Apraxia of eyelid opening (AEO) is a rare neurological disorder characterized by an inability to voluntarily initiate eyelid elevation despite preserved eyelid musculature and strength. Our case involved a 71-year-old female pianist who developed AEO following a ruptured basilar artery tip aneurysm complicated by right thalamic infarction, midbrain edema, intraventricular hemorrhage, and subarachnoid hemorrhage. During inpatient rehabilitation, examination demonstrated an inability to initiate the act of opening her eyes after closure despite preserved eyelid strength and the absence of blepharospasm or ptosis. This was consistent with AEO, which is primarily a clinical diagnosis. She also exhibited aphasia, limb apraxia, apraxia of speech, left hemineglect, and incomplete quadriparesis. Bromocriptine 2.5 mg nightly was initiated, off-label, to target her neglect and apraxia. Within three days, she regained the ability to voluntarily open and close her eyes. Concurrent improvements were observed in limb apraxia and apraxia of speech, allowing greater participation in rehabilitation, including resumption of piano playing. She continued to improve functionally and was ultimately discharged home with her family. Given the limited evidence supporting pharmacologic management of AEO, bromocriptine may represent a potential therapeutic option in appropriately selected patients with supranuclear eyelid opening dysfunction. Additional case series and prospective studies are needed to better define its efficacy, safety, and role in the management of AEO.

Caroticoclinoid foramen (CCF) is an inconsistent structure formed due to the ossification of either the caroticoclinoid ligament or a dural fold extending between the anterior and middle clinoid processes of the sphenoid bone during development. For the surgical procedure of anterior clinoidectomy in case of a paraclinoid aneurysm of the internal carotid artery (ICA), the presence of a bony CCF may lead to heavy haemorrhage and other complications like CSF rhinorrhea, injury of adjacent structures like the optic nerve and oculomotor nerve. We present a case of incomplete bilateral caroticoclinoid foramina in a dry female human skull of unknown age, with no structural deformity. The diameter of the incomplete CCF on the right side measured 3.9 mm, while that of the left side was 4 mm. The interspicular distance between the opposing bony spurs was estimated to be 1.1 mm on the right side and 0.8 mm on the left side. The ICA, while traversing through the cavernous sinus, passes medial to the anterior clinoid process. Therefore, neurosurgeries approaching the anterior clinoid process are likely to damage the ICA and surrounding intracranial structures if CCF is present. This case is interesting due to the unusual pattern with regard to its bilaterality, not reported earlier, and its significance to the knowledge of the skull-base anatomy and implications for neurosurgical anatomy.

Thoracic aortic aneurysms are often incidental findings that require close follow-up monitoring and eventual surgical or endovascular treatment to prevent life-threatening dissection. Their complex relationship with physical activity requires further research to balance cardiovascular risk reduction against the dangers of acute blood pressure peaks.

To evaluate the clinical efficacy of navigated laser photocoagulation (Navilas®) for persistent macular edema (ME) secondary to branch retinal vein occlusion (BRVO), and to determine whether angiographic microaneurysm (MA) morphology, including clustered MAs, telangiectatic capillaries (TelCaps), and MAs within collateral vessels, is associated with successful discontinuation of anti-vascular endothelial growth factor (VEGF) therapy. This retrospective observational study included eyes with persistent BRVO-associated ME treated with Navilas® at Nagoya City University Hospital between June 2014 and February 2022 and followed for at least 3 months. Clinical data and multimodal imaging findings were retrospectively reviewed. Outcomes included changes in best-corrected visual acuity and central subfield thickness, changes in anti-VEGF injection frequency, and successful discontinuation of anti-VEGF therapy. Angiographic MA morphology was assessed using fluorescein angiography and indocyanine green angiography. Logistic regression analysis was performed to identify morphological predictors of treatment discontinuation. Best-corrected visual acuity remained stable throughout follow-up after Navilas®. Approximately 60% of eyes achieved successful discontinuation of anti-VEGF therapy. Discontinuation was achieved in 63% (5 out of 8) of eyes with TelCaps, 33% (2 out of 6) of eyes with MAs within collateral vessels, and 27% (3 out of 11) of eyes with clustered MAs. In eyes that required continued anti-VEGF therapy, the injection frequency was significantly reduced compared with the pretreatment period. Logistic regression analysis demonstrated that the presence of clustered MAs was significantly associated with failure to discontinue anti-VEGF therapy. Navilas® appears to be an effective adjunctive treatment for persistent BRVO-associated ME, maintaining visual function while reducing the burden of anti-VEGF therapy. The presence of clustered MAs may serve as a useful angiographic biomarker of suboptimal response to navigated laser treatment, potentially reflecting severe localized hyperpermeability and extensive capillary nonperfusion. Angiographic assessment of MA morphology may therefore help refine patient selection and guide individualized treatment strategies.

Background and Objectives: Delayed cerebral ischemia (DCI) is a major determinant of poor outcome after aneurysmal subarachnoid hemorrhage (aSAH), yet early risk prediction remains difficult, particularly in sedated or ventilated intensive care patients. We evaluated whether a large language model (LLM) could predict DCI from phase-based dynamic clinical data, compared with intensive care specialists. Materials and Methods: In this single-center, retrospective study, 216 consecutive patients with aSAH were assessed at three predefined phases of accumulating clinical data (day 1; days 1 + 3; days 1 + 3 + 5). For each patient-phase, an LLM (ChatGPT, GPT-5.5 Thinking) and two blinded intensive care specialists predicted DCI risk using only the data available up to that time point. DCI was adjudicated by a blinded three-member panel. Discrimination was assessed by the area under the receiver operating characteristic curve (AUC), with non-inferiority defined a priori as Δ = 0.10. Calibration, decision-curve analysis, and reproducibility were also assessed. Results: Of 216 patients, 60 (27.8%) were DCI-positive and 15 were indeterminate; the primary sample comprised 201 patients. In the prespecified primary analysis, the LLM met the non-inferiority criterion relative to both specialists across all three phases (LLM AUC 0.703-0.747; specialists 0.712-0.764); however, in an equal-granularity sensitivity analysis, non-inferiority remained supported only in Phases 2 and 3 and was not demonstrated in Phase 1. Discrimination increased numerically as data accumulated (Phase 1 vs. 3, p = 0.072), an increase that was attenuated in a landmark-restricted analysis accounting for DCI-onset timing. The LLM showed the lowest false-reassurance rate (3.3-11.7%), reflecting a more cautious threshold rather than better discrimination. Confidence did not reliably indicate accuracy (~25% of high-confidence predictions were wrong); outputs were highly reproducible (Fleiss κ 0.887; intraclass correlation coefficient (ICC) 0.968). Conclusions: An LLM achieved DCI discrimination that was non-inferior to-but not better than-that of experienced specialists; its unreliable confidence scores support clinician-supervised rather than autonomous use.

Introduction: Ruptured intracranial aneurysms (RIAs) are a significant cause of morbidity and mortality. While individual-level risk factors for aneurysmal subarachnoid hemorrhage (aSAH) are well established, the influence of meteorological variables has been widely debated but remains unclear. Methods: We retrospectively analyzed 1504 endovascularly treated intracranial aneurysm cases from two stroke centers (2018 to 2024). We matched daily weather data to presentation dates. We used variance inflation factor (VIF) analysis to remove collinear features. Multivariable logistic regression models were adjusted for age and sex. We developed extreme gradient boosting (XGBoost) models using weather variables alone and in combination with demographic covariates (age, sex, race, smoking status, and family history). Results: Of 1504 cases, 377 (25.1%) presented with rupture. In univariate logistic regression, greater humidity (odds ratio [OR] 0.988 per 1% relative humidity, 95% confidence interval [CI] 0.979 to 0.998, p = 0.0135) and greater ultraviolet (UV) index (OR 0.951 per index unit, 95% CI 0.914 to 0.990, p = 0.0146) were associated with reduced odds of rupture, whereas greater snow depth (OR 1.360 per inch, 95% CI 1.068 to 1.731, p = 0.0126) and advanced moon phase (OR 1.589 per full lunar cycle, 95% CI 1.064 to 2.373, p = 0.0237) were associated with increased odds. On multivariable analysis, only female sex remained protective (OR 0.605, 95% CI 0.386 to 0.949, p = 0.0285), and greater sea level pressure trended toward lower odds of rupture without reaching significance (OR 0.962, p = 0.0523). Findings were consistent in a full-cohort, center-adjusted sensitivity analysis. The weather-only XGBoost model yielded an area under the receiver operating characteristic curve (AUC) of 0.560 and a recall of 78%, which improved to an AUC of 0.590 and a recall of 83% after adding demographic variables. SHapley Additive exPlanations (SHAP) analysis identified precipitation and cloud cover as key meteorological features. Conclusions: Several weather variables correlated with rupture risk in univariate analysis, but overall predictive value was limited. Machine learning improved sensitivity while confirming patient features as the dominant contributors. Weather on the day of presentation was not significantly associated with rupture.

Background: Before the COVID-19 pandemic, the higher prevalence of gastrointestinal symptoms, severe inflammatory response, and cardiac failure in patients with Kawasaki Disease Shock Syndrome (KDSS) lets us hypothesize that KDSS is triggered by superantigens produced by bacteria that colonize the gastrointestinal tract and activate TCRVβ2+ and TCRVβ8+ cells, leading to a massive proinflammatory stage and cardiovascular instability. Methods: This is a case-control study in patients with KDSS (cases, 8 patients) or with Kawasaki disease (KD; controls, 71 patients), in the acute phase before intravenous immunoglobulin (IVIG) treatment, from the National Institute of Pediatrics, Mexico City, from 2016 to 2019. Clinical and laboratory data were obtained with quantification of TCRVβ2+ and TCRVβ8+ T cells by flow cytometry. Superantigen-associated gene-positive bacterial isolates from stool cultures were obtained by final point-PCR assay. Statistical analysis was done with one-way ANOVA and Welch's post hoc test, Chi-square test and odds ratio (OR). Statistical significance was defined as p < 0.05. Results: The peripheral proportion of CD4+TCRVβ2+ T cells was lower in the KDSS group than in the KD group, whereas the CD25-positive T-cell subsets showed no statistically significant differences between groups. Significant associations between staphylococcus enterotoxin A (SEA)/KDSS [OR = 23.3, CI95% = 1.8-296.2, p = 0.014] and superantigen/coronary aneurysms (p < 0.001) were found. Conclusions: These results suggest that SEA produced by bacteria that colonize the gastrointestinal tract and cross the intestinal barrier may activate CD3+/CD4+/TCRVβ2+ T cells, as a trigger of shock in a group of patients with KD. Also, each subtype of KD could have different etiologies explaining the inconsistencies in the detection of superantigens in patients with KD.

Background/Objectives: Despite high sensitivity in deep learning models for identifying candidate locations of unruptured cerebral aneurysms (UCAs), excessive false-positive (FP) findings and insufficient characterization of their anatomical distribution remain barriers to clinical integration. We evaluated a multi-stage deep learning framework for reducing anatomy-specific FPs in TOF-MRA-based UCA screening. Methods: This retrospective multicenter study analyzed TOF-MRA images from 404 scans across seven institutions. A baseline model (Model-A) was compared with an updated model (Model-B) incorporating a secondary cluster-filtering algorithm. Reference standards were established by expert reviewers. Aneurysm-wise sensitivity was compared using McNemar's test, FPs per case using the Wilcoxon signed-rank test, and FP distributions by vascular location. Results: Aneurysm-wise sensitivity was 94.3% (231/245) for Model-A and 93.9% (230/245) for Model-B, with 1.16 and 0.879 FPs per case, respectively, representing a significant 24% FP reduction (p < 0.001). Per-aneurysm sensitivity did not differ significantly (McNemar's test, p = 1.00). Model-B suppressed mimics in the internal carotid artery (ICA) and middle cerebral artery (MCA). Aneurysms were most frequent in the ICA (29%) and MCA (22%). Setting Model-A FPs as 100%, ICA and MCA accounted for 47.1% and 11.3% in Model-A and decreased to 34.5% and 7.7% in Model-B. In an exploratory regional analysis with Holm adjustment, FP reductions remained significant in the ICA (adjusted p < 0.001) and MCA (adjusted p = 0.003). Conclusions: A secondary cluster-filtering algorithm reduced FP candidate findings by 24% with similar sensitivity point estimates (paired difference -0.4 percentage points, 95% CI -3.1 to +2.1). Region-specific error analysis revealed the anatomical dependency of FP reduction. The impact on reading workflow and patient outcomes requires prospective evaluation.

Background: Maintaining hemodynamic stability is crucial during coil embolization of unruptured intracranial aneurysms. Remimazolam has been suggested to exert less cardiovascular depression than propofol and may therefore provide more stable hemodynamic conditions. This study compared the hemodynamic effects of remimazolam and propofol when used for anesthesia induction and maintenance in patients undergoing coil embolization with I-gel airway management. Methods: In this single-center, randomized study, adults undergoing elective coil embolization for unruptured intracranial aneurysms were assigned to remimazolam or propofol induction followed by I-gel insertion. The primary outcome was the peak-to-nadir systolic blood pressure difference during the peri-induction period. Secondary outcomes included the peak-to-nadir mean arterial pressure difference, lowest systolic and mean arterial pressures, the incidence of hypotension, vasoactive drug requirements, and recovery outcomes. Results: Of the 50 patients randomized, 46 were included in the analysis, including 22 in the remimazolam group and 24 in the propofol group. The peri-induction peak-to-nadir systolic blood pressure difference was smaller with remimazolam than with propofol (38.2 ± 13.2 vs. 51.7 ± 13.4 mmHg, p = 0.001). The peak-to-nadir mean arterial pressure difference was also smaller, while the lowest systolic and mean arterial pressures were higher, with remimazolam. The incidence of hypotension was lower with remimazolam (40.9% vs. 87.5%, p = 0.002), with correspondingly lower requirements for ephedrine and norepinephrine. Conclusions: Remimazolam-based anesthesia was associated with a smaller peri-induction peak-to-nadir systolic blood pressure difference, a lower incidence of hypotension, and less frequent vasoactive drug use than propofol during I-gel-facilitated anesthesia for unruptured intracranial aneurysm coil embolization. These findings suggest a favorable hemodynamic profile in this setting and support further evaluation in larger trials.

Background: Neurosurgery depends heavily on implanted biomaterials, and the endovascular treatment of intracranial aneurysms (IAs) is the paradigmatic case, since coils, flow diverters and intrasaccular devices achieve durable occlusion only through intrasaccular thrombus organization and endothelial coverage of the neck, both governed by the local flow environment. Computational fluid dynamics (CFD) resolves that environment but is too slow and too solver-dependent for clinical or device design use. Graph and geometric deep learning operates natively on the unstructured meshes in which vascular anatomy and implanted scaffolds are represented and has been proposed as the technology that would close this gap. Methods: Four databases were searched up to 29 July 2026 for original studies developing or validating graph-based or geometric deep learning applied to IA geometry, with a hemodynamic or clinical outcome. Screening and extraction were performed in duplicate; risk of bias with PROBAST and artificial intelligence signaling items, reporting with TRIPOD+AI, and synthesis followed SWiM. Results: Twelve studies (2021 to 2026) were included: seven clinical (1965 aneurysms, plus 81 externally) and five computational (up to 984 geometries). Learned geometric representations discriminated rupture, growth and post-embolization recanalization better than morphological indices and then PHASES, reaching an area under the curve of 0.795 to 0.97 internally. Graph and point cloud surrogates reproduced hemodynamic fields with normalized errors of 2% to 5% in seconds rather than hours, and one transformer-based graph network predicted the extent and timing of intra-aneurysmal thrombus formation over a reactive surface. External validation was reached by two studies, and clinical utility was achieved in one; discrimination fell from 0.85 to 0.71 in one external test, and surrogate error rose from 4.1% to 19.1% on patient-derived anatomy. No model was trained on a device-laden geometry. Additionally, 5/7 clinical studies classified cross-sectional rupture status rather than prospectively predicting future rupture. Conclusions: Graph and geometric deep learning has substantially reduced the computational burden of hemodynamic analysis, but reliable generalization to unseen patient-specific anatomy remains a relevant challenge. Shared patient-specific benchmarks, prespecified external validation, reporting of calibration, and extension of training corpora to implanted anatomy are necessary next steps towards virtual evaluation of neurovascular biomaterials.

Intraprocedural rupture (IPR) during coiling of ruptured intracranial aneurysms is a serious complication. In this study, we assessed whether center volume influences the risk of IPR. For this purpose, we conducted a systematic review (1996-present) including a final total of 98 studies. Centers were classified as high-volume (≥20 cases/year) or low-volume (<20), with the IPR rate as the primary outcome, and subgroup analyses by vascular territory and meta-regression were performed to quantify volume effects. The IPR rate was lower at high-volume centers than low-volume centers (3.5% [95% CI, 3.01-4.06] vs. 5.37% [95% CI, 4.06-7.07]; p < 0.01). Subgroup analyses by territory favored high-volume centers for anterior cerebral artery aneurysms (5.41% vs. 17.24%; p = 0.01) and middle cerebral artery aneurysms (7.49% vs. 50.0%; p < 0.01), while posterior circulation showed no significant difference (8.76% vs. 3.61%; p = 0.14). The meta-regression showed a statistically significant association in the overall IPR rate, with a regression coefficient of -0.65 (p = 0.0047). These findings potentially suggest a volume-outcome relationship, in which a higher annual case volume is associated with a lower risk of IPR during coiling of ruptured intracranial aneurysms.

Ubiquitination and deubiquitination are dynamic post-translational regulatory processes that control protein stability and signaling. Deubiquitinases (DUBs), which remove ubiquitin chains from target proteins, have emerged as important regulators of vascular homeostasis and disease. In this review, we summarize recent progress in defining the roles of DUBs in major vascular pathologies, including vascular inflammation, remodeling, neointimal formation, angiogenesis, endothelial barrier dysfunction, thrombosis, and fibrosis. Accumulating evidence indicates that distinct DUBs act in a cell type- and context-dependent manner in endothelial cells, vascular smooth muscle cells, immune cells, and fibroblasts, contributing to vascular diseases such as aortic aneurysm, atherosclerosis, pulmonary hypertension, ischemic stroke, and intimal hyperplasia. These findings support DUBs as key regulatory nodes integrating ubiquitin signaling with inflammatory and stress-response pathways in the vasculature. In parallel, efforts to pharmacologically modulate DUB activity have led to the development of selective inhibitors and activators, although challenges remain in achieving substrate specificity and tissue selectivity. Overall, DUBs represent promising therapeutic targets for vascular disease, and future studies should focus on defining disease-specific DUB-substrate networks and developing context-dependent strategies for precise vascular intervention.