Objective: The objective of this systematic review and meta-analysis is to evaluate the efficacy, safety, time to international normalized ratio (INR) reversal, and total volume of four-factor prothrombin complex concentrate (4-PCC) administered using fixed-dose versus weight-based dosing strategies in patients requiring urgent warfarin reversal, with specific focus on clinical outcomes of hemostatic efficacy, thromboembolic events, and mortality rates. Methods: A comprehensive systematic review was conducted using the PubMed, Embase, and Cochrane databases from inception through October 2023. We searched for randomized clinical trials or observational studies that compared efficacy or safety outcomes of fixed versus variable 4-PCC dose in adult patients. Results: In the 14 included studies, the overall use of fixed-dose 4-PCC was associated with a lower likelihood of reaching the INR goal (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.80–0.89) compared to the variable-dose group. In addition, a significantly larger proportion of patients (169 of 651, 26%) required an additional dose of 4-PCC. The rates of mortality (RR, 0.85; 95% CI, 0.70–1.03) and thromboembolic events (RR, 1.27; 95% CI, 0.65–2.45) were similar between the two treatment groups. Conclusion This systematic review and meta-analysis showed that variable dosing of 4-PCC more successfully achieves the target INR for warfarin reversal compared to fixed dosing. However, the dosing strategies have similar mortality and thromboembolic rates. While fixed dosing offers a simpler approach, it may require additional administration. Future studies should focus on optimizing dosing strategies to balance efficacy, safety, and practicality in various clinical scenarios

Objective: Endovascular treatment of cerebrovascular diseases is often challenging due to small caliber, tortuous distal vessels. Several devices and techniques have evolved to overcome these challenges. Recently, a low profile dual lumen microballoon catheter, specifically designed for distal navigation is employed for neurovascular procedures. Due to its recent advent, scarce data is available on clinical utility and safety of Scepter Mini. The aim of this case series is to report our initial experience with Scepter Mini in the management of various cerebrovascular diseases. Methods: All interventional neurovascular cases performed using Scepter Mini between January 2020 till April 2021 were included. Data regarding patient demographics, procedural details and complications was retrospectively collected from patient’s electronic medical record and procedure reports. Results: Total twelve embolization procedures were performed in eleven patients, including six brain arteriovenous malformation, two dural arteriovenous fistula, one vein of Galen malformation and three hyper-vascular glomus tumor embolizations. All procedures were successfully performed with adequate penetration of the embolic agent. Complete embolization was performed in six procedures, while intended partial embolization was performed in the rest of procedures. Scepter Mini was solely used in ten procedures, however in the other two embolization procedures it was used as an additional conjunct tool to complete the intended embolization. No balloon related complication was observed in any procedure. Conclusions Scepter Mini dual lumen microballoon catheter is safe and feasible for delivery of liquid embolic agents for cerebrovascular embolization procedures.

84 years old gentle man with past medical history of hypertension and diabetes presented with sudden onset right sided weakness and aphasia for two hours. Initial neurological assessment revealed National Institute of Health Stroke Scale (NIHSS) 17. Computed tomography (CT) scan demonstrated minimal early ischemic changes along left insular cortex with occlusion of left middle cerebral artery (MCA). Based on clinical and imaging findings, decision was made to perform mechanical thrombectomy procedure. Initially, right common femoral artery approach was utilized. However, due to unfavorable type-III bovine arch, left internal carotid artery could not be engaged via this approach. Subsequently, access was switched to right radial artery. Angiogram revealed small caliber radial artery, with larger caliber ulnar artery. Attempt was made to advance the guide catheter through the radial artery, however significant vasospasm was encountered. Subsequently, ulnar artery was accessed and successful thrombolysis in cerebral infarction (TICI) III left MCA reperfusion was achieved with a single pass of mechanical thrombectomy via this approach. Post procedure neurological examination demonstrated significant clinical improvement. Doppler ultrasound 48 hours after the procedure demonstrated patent flow in radial and ulnar arteries with no evidence of dissection.

Giant internal carotid artery (ICA) aneurysms are complex vascular lesions which are difficult to treat with open as well as endovascular surgery. Parent vessel occlusion is a well-established treatment option for such aneurysms. However, there have been a few reported cases of ruptured aneurysms related to the persistent retrograde filling after parent vessel occlusion. We report a case which highlights the usage of the flow diverter stent as a potential treatment strategy for the management of retrograde filling of aneurysms. A 54-year-old female was found to have a giant left ICA aneurysm on a brain magnetic resonance imaging during workup for headaches. She underwent occlusion of the left ICA proximal to the aneurysm using multiple coils. However, follow up angiograms after 6 months and 2 years demonstrated persistent retrograde filling of the left ICA aneurysm through the posterior communicating (PCOM) artery. Eventually, she was successfully treated with a flow diverter stent across the PCOM artery into the distal ICA. Follow up angiogram after 6 months showed patent flow in the PCOM artery and the distal ICA. with complete occlusion of the aneurysm. Using a flow diverter stent after insufficient parent vessel occlusion for giant intracranial aneurysms may be a feasible treatment option and an addition to the neurovascular treatment armamentarium.

Giant internal carotid artery (ICA) aneurysms are complex vascular lesions which are difficult to treat with open as well as endovascular surgery. Parent vessel occlusion is a well-established treatment option for such aneurysms. However, there have been a few reported cases of ruptured aneurysms related to the persistent retrograde filling after parent vessel occlusion. We report a case which highlights the usage of the flow diverter stent as a potential treatment strategy for the management of retrograde filling of aneurysms. A 54-year-old female was found to have a giant left ICA aneurysm on a brain magnetic resonance imaging during workup for headaches. She underwent occlusion of the left ICA proximal to the aneurysm using multiple coils. However, follow up angiograms after 6 months and 2 years demonstrated persistent retrograde filling of the left ICA aneurysm through the posterior communicating (PCOM) artery. Eventually, she was successfully treated with a flow diverter stent across the PCOM artery into the distal ICA. Follow up angiogram after 6 months showed patent flow in the PCOM artery and the distal ICA. with complete occlusion of the aneurysm. Using a flow diverter stent after insufficient parent vessel occlusion for giant intracranial aneurysms may be a feasible treatment option and an addition to the neurovascular treatment armamentarium.