Neurosurgery
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Flow diverters (FDs) have changed the management of brain aneurysms; not only for complex aneurysms (giant, fusiform and blister) refractory to conventional therapies, but also for unruptured lesions previously managed by traditional surgical or coil-based endovascular methods. Since 2011 when the PipelineTM Embolization Device (Medtronic) was cleared by the Food and Drug Administration for adults with large or giant wide-neck intracranial aneurysms of the internal carotid artery proximal to the posterior communicating segment, the role of flow diversion for aneurysm treatment has expanded-supported by favorably low complication and high cure rates compared with alternative treatments. Here we review the key clinical trials and the long term outcomes that have demonstrated safety and efficacy of minimized porosity endoluminal devices in the treatment of cerebral aneurysms.
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A better understanding of differences in outcomes of mechanical thrombectomy performed within and outside clinical trials will assist in optimal implementation of the procedure for acute ischemic stroke patients in general practice. ⋯ Mechanical thrombectomy performed as part of clinical trials was associated with lower rates of in-hospital mortality and lower rates of moderate to severe disability compared with those performed outside clinical trials.
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Posterior circulation aneurysms are often associated with a higher risk of rupture and compressive symptoms compared to their anterior circulation counterpart. Due to high morbidity and mortality associated with microsurgical treatment of those aneurysms, endovascular therapy gained ascendance as the preferred method of treatment. ⋯ While treatment of saccular and dissecting aneurysms is often associated with comparatively good outcomes, fusiform and dolichoectatic aneurysms should be carefully selected prior to treatment to avoid devastating thromboembolic complications. Occlusion of covered posterior circulation branches showed no correlation with ischemic complications, and appropriate antiplatelet regimen and switching Clopidogrel nonresponders to different antiplatelet agents were associated with lower complication rates following flow diversion of posterior circulation aneurysms.
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Endovascular thrombectomy is currently the standard of care for acute ischemic stroke (AIS). Although earlier trials on endovascular thrombectomy were performed using stent retrievers, recently completed the contact aspiration vs stent retriever for successful revascularization (ASTER) and a comparison of direct aspiration versus stent retriever as a first approach (COMPASS) trials have shown the noninferiority of direct aspiration. ⋯ Refinement of ADAPT thrombectomy by incorporating reperfusion catheters with higher inner diameters and thus higher aspiration forces is associated with better outcomes, shorter procedure times, and lower likelihood of using additional devices without impacting complication rates.
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Admitting patients to an intensive care or medium care unit (ICU/MCU) after adult supratentorial tumor craniotomy remains common practice even though some studies have suggested lower level care is sufficient for selected patients. We have introduced a "no ICU, unless" policy for tumor craniotomy patients. ⋯ Changing our policy from "ICU, unless" to "no ICU, unless" reduced complication rates and length of stay in the hospital while keeping patients satisfied. Hospital costs related to the admission have been significantly reduced by the new policy.