and rebleeding occurred in 0.33% of cases. Adequate and complete occlusion at 12 months were 83.77% and 59.42%, respectively. Good functional outcomes at 90 days were 87.27%, with a retreatment rate of 7.54%. Procedure-related mortality and morbidity were 0.39% and 1.39%. The overall complication rate was 12.82%, with thromboembolic and hemorrhagic events in 4.55% and 1.05% of cases, respectively. Conclusion Our findings indicate that the WEB device is a safe and effective treatment for RIAs, offering high rates of adequate occlusion, good functional outcomes, and low complication rates. This evidence reaffirms the WEB device’s safety and efficacy, supporting its wider adoption in clinical use.

Background Flow diverters (FDs) are increasingly used off-label for distal cerebral aneurysms (DCAs), those located at or beyond the anterior cerebral artery (ACA) A2, middle cerebral artery M2, and posterior cerebral artery P2 segments. However, data on their safety and efficacy remain limited. This systematic review and meta-analysis synthesizes current evidence on FD treatment for DCAs. Methods A comprehensive search was performed across PubMed, Scopus, and Web of Science, including studies with ≥5 patients reporting FD treatment of DCAs. Efficacy outcomes included adequate and complete aneurysm occlusion and retreatment rates. Safety outcomes included good functional outcome (modified Rankin Scale (mRS) score 0–2), procedure-related morbidity, mortality, complications, in-stent stenosis, and covered branch occlusion at follow-up. Pooled analyses with 95% confidence intervals (CI) were conducted using a random-effects model. Results Eighteen studies (441 patients, 70% women; mean age: 57.2±13.6 years) with 445 DCAs were included. Most aneurysms were unruptured (93.7%) and located in the ACA territory (78.4%). Adequate and complete occlusion at last follow-up were 90% (95% CI, 86 to 95) and 79% (95% CI, 74 to 85), respectively. The retreatment rate was 1.6% (95% CI, 0.2 to 3). Good functional outcome was achieved in 97% (95% CI, 95 to 99). Procedure-related complications occurred in 9% (95% CI, 5 to 13), with morbidity and mortality of 1.5% and 0.6%, respectively. In-stent stenosis and covered branch occlusion rates were 3% (95% CI, 0 to 8) and 5.5% (95% CI, 2 to 9), respectively. Conclusion FDs appear to be safe and effective for DCAs, with high occlusion rates and low retreatment and complication rates.

BACKGROUND: A minority of patients with stroke qualify for intravenous thrombolysis (IVT) within 4.5-hour window. The safety and efficacy of IVT beyond this period have not been well studied. METHODS: We systematically searched MEDLINE, Embase, Cochrane, and ClinicalTrials.gov for relevant randomized clinical trials. Randomized clinical trials comparing IVT versus standard medical care in patients with ischemic stroke beyond 4.5 hours of symptom onset or last known well without mechanical thrombectomy (MT) were included. Primary outcomes were excellent (modified Rankin Scale score of 0–1) and good (modified Rankin Scale score of 0–2) functional outcomes at 90 days, symptomatic intracerebral hemorrhage (sICH), and death at 90 days. Pooled odds ratios (ORs) with 95% CIs were calculated using a random-effects model. Heterogeneity was assessed by Q test and quantified by I ² values. RESULTS: Eight randomized clinical trials (1742 patients; mean age, 69.8±9 years, 63.5% men) were included. Compared with standard medical care, IVT achieved higher rates of excellent (OR, 1.43 [95% CI, 1.17–1.75]; Q =2.30; P =0.94; I ² =0%) and good functional outcomes (OR, 1.36 [95% CI, 1.12–1.66]; Q =2.07; P =0.96; I ² =0%) at 90 days but also increased sICH rates (OR, 4.25 [95% CI, 1.67–10.84], Q =0.48; P =0.99; I ² =0%). Mortality at 90 days did not significantly differ between treatment groups (OR, 1.28 [95% CI, 0.87–1.89]; Q =4.63; P =0.59; I ² =0%). Subanalyses yielded numerically higher odds of excellent functional outcomes when patients were selected with perfusion imaging (3 studies, OR, 1.45 [95% CI, 1.08–1.94]) compared with diffusion-weighted imaging–fluid-attenuated inversion recovery mismatch (3 studies, OR, 1.34 [95% CI, 0.94–1.91]) and when treated with tenecteplase (3 studies, OR, 1.47 [95% CI, 1.06–2.04]) compared with alteplase (5 studies, OR, 1.38 [95% CI, 1.08–1.78]). CONCLUSIONS: IVT for ischemic stroke beyond 4.5 hours, without MT, led to increased odds of excellent and good functional outcomes compared with standard medical care, despite higher odds of sICH, and a nonsignificant numerical increase in mortality.