Kiarash Ferdowssian

Background: Sex differences in cerebrovascular disease are established determinants of outcome in acute stroke care and vascular interventions, but evidence in cerebrovascular bypass surgery remains limited. This study examined whether biological sex was associated with outcome after superficial temporal artery to middle cerebral artery (STA-MCA) bypass in patients with atherosclerotic cerebrovascular disease (ACVD). Methods: We retrospectively screened adults undergoing extracranial-to-intracranial (EC-IC) bypass (2012–2025) and included ACVD patients treated by STA-MCA bypass with available follow-up. The primary outcome was modified Rankin Scale (mRS) at latest follow-up, analyzed using proportional odds regression. Multivariable models adjusted for age, preoperative mRS, and vascular comorbidities. Cerebrovascular reserve capacity (CVRC) was analyzed in a subgroup. Results: A total of 140 patients (30.7% female) were included. Disease morphology varied by sex, with more multivessel (65.1% vs. 47.4%) and stenotic disease (39.5% vs. 20.6%) in females and more isolated internal carotid artery occlusion in males (43.3% vs. 16.3%). The 30-day risk of symptomatic ischemic stroke was higher in females than in males (9.3% vs. 1.0%). A similar pattern was observed at follow-up (median 13.5 months), with ischemic events predominating in females (16.3% vs. 7.2%) and hemorrhagic events occurring exclusively in males (5.2%). Female sex was independently associated with worse functional outcome (OR 2.59, 95% CI 1.28–5.30, p=0.008). Preoperative mRS was the strongest determinant of outcome (OR 4.30, 95% CI 3.07–6.18, p<0.001). Adjusted analysis detected no significant association between CVRC and outcome (OR 0.80, 95% CI 0.24–2.70, p=0.721). Conclusions: Female sex was independently associated with worse functional outcome after STA-MCA bypass, independent of preoperative functional status, hemodynamic impairment and cardiovascular comorbidities. These findings identify sex as a clinically relevant determinant of outcome in cerebrovascular bypass surgery and should be considered in future risk stratification and trial design.

Background: Evidence regarding the clinical course of unruptured giant intracranial aneurysms (GIAs) after conservative management (CON), microsurgical treatment (SURG) or endovascular treatment (EVT) remains limited. We aimed to assess mortality, functional outcome, symptom course and retreatment rates after different management strategies. Methods: In this prospective, multinational registry, patients with unruptured GIAs treated at 37 neurovascular centres between 2008 and 2018 were included. Outcomes after CON, EVT or SURG were analysed with standardised 3-year follow-up. The study is registered at ClinicalTrials.gov. Results: We included 339 patients of whom 22.7% received CON, 42.8% EVT and 34.5% SURG. Three-year survival was 64.0% (95% CI 53.73% to 76.20%) in the CON group, 82.0% (95% CI 75.42% to 89.17%) in the EVT group and 93.5% (95% CI 88.91% to 98.28%) in the SURG group (p<0.001). Favourable neurological outcome (modified Rankin Scale 0–2) declined to 53.0%, 66.9% and 75.7% in the CON, EVT and SURG groups, respectively (p<0.01). Symptom improvement at 3 years occurred in 10.3% of CON, 22.1% of EVT and 11.1% of SURG patients, while deterioration was observed in 7.7%, 8.5% and 15.8%, respectively. Retreatment was required in 22.8% of EVT patients and 6.2% of SURG patients (p<0.01). Conclusions: EVT and SURG were associated with significantly improved survival and functional outcomes compared with conservative management of unruptured GIAs. In patients eligible for intervention, both treatment modalities represent reasonable and effective options, with a high proportion of patients achieving favourable clinical outcomes. Trial registration number: NCT02066493 .

BACKGROUND AND OBJECTIVES: Evidence on how different antithrombotic therapies influence microsurgical evacuation efficacy in spontaneous intracerebral hemorrhage (ICH) is limited. Antithrombotic agents may increase hematoma volume and impact postoperative outcomes, complicating surgical management. As growing evidence supports surgical ICH evacuation, understanding the role of antithrombotics and emergency reversal strategies is critical. The aim of this study was a comparative overview on how common types of antithrombotic therapy influence radiographic and clinical outcomes in surgically treated ICH. METHODS: In this retrospective study, we included consecutive patients who underwent microsurgical hematoma evacuation for supratentorial ICH between 2008 and 2022. Patient characteristics, antithrombotic therapy, reversal strategies, neuroimaging, and 12-month functional outcome (modified Rankin Scale) were reviewed. Preoperative antiplatelet therapy (APT), vitamin K antagonists, direct oral anticoagulants, and combined antiplatelet/anticoagulant therapy (Comb) was compared with no antithrombotic medication. Multivariable regression models were used to analyze the association between antithrombotic therapy, radiographic, and clinical outcomes. RESULTS: Overall, we included 232 patients with supratentorial ICH (APT: 53, vitamin K antagonists: 29, direct oral anticoagulant: 13, Comb: 17). Patients with any type of antithrombotic therapy presented with larger absolute preoperative hematoma volumes than patients without prior antithrombotic medication. Combined antiplatelet/anticoagulant therapy affected preoperative ICH volume to the greatest extent (volume difference: 14.9 mL; 95% CI: 0.9, 29.0). APT was associated with a 1.4-fold increase in relative postoperative ICH volume (95% CI: 0.9, 2.1), while combined therapy was associated with a 2.1-fold increase (95% CI: 1.1, 4.0). Unfavorable outcome (modified Rankin Scale ≥4) affected 73.5% of patients and was linked to larger preoperative hematomas (63 mL vs 49 mL) and higher relative postoperative hematoma volume (13.7% vs 7.5%). CONCLUSION: Despite preoperative emergency reversal, antithrombotics contributed to higher hematoma volumes, poorer microsurgical evacuation efficacy and worse functional outcome. Particularly for patients receiving APT, the findings underline the importance of optimizing antithrombotic reversal strategies.