Eberval Gadelha Figueiredo

Background: Segmental location changes the arterial and branch relationships encountered during middle cerebral artery (MCA) aneurysm clipping, but its ability to anticipate a multiple-clip construct is uncertain. This study evaluated the association between aneurysm segmental location and multiple-clip reconstruction. Methods: This retrospective single-center cohort screened 107 adults who underwent microsurgical clipping of MCA aneurysms. The location analysis included 86 operations with recorded segmental location. The primary exposure compared bifurcation-involving aneurysms with proximal or distal M1 aneurysms. Multiple-clip reconstruction was operationally defined as use of at least two documented permanent clips. Exact tests and logistic regression adjusted for aneurysm size category and the presence of multiple aneurysms were used. Results: The cohort included 62 bifurcation-involving and 24 M1-segment aneurysms. Multiple-clip reconstruction was used in 31/86 operations (36.0%): 21/62 bifurcation-involving cases (33.9%) and 10/24 M1-segment cases (41.7%; exact odds ratio 0.72, 95% confidence interval 0.25–2.14; p = 0.618). Segmental location was not independently associated with the outcome after adjustment (adjusted odds ratio 0.61, 95% confidence interval 0.22–1.73; p = 0.351). Non-small aneurysm category was independently associated with multiple-clip reconstruction (adjusted odds ratio 5.99, 95% confidence interval 1.93–18.56; p = 0.002). Four-category and sensitivity analyses were concordant. Conclusions: Multiple-clip reconstruction occurred across all recorded MCA segmental locations. Segmental location alone did not identify operations requiring multiple clips, whereas recorded aneurysm size category provided stronger information. Location should therefore be integrated with lesion morphology rather than used as a stand-alone marker of clip-construct complexity.

Background: Lumbar puncture (LP) is essential for detecting intracranial hypertension (IH) but is often non‐diagnostic and not without complications. A skull extensometer‐based non‐invasive intracranial pressure waveform assessment (NIWA) has shown promise in detecting IH in neurocritical settings. This study investigated its feasibility and accuracy among outpatient neurological individuals. Methods: This cross‐sectional study enrolled adults referred to routine outpatient LP at a tertiary‐care hospital. Subjects underwent baseline supine NIWA, then were sequentially divided (2:1:1 ratio) to: LP then follow‐up supine NIWA; follow‐up NIWA while sitting then LP; or follow‐up NIWA during Valsalva maneuver then LP. Several waveform parameters and their variation between baseline and follow‐up assessments were compared with LP results. IH was defined as LP opening pressure > 25cmH ₂ O. Results: The study included 130 subjects, and 28 (21.5%) presented with IH. Dicrotic peak slope < 0.143 predicted IH with 89.5% sensitivity and 29.7% specificity (AUROC = 0.680, 95% CI 0.541–0.819). Equations derived from multivariate logistic regression models including mostly latency‐related parameters of the entire waveform and its percussion and dicrotic peaks predicted cerebrospinal fluid (CSF) chemocytology changes with AUROC = 0.661 (95% CI 0.542–0.780) and overall abnormal LP results (IH and/or altered CSF chemocytology) with 96.2% sensitivity and 24.1% specificity (AUROC = 0.696, 95% CI 0.572–0.820). Parameter changes after LP, during Valsalva maneuver, and sitting position did not improve diagnostic accuracy. Conclusions: NIWA was feasible and detected IH and CSF changes with high sensitivity among real‐world neurological outpatients. While LP remains pivotal to many cases, pre‐LP screening with NIWA may enhance diagnostic yield and mitigate complications and healthcare‐related costs.

The clinical management of small, unruptured intracranial aneurysms, particularly those measuring less than 5 mm, represents a significant area of debate in neurovascular surgery. The decision to pursue invasive treatment versus conservative surveillance is often guided by limited and sometimes conflicting evidence, leaving a critical gap in clinical decision-making. This study aimed to meticulously characterize the five-year natural history and morphological evolution of a cohort of patients with untreated small intracranial aneurysms (defined as < 5 mm), managed conservatively with serial angiographic surveillance. We conducted a longitudinal cohort study at a single tertiary academic center, enrolling 113 patients (101 female, 89.4%; 12 male, 10.6%; mean age 59 years) with at least one unruptured intracranial aneurysm measuring < 5 mm, diagnosed by digital subtraction angiography (DSA). All patients were managed with a conservative “watch-and-wait” protocol, which included a follow-up DSA at five years. The primary endpoints were morphological changes, including dimensional growth, shrinkage, complete resolution, de novo formation of new aneurysms, and the incidence of aneurysmal subarachnoid hemorrhage (SAH). Over the cumulative 565 patient-years of follow-up, no instances of aneurysmal rupture or SAH were observed. Most aneurysms were located in the anterior circulation (92.2%). The vast majority of aneurysms (n = 87; 77.0%) demonstrated complete morphological stability. A small subset of aneurysms exhibited dynamic changes: 12 (10.6%) demonstrated minor growth but remained within the < 5 mm size category, 6 (5.3%) decreased in size, and 5 (4.4%) underwent complete spontaneous resolution. De novo aneurysm formation was identified in 3 patients (2.7%). While traditional vascular risk factors like hypertension and oral contraceptive use showed no significant correlation with aneurysm behavior, a paradoxical and statistically significant association was found with smoking, which correlated with a higher likelihood of aneurysm resolution (p = 0.016). This study supports that a conservative management strategy with planned imaging surveillance is a safe and viable option for patients with unruptured intracranial aneurysms smaller than 5 mm. The absence of rupture over five years, coupled with the low rate of significant growth, suggests that these lesions have a very low observed risk of rupture and morphological progression over five years. These findings support conservative management for most patients with UIAs < 5 mm, although treatment decisions should remain individualized according to patient- and aneurysm-specific risk factors.

Background: Microsurgical planning for middle cerebral artery (MCA) aneurysms usually emphasizes aneurysm size, rupture status, dome projection, neck configuration, and branch incorporation. The preoperative course of the parent M1 segment may also influence exposure and proximal control. This single-center surgical cohort evaluated whether M1 morphology is associated with temporary clipping during MCA aneurysm surgery. Methods: Adult patients who underwent microsurgical clipping of MCA aneurysms involving the M1-bifurcation complex between 2006 and 2018 were retrospectively analyzed. M1 morphology was independently classified on preoperative vascular imaging as straight, upward-curved, or downward-curved by two senior cerebrovascular neurosurgeons. Temporary clipping was the primary outcome. Analyses were descriptive and unadjusted because of limited event counts. Results: Eighty-six patients were included. Interobserver agreement for M1 classification was 95.3% (Cohen’s kappa = 0.92). M1 morphology was straight in 47 patients (54.7%), upward-curved in 27 (31.4%), and downward-curved in 12 (14.0%). Temporary clipping was used in 3 of 47 straight M1 cases (6.4%), 6 of 27 upward-curved cases (22.2%), and 4 of 12 downward-curved cases (33.3%; p = 0.041). In the straight-versus-curved analysis, temporary clipping was used in 3 of 47 straight cases (6.4%) and 10 of 39 curved cases (25.6%). Curved M1 morphology was associated with higher unadjusted odds of temporary clipping (odds ratio 5.06, 95% confidence interval 1.28–19.96; p = 0.017). Intraoperative rupture was numerically more frequent in curved anatomy, whereas multiple-clip use was similar. Conclusions: Curved M1 morphology was associated with greater temporary clipping use during MCA aneurysm clipping. Temporary clipping was interpreted as a technical marker of proximal control demand rather than as a complication. These single-center, unadjusted findings are hypothesis-generating, do not establish causality, and require external validation. The study was not designed to assess postoperative clinical or angiographic outcomes.

BACKGROUND AND OBJECTIVES: Pediatric brain arteriovenous malformations (AVMs) have higher recurrence rates than adult lesions, yet the long-term durability of transvenous embolization (TVE) in children remains poorly defined. We therefore evaluated long-term clinical and angiographic outcomes after curative TVE for ruptured pediatric AVMs. METHODS: This multicenter retrospective cohort comprised 12 pediatric patients (older than 18 years) treated with curative TVE from 2012 to 2025. Angiographic cure was defined as complete obliteration on 6-month digital subtraction angiography (DSA). Long-term surveillance included annual MRI/magnetic resonance angiography, with confirmatory DSA if recurrence was suspected. RESULTS: Complete angiographic obliteration was achieved in all patients at 6 months. Over a mean follow-up of 103 ± 39 months, no delayed hemorrhages occurred. Late AVM recurrence was identified in 2 patients (17%) after documented angiographic cure and was detected only on delayed imaging surveillance. One recurrence involved a lesion with previous superficial venous drainage, whereas the other occurred in a lesion with deep venous drainage. Both were successfully retreated endovascularly without added morbidity. CONCLUSION: TVE provides durable hemorrhage control in selected pediatric AVMs; however, late recurrence may still occur despite early angiographic cure. These findings confirm that TVE is no exception to the well-documented late recurrence rate of pediatric AVMs across all treatment modalities, reinforcing that prolonged imaging surveillance is as essential after TVE as after microsurgery or radiosurgery.

Alpha 1-antitrypsin (A1AT) helps maintain vascular-wall integrity, but its role in the formation and rupture of intracranial aneurysms is unclear. To compare A1AT levels between patients with ruptured and unruptured intracranial aneurysms and assess the associations with vasospasm and functional outcomes. We retrospectively analyzed the medical records of patients who had serum A1AT levels measured between 2018 and 2022 during routine outpatient evaluations. The sample included 233 patients with unruptured intracranial aneurysms, 114 with ruptured aneurysms, and 55 controls with intracranial arteriovenous malformations (AVMs), but without aneurysms. The mean A1AT levels were 134.9 ± 23.3 mg/dL in the unruptured group, 132.1 ± 20.3 mg/dL in the ruptured group, and 132 ± 19 mg/dL in the controls. The A1AT levels did not exhibit a significant association with the presence of intracranial aneurysms when compared to the levels of the control group (odds ratio [OR]: 1.07; 95%CI: 0.93-1.25; p = 0.40) or with aneurysm rupture (OR: 0.94; 95%CI: 0.84-1.04; p = 0.27) when compared to the levels of the unruptured group. Similarly, there were no statistically significant correlations between the protein concentrations and vasospasm (OR: 0.94; 95%CI: 0.69-1.22; p = 0.67) or functional outcomes defined by a score ≤ 2 on the modified Rankin Scale (OR: 0.77; 95%CI: 0.51-1.27; p = 0.23). The A1AT levels did not differ between the groups with ruptured and unruptured aneurysms, neither were they associated with vasospasm nor functional outcomes.

Background: Posttraumatic stress disorder (PTSD) is increasingly recognized as a sequela of subarachnoid hemorrhage (SAH); however, its prevalence and clinical correlates remain understudied. This study assessed the prevalence of PTSD symptoms and associated psychological symptoms among survivors of SAH. Methods: A 6-month prospective analysis of 45 SAH survivors from the GASH trial (NCT03569540) was conducted. PTSD symptoms were evaluated using the Screen for Posttraumatic Stress Symptoms (SPTSS), with concurrent assessment of anxiety/depression (Hospital Anxiety and Depression Scale, HADS) and functional outcomes (modified Rankin Scale). Results: At six months post-SAH, 55,56% ( n = 25) of patients met the SPTSS criteria for significant PTSD symptoms. Avoidance (mean score: 23,36 ± 11,75) and hyperarousal (19,52 ± 10,22) were the most prominent symptoms. PTSD was strongly associated with concurrent anxiety (HADS-A ≥ 7; p < 0.001) and depression (HADS-D ≥ 6; p < 0.001). Conclusion: Nearly half of SAH survivors screened positive for PTSD-related symptoms within six months, with avoidance behaviors predominating. The high comorbidity of anxiety and depression underscores the necessity for integrated neuropsychiatric care in SAH follow-up protocols.