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Chronic migraine refractory to medical treatment represents a common debilitating primary neurovascular disorder associated with great disability, high financial costs, reduced rates of productivity and impaired health-related quality of life. To demonstrate the feasibility of scalp (trigger areas) nerve decompression as a treatment alternative in the management of refractory CM patients From January 2005 to January 2020, we retrospectively collected data of 154 patients diagnosed with chronic migraine that underwent trigger site nerve decompression. These trigger areas were divided according the nerve compromise as frontal (supraorbital nerve), temporal (auriculotemporal nerve), occipital (greater occipital nerve). Following extensive clinical evaluation, the surgical treatment was performed after under local anesthesia and required the release of the affected nerve from surrounding connective tissue adhesions, and vascular conflicts. Of the total amount of patients, 91 (59.09%) patients underwent auriculotemporal nerve decompression, 27 (13.63%) cases supraorbital nerve decompression, 15 (9.74%) patients greater occipital nerve decompression, and the remaining 21 (13.63%) patients had more than one procedure of nerve decompression. At 1-year follow or latest follow-up, 96 (62.2%) patients were considered as cured, 29 cases (18.83%) reported improvement of their symptoms, 21 (13.64%) patients considered only a partial symptomatic remission and 5 (3.25%) patients reported no change or failed surgical treatment. Nerve decompression of trigger site areas (frontal, temporal, occipital) by removal of tissue, muscles and vessels in patients with medically refractory CM is a feasible alternative treatment modality with a high success of up to 80.5% •Refractory chronic migraine is a common debilitating disorder.•Trigger areas refer to the affected area and its anatomical distribution.•Affected triggered areas are frontal, temporal and occipital.•Nerve decompression requires removal of tissue adhesions, muscles and vessels compromising the respective nerve.

Background/Objectives: Headaches in Moyamoya angiopathy are common but poorly understood. We aimed to investigate if headaches in Moyamoya angiopathy improve after revascularization surgery and whether this is associated with improvement in cerebrovascular reactivity on MRI (CVR-MRI). Methods: We included consecutive adult patients with Moyamoya angiopathy who had chart data on headaches, CVR-MRI, and underwent extracranial–intracranial bypass surgery between January 2010 and September 2022 at a tertiary neurovascular referral center. Clinical and CVR-MR imaging data of all patients were collected through systematic chart review, complemented by standard-of-care headache questionnaires from patients who were operated between 2018 and 2022. We evaluated headache features and explored the association between headaches and CVR before and after revascularization surgery. Results: Fifty-nine patients were included (mean age 47 ± 14 years, 43 females (73%)); among them, 41/59 (69%) reported headaches pre-surgery. Headache improved in 28/41 (68%) patients after revascularization surgery with a reduction in pain severity (median VAS-score from 5/10 to 2.5/10; p = 0.002), analgesic use (from 84% to 40%; p = 0.007), and sick leave (from 60% to 16%; p < 0.001). Improvement in headaches was associated with improvement in CVR (OR 5.3; 95% CI: 1.2–23.5) and sick leave reduction (OR 1.4; 95% CI: 1.6–121.4). Conclusions: Headaches in Moyamoya angiopathy are common and disabling. They may improve in most patients after revascularization surgery and seem to be associated with improvement in CVR, supporting the hypothesis of a potential vascular origin of the headaches.

The etiology of moyamoya disease (MMD) remains unknown. The main pathological finding is fibrocellular thickening of the intima, irregular undulation of the internal elastic lamina affecting the distal portions of the internal carotid artery and A1 and M1 segments. Our aim is to describe the histological and electron microscope ultrastructural characteristics of cortical MMD vessels (middle cerebral artery) in hemorrhagic and ischemic presentation along different Suzuki stages. From January 2022 to December 2022, we collected clinical and radiological data of 310 patients with MMD, among them we identified 52 patients that underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass. We collected arterial walls (excisional arteriotomy) of the recipient arteries specifically, M3 or M4 segments of the MCA. Observations and micrographs were captured utilizing an HT7700 transmission electron microscope. MMD patients exhibit severe internal elastic lamina (IEL) changes as compared to patients with intracranial atherosclerosis. Hemorrhagic MMD presentation showed a higher score of IEL ruptured when comparing to ischemic presentation. Endothelial cells in hemorrhagic MMD showed more significant contraction compared to those in ischemic moyamoya disease. Hemorrhagic and ischemic MMD patients showed no statistically significant differences when correlated to Suzuki stages and cerebral perfusion. MMD patients exhibit IEL changes and endothelial cells contraction extending into the distal segments of the middle cerebral artery. Hemorrhagic MMD presentation has higher IEL rupture score making these patients probably more susceptible for hemorrhage. This study provides an inside of the extension of MMD into the brain surface.

The lateral supraorbital (LSO) approach is a minimally invasive craniotomy widely used in the surgical treatment of intracranial aneurysms (IAs). A protective bypass is considered a safety measure in high-risk and complex clipping procedures to maintain distal cerebral flow. However, the protective bypass has so far only been applied through a pterional or larger craniotomy. We aimed to describe the characteristics of the superficial temporal artery to middle cerebral artery (STA-MCA) bypass through the LSO craniotomy to treat complex IAs. We retrospectively identified six patients with complex IAs who underwent clipping and a protective STA-MCA bypass through the LSO approach between January 2016 and December 2020. The STA donor artery was harvested through the same curvilinear skin incision with a small extension, and it was anastomosed to the opercular segment of the MCA. Subsequently, aneurysm clipping followed standardized steps. Anastomosis was successful in all patients. Despite requiring temporary occlusion of the parent artery, all aneurysms were successfully clipped without any neurological deterioration. A protective STA-MCA bypass is feasible through the LSO approach with certain technical modifications. This technique helps protect distal cerebral flow for safe clip placement in the treatment of complex IAs with the associated benefits of a less invasive craniotomy. •This study highlights the application of protective bypass through the lateral supraorbital craniotomy.•We present the characteristics of the procedure and delineate the technical aspects.•All bypass grafts were successfully anastomosed in our case series of complex intracranial aneurysms.•STA-MCA bypass is feasible through the lateral supraorbital approach with certain technical modifications.

Background: Anterior choroidal artery (AChoA) aneurysms pose a challenge for both endovascular and clipping procedures. The eloquent territory supplied by the parent vessel has limited collateralization and its compromise can lead to significant morbidity. This study aims to analyze the clinical outcomes and procedure-related complications of clipping and endovascular treatment of AChoA aneurysms to aid physician decision making. Methods: Thirty-two ruptured and unruptured AChoA aneurysms that underwent catheter angiography at a single neurovascular center between January 2000 and December 2023 were included. Either conservative management, clipping, and/or endovascular treatment were performed. Clinical outcomes and complications were analyzed retrospectively. Results: Twenty-four endovascular treatments and seven clipping procedures were included. Of the total 24 endovascular procedures, 46% were primary coiling, 25% were balloon-assisted coiling, 13% were flow diverting stent, 8% were combined balloon-assisted coiling and flow diverting stent, and 8% were combined balloon-assisted and stent-assisted coiling. There was no procedure-related mortality in both groups. No intra- or post-procedural ruptures/re-ruptures occurred during follow-up in both endovascular and clipping cohorts. AChoA territory infarcts occurred in 4% of the endovascular and 29% of the clipping cohorts. Other thromboembolic complications occurred in 4% of the endovascular cohort. The recurrence rate requiring retreatment was 12.5% for the endovascular and 43% for the clipping cohort. A favorable clinical outcome (mRS ≤ 2) was 78% for the endovascular cohort and 67% for the clipping cohort. Conclusions: Endovascular and clipping outcomes align with prior studies, with endovascular showing a favorable safety profile. Both approaches are viable, though they present distinct risks and advantages.

Abstract BACKGROUND Paraclinoid aneurysms are among the most challenging aneurysms to treat. Computed tomography (CT) angiography helps in evaluating the radiological characteristics of these aneurysms next to bony structures. OBJECTIVE To present the CT angiography characteristics of paraclinoid aneurysms in order to better understand such pathology. METHODS The study examined CT angiography-based anatomical characteristics obtained retrospectively from 136 patients with 144 paraclinoid aneurysms selected from single-defined catchment populations in Finland. We examined the diameters of the parent artery (internal carotid artery), the location of the aneurysm, its dimensions (width, height, neck), and aneurysm wall irregularity. RESULTS We analyzed 144 paraclinoid aneurysms in 136 patients admitted to the hospital during 2000-2014. Multivariable analysis reveals that rupture aneurysms have the following radiological features: aneurysm larger than 5 mm in diameter (P = .006), irregular wall (P = .046), superior location, larger aspect ratio (P = .039), and neck wider than parent artery (P < .001). CONCLUSION Smaller diameter of the internal carotid artery and superior location, as well as a large and irregular aneurysm wall, are radiological characteristics of ruptured paraclinoid aneurysms, which CT angiography can measure easily.

Background Ischemic stroke (IS) is a leading cause of death and disability worldwide, but traditional risk factors do not fully explain its pathophysiology. Neuronal death in IS is influenced by multiple pathways, including sphingolipid metabolism, which plays a significant role in neuronal function and survival. Ceramides, key sphingolipid molecules, are involved in various neuronal processes, including cell death. This study aims to explore the relationship between sphingolipid metabolism and neuron death in IS using bulk and single‐cell transcriptomics. Methods We obtained sphingolipid metabolism gene sets from the GeneCard database and analyzed differential gene expression in IS datasets from the GEO database, including human peripheral blood bulk data (GSE16561) and MCAO mouse peripheral blood scRNA sequencing data (GSE225948). Gene set enrichment analysis (GSEA), immune infiltration analysis using CIBERSORT, and protein‐protein interaction network construction were performed. Single‐cell RNA sequencing (scRNA‐seq) data were used to identify key genes and analyze cellular heterogeneity, differentiation, and cell interactions. In vivo validation of key gene expression was conducted in MCAO rats. Results GSEA revealed significant changes in the sphingolipid metabolism pathway in IS patients. Immune infiltration analysis showed altered immune cell profiles, with decreases in CD8 T cells and increases in monocytes and neutrophils. Enrichment analysis of sphingolipid metabolism‐related genes highlighted pathways such as the sphingolipid signaling pathway and ceramide metabolism. Protein‐protein interaction network analysis identified 19 key genes linked to sphingolipid metabolism and neuron death. scRNA‐seq analysis revealed significant changes in sphingolipid metabolism in monocytes and neutrophils, with the App gene showing notable differential expression. Pseudotime analysis suggested diverse differentiation trajectories in monocytes, and cell interaction analysis indicated potential communication between monocytes and B cells. In vivo validation confirmed higher App gene expression in MCAO rats compared to sham controls. Conclusion This study provides comprehensive insights into the role of sphingolipid metabolism in ischemic stroke, identifying key genes and cellular mechanisms involved in neuron death. The findings suggest that sphingolipid metabolism, particularly through the App gene, may be a potential therapeutic target for IS. Further exploration of the molecular mechanisms and cellular interactions involving sphingolipids could lead to novel therapeutic strategies for ischemic stroke. First, we evaluated of differences in sphingolipid metabolism using peripheral blood samples from IS patients and healthy controls. Then, we identify the hub genes linking sphingolipid metabolism and neuronal death via modular analysis of protein‐protein interaction networks. Next, we verify the expression differences in hub genes linking sphingolipid metabolism and neuronal death using scRNA and evaluate the sphingolipid metabolism in cells. Finally, we explore the App gene function and validate the expression of the App gene in vivo.

Introduction: Posterior cerebral artery (PCA) aneurysms represent up to 1% of all cerebral aneurysms. P1-P2 perforator aneurysms are thought to be even less prevalent and often require complex treatment strategies due to their anatomical and morphological characteristics, with risk of a perforator infarct. We studied the treatment of P1-P2 perforator aneurysms in a single-center cohort from a high-volume tertiary center, reporting clinical and anatomical characteristics, treatment strategies, and outcomes. Methods: A retrospective analysis of adult patients with a P1-P2 perforator aneurysm who presented at our institution between January 2000 and January 2023 was performed. The patients were analyzed for demographics, clinical presentation, imaging findings, treatment techniques, outcomes, and complications. Subgroup analyses between ruptured versus non-ruptured cases were included. Results: Out of 2733 patients with a cerebral aneurysm, 14 patients (0.5%) presented with a P1-P2 perforator aneurysm. All six patients with a ruptured aneurysm were treated by endovascular coiling, of whom one patient (16.7%) required surgical clipping of a recurrence. One out of eight (12.5%) patients with unruptured aneurysms was treated by surgical clipping. P1-P2 perforator aneurysms predominantly affected middle-aged individuals (median 59.5 years), with 10/14 (71.4%) being female. Endovascular coiling was the primary treatment modality overall, yielding favorable technical outcomes, however, it was complicated by a perforator infarct in two patients (33.3%) without new permanent morbidity or mortality secondary to treatment. Conclusions: P1-P2 perforator aneurysms are a rare subtype of intracranial aneurysm. Endovascular coiling could present an effective treatment modality; however, care should be taken for ischemic complications in the dependent perforator territory. Larger studies are required to provide more insights.

Background  Cerebral venous thrombosis (CVT) is a rare cerebrovascular disorder, comprising <1% of all strokes. The incidence of CVT is higher in females but a small number of cases suggest that men have a higher risk for CVT in high elevation. The aim of this retrospective cohort study is to investigate this gender-related relationship and to describe the baseline characteristics and treatment outcomes of patients who suffered CVT at high altitude in eastern Nepal. Methods  We conducted a retrospective analysis of 21 consecutive patients with CVT at a tertiary care center in Nepal from July 2017 to January 2018. Clinical data, radiologic characteristics, therapeutic strategies, and outcomes were analyzed. The Glasgow Outcome Scale (GOS) at discharge was reported for each patient.  Result The study cohort comprised 21 patients (76% males) with a mean of 56 years. Medical comorbidities included hypertension (76%) and diabetes mellitus (57%). All patients received low-molecular-weight heparin therapy (LMWH). Eight patients (38%) underwent decompressive craniectomy while the remaining 13 (62%) were treated with medical therapy alone. The GOS at discharge was 5 in 57%, 2-4 in 33%, and 1 in 10%. Conclusion  In our series, men were found to have a higher risk for CVT at high altitude. The reversal in the gender ratio could be related to elevation, but could also be confounded by alcoholism. Increasingly sophisticated imaging techniques, such as computed tomography venography (CTV) and magnetic resonance venography (MRV), have facilitated the diagnosis of CVT. LMWH is a safe and easily accessible treatment option, especially in developing countries. Further studies are needed to assess the incidence and prevalence of CVT in the developing world, to establish the gender-related trends.

Tissue samples of arteriovenous malformations of the brain were obtained from 72 patients. The majority of the samples had an activating mutation in KRAS, a gene previously implicated in tumorigenesis.