Introduction: Chronic occlusion of the ICA (COICA) is an important cause of ischemic strokes. Evidence has showed that medical management (MM) alone is not sufficient for prevention of ischemic events. Carotid occlusion endovascular revascularization & stenting (COERS) is a promising technique, yet its safety and superiority to MM remain unclear. Objective: To pool and compare rates of safety and efficacy outcomes of COERS versus MM of COICA. Methods: We conducted a systematic search in Embase, Medline, and Web of Science for studies reporting short and long-term outcomes of symptomatic COICA patients who received MM and/or COERS. Main efficacy outcomes were successful recanalization and long-term recurrence of ischemic events. Safety outcomes for COERS were periprocedural (<30 days) events. We performed a meta-analysis of proportions for MM and COERS groups, using GLMM transformation and a random-effects model. Results: 11 studies contained data of COICA patients undergoing COERS, 3 studies of patients who received only MM, and 2 studies compared both arms; they provided data for 513 and 313 patients in the COERS and MM groups, respectively. The pooled recanalization rate after treatment with COERS was 75% (95% CI 0.67-0.82, PI 0.49-0.94, I 2 64%). Recurrence rates of ischemic events at long-term follow-up were 19% (95% CI 0.15-0.25, PI 0.11-0.32, I 2 25%) with MM, and 11% (95% CI 0.07-0.19, PI 0.02-0.42, I 2 2%) after COERS; comparison meta-analysis showed a similar non-significant trend (MM:24% vs. COERS:13%, OR 0.52, 95% CI 0.17-1.59, I 2 0%). The rate of periprocedural events in the COERS group were 2.3% (95% CI 0.012-0.045, I 2 0%) for stroke/TIA, and 2.1% (95% CI 0.011-0.038, I 2 0%) for any ICH. Conclusion: COERS is a feasible technique and a safe strategy for maximizing secondary stroke prevention for the treatment of symptomatic COICA. Still, further prospective trials to better define safety and efficacy boundaries are needed before starting a RCT.

Introduction : The PHASES score was developed to predict the 5‐year risk of rupture for intracranial aneurysms (IAs). However, only populations from North America, Europe, and Japan were included in the original study. As the population of origin is an item in the score, it has yet to be applied in a Latin American population. We aimed to determine the best approximation to employ this model in this previously unstudied population. Methods : We extracted the data of 848 Peruvian patients with ruptured (n = 486) and unruptured (n = 362) IAs from 2010 to 2020. According to the PHASES score, the North American and European (other than Finish), Japanese, and Finnish populations are rated with 0, 3 and 5 points, respectively. Therefore, we developed three PHASES‐derived models in which our Peruvian population is rated with 0 (Model A), 3 (Model B), and 5 (Model C) points. We compared the observed probability of each model to the expected probability reported by the original PHASES score using a scatter plot. We then compared the goodness‐of‐fit of each model using the Hosmer‐Lemeshow test in STATA version 14. Results : Nineteen percent of the patients were female. Hypertension was found in 34% of patients and 15% were >70 years. Fifty‐four percent of the aneurysms were smaller than 7mm, 25% ranged between 7 and 9.9mm, 18% were between 10 and 19.9mm, and 3% were larger than 20mm. Previous subarachnoid hemorrhage was found in 4%. The location of the aneurysms was the internal carotid artery in 4%, the middle cerebral artery in 4%, and arteries of the anterior and posterior circulation (including the anterior and posterior communicating artery) in 92%. When Model A was applied, 63% of the patients among the ruptured subgroup have an estimated 5‐year risk of rupture of <3% while 77% of the patients have an estimated risk of <3% in the unruptured subgroup. When Model B was applied, 30% of the patients among the ruptured subgroup have an estimated 5‐year risk of rupture of <3% and 42% of patients among the unruptured subgroup have an estimated risk of <3%. When Model C was applied, 96% of the patients among the ruptured subgroup have an estimated 5‐year risk of rupture of >3% while in the unruptured subgroup an estimated risk of <3% was observed only in 4% of the patients. When comparing observed to expected frequencies, model B presented a better calibration to the values reported by the original PHASES score. Additionally, the Hosmer‐Lemeshow showed Model B to have improved goodness‐of‐fit, compared to other models, although all presented adequate fit. Conclusions : We found that rating the Peruvian population with 3 points was the best approximation to the estimated risk calculated by the PHASES score to predict the 5‐year risk of rupture for IAs.

Introduction : The Population, Hypertension, Age, Size, Earlier Subarachnoid Hemorrhage (SAH), Site (PHASES) score was developed in North America, Europe, and Japan and it is a widely used model in day‐to‐day clinical practice for intracranial aneurysm (IA) rupture risk stratification. Here, we aimed to determine the predictors of aneurysm rupture and assess the components of the PHASES score in a Latin American population. Methods : Four hundred eighty‐six Peruvian patients presented at our institution with ruptured IAs between 2010 and 2020. We retrospectively collected the following variables: age, sex, a hypertension or diabetes mellitus history, previous SAH, the aneurysm size in millimeters (<5, 5–6.9, 7–9.9, 10–19.9, and ≥20), aneurysm morphology (saccular or non‐saccular), neck diameter (≤4 and >4), presence of a pseudoaneurysm, and aneurysm location. We then performed two separate multivariate analysis. For the first one, we included variables using a stepwise approach with a cut‐off p‐value of 0.2 in univariate logistic regression. For the second one, we evaluated the PHASES score components. A p‐value of 0.05 was considered statistically significant. Results : The median age was 56 years old, and 114 females were included. One hundred seventy‐five patients had a hypertension history, 21 had a diabetes history, and 11 had a previous SAH. Seventy‐eight patients had an aneurysm with <5mm, 118 with 5–6.9mm, 125 with 7–9.9mm, 85 with 10–19.9, and 10 patients with an aneurysm >20mm. There were 372 patients with a saccular aneurysm and an associated pseudoaneurysm was found in 197 patients. The most common location was posterior communicating artery (n = 219), followed by the anterior cerebral artery (n = 125), the middle cerebral artery (MCA) (n = 58), branches from the posterior circulation (n = 33), and finally by a paraclinoid aneurysm (n = 33). In our initial multivariate analysis, only the presence of an associated pseudoaneurysm was an independent predictor for aneurysm rupture (OR 7.93; 95% CI 3.45 – 18.25). An age >70 years (OR 1.12; 95% CI 0.3 – 4.12), the male sex (OR 1.39; 95% CI 0.54 – 3.62), a hypertension history (OR 1.14; 95% CI 0.53 – 2.44), a size of 10–20mm (OR 1.46; 95% CI 0.46‐ 4.64), and location in the MCA (OR 1.07; 95% CI 0.25 – 4.57) also predicted a higher rupture risk but without statistical significance. When we performed a multivariate logistic regression of the factors making up the PHASES score, we found that only the age (OR 1.79; 95% CI 1.11‐ 2.88) and a hypertension history (OR 1.61; 95% CI 1.14 – 2.27) were independent predictors of aneurysm rupture. Conclusions : Based on our findings and its limitations, we observed that the presence of an associated pseudoaneurysm was a predictor for aneurysm rupture. Moreover, we found that only two of the five components of the PHASES score were predictors of the event in our population: the age and a hypertension history. Therefore, new research should be carried out in the Latin American population to establish predictors for the development of clinical predictive models in this field.

Introduction : Grade III Spetzler‐Martin (SM) brain arteriovenous malformations (AVMs) presents high variability in terms of size (S), angioarchitecture, flow characteristics, a frequent involvement of eloquent areas (E), and presence of central venous drainage (V). Therefore, this specific group fall into a gray zone in which the best treatment option is not stablished. Here, we aimed to assess the safety and efficacy of intent‐to‐cure embolization in pediatric grade III AVM management at two institutions. Methods : Pediatric patients (<18 years of age) with grade III AVMs treated with intent‐to‐cure embolization in two institutions between 2010 and 2019 were included. These two centers primarily perform endovascular treatment with intention to cure, which means that they attempt to occlude the maximal volume of nidus in a single session. Then, if the first session is not curative or the result is partial, a subsequent embolization is planned to completely occlude the AVM nidus. The clinical features, obliteration rates, and intraoperative complications were retrospectively collected from the clinical records. We categorized the AVMs based by the SM features: Type 1 = S1E1V1, Type 2 = S2E1V0, Type 3 = S2E0V1, and Type 4 = S3E0V0. The Institutional Review Boards approved this study. Results : Twenty‐seven children (19 females; mean age: 12 years, standard deviation: 3.9 years) with grade III AVMs underwent 47 embolization sessions. The most common presentation was intracranial hemorrhage (66%), and the majority (48%) were deep lesions (basal ganglia, corpus callosum, ventricle). The size of AVMs was <3 cm in 16 patients, 3 – 6 cm in 9, and >6 cm in 2; 21 AVMs were in eloquent cortex and 20 had deep venous drainage. The AVMs were Type 1 in 16 cases, Type 2 in 5, Type 3 in 4, and Type 4 in 2. Complete obliteration was achieved in 12 patients (44%), including 37% of AVMs exclusions after a single session. Eight (30%) patients had multiple embolizations. The AVM was obliterated after a single session in 10 patients (63%) with Type 1 AVMs (small lesions). The most common embolic agent employed was Squid (17/44), followed by Onyx (14/44) and Histoacryl (6/44). Intraoperative complications were reported in 5 (4 microperforations, 1 microcatheter rupture) out of 47 sessions (11%), with only one complication in the large AVM group (Types 2 ‐ 4). Deaths were not reported. Conclusions : Endovascular treatment with intent‐to‐cure of grade III SM AVMs in the pediatric population has demonstrated adequate complete obliteration rates with acceptable intraoperative complication rates. Therefore, long‐term follow‐up in this population is necessary in order to assess the real impact of embolization in terms of cure rates.