Predictive Value of the Systemic Immune-Inflammation Index for Periprocedural Complications in Flow Diverter Treatment for Patients with Intracranial Aneurysms

Predictive Value of the Systemic Immune-Inflammation Index for Periprocedural Complications in Flow Diverter Treatment for Patients with Intracranial Aneurysms | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Predictive Value of the Systemic Immune-Inflammation Index for Periprocedural Complications in Flow Diverter Treatment for Patients with Intracranial Aneurysms Jiwan Huang, Yaxian Huang, Xin Feng, Chi Huang, Mengshi Huang, and 17 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4833682/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Oct, 2024 Read the published version in Neurosurgical Review → Version 1 posted 11 You are reading this latest preprint version Abstract Flow-diverter devices (FDs) are effective in treating intracranial aneurysms (IAs) but carry substantial periprocedural risks, particularly ischemic complications. This study aimed to determine if elevated Systemic Immune-Inflammation Index (SII) can independently predict these risks and assess the impact of age and dual antiplatelet therapy on this association. We conducted a retrospective analysis of patients treated with FDs between February 2016 and August 2023, using blood samples taken within six days before surgery to calculate SII. Logistic regression and decision tree analyses assessed the link between SII and periprocedural complications, with subgroups exploring influencing factors. Multivariable analysis identified high SII as an independent predictor of periprocedural complications (OR=5.306, 95% CI: 1.367-18.455; P=0.009). The decision tree model confirmed SII > 0.437 as a critical threshold. Subgroup analysis showed a pronounced association of SII with periprocedural complications in patients ≥65 years (OR=36.979, 95% CI: 2.103-650.134; P=0.014) and in those on clopidogrel therapy (OR=16.921, 95% CI: 2.733-104.746; P=0.002). An elevated Systemic Immune-Inflammation Index (SII) >0.437 significantly correlates with increased periprocedural complications (6.5% vs. 1.8%, P=0.017). Although not statistically significant, higher SII is associated with a greater rate of ischemic events (3.9% vs. 0.9%). Elevated preoperative SII independently predicts periprocedural complications, particularly ischemic events, in patients undergoing FDs treatment for intracranial aneurysms. This association is especially significant in older patients and those on clopidogrel therapy. Trial Registration: ClinicalTrials.gov (NCT06446778). Registered on May 22, 2024. Systemic immunity-inflammation index Flow diverter Periprocedural complications Intracranial aneurysms Figures Figure 1 Figure 2 Figure 3 Introduction Flow-diverter devices (FDs) have gained global recognition for their safety and efficacy in aneurysm management, with occlusion rates ranging from 76–90%.[ 1 – 3 ] Despite these promising outcomes, flow-diversion treatment is associated with an overall complication rate of 10.1%.[ 4 ] Consequently, the identification of risk factors for such adverse events is paramount to optimize therapeutic outcomes. Previous studies have predominantly concentrated on demographic, clinical, and morphological determinants, with the role of immune-inflammatory status receiving less attention.[ 5 ] Inflammatory responses, mediated by immune cells and platelet activation, are crucial for aneurysm repair through endothelial proliferation, yet may also precipitate in-stent stenosis and thrombosis.[ 6 ] Moreover, heightened inflammation could destabilize aneurysms, increasing the risk of periprocedural hemorrhage.[ 7 ] The significance of inflammation in periprocedural management has been well established in the context of percutaneous coronary intervention.[ 8 ] However, the association between inflammation and periprocedural complications in FDs treatment remains unclear. The systemic immune-inflammation index (SII), which incorporates neutrophil, lymphocyte, and platelet counts, reflects the complex interactions among immunity, inflammation, and coagulation processes. This complexity suggests that SII may be more sensitive in assessing the risk of vascular events.[ 9 ] While it shows promise in predicting complications in cardiovascular interventions and cerebrovascular incidents,[ 8 , 10 ] further research is needed to determine its prognostic value in cerebrovascular interventions. Hence, this study aims to elucidate the correlation between preoperative SII and periprocedural complications in patients treated with FDs, refining intervention strategies and enhancing patient prognosis. MATERIALS AND METHODS Study design We conducted a retrospective analysis of a prospectively maintained database at our center. Consecutive patients treated with FDs between February 2016 and August 2023 were retrospectively reviewed. The inclusion criteria included the following: (1) Aged over 18 years old; (2) IAs treated with FDs. Exclusion criteria for the study were: (1) patients complicated by other cerebrovascular diseases (e.g., Moyamoya disease, arteriovenous malformation, or arteriovenous fistula); (2) patients with other conditions affecting inflammatory cell counts, such as acute infectious inflammation (e.g., pneumonia or urinary tract infection), autoimmune diseases, or a history of cancer; (3) patients with inadequate venous blood samples collected upon admission, poor image quality, or incomplete medical records. This study received approval from the institutional review boards of centers, and informed consent was waived owing to the anonymous design of the study. Data collection and definitions On the admission day, demographic and clinical characteristics were systematically recorded for all participants. These included age, gender, BMI, and medical history (hypertension, diabetes mellitus, dyslipidemia, history of smoking, drinking, hemorrhage, ischemic, and coronary artery disease). Angiographic evaluations of IAs such as location, morphology, neck width, tandem aneurysms (multiple IAs in close proximity to one another on the same or adjacent vascular segments that are not interconnected), regular aneurysms (without daughter sacs or lobulations), vessel diameter (the mean diameter of the parent vessel at the proximal and distal ends of the aneurysms) were conducted. The angiographic data was analyzed by two researchers, while three seasoned neurointerventionalists, each with over a decade of experience, supervised the measurements. Detailed procedural data were extracted from the electronic medical records, documenting dual antiplatelet therapy, FDs specifics, nominal stent diameter and length, coiling assistance, and balloon angioplasty usage. Periprocedural complications, defined as cerebrovascular incidents within 30 days post-procedure, included intraoperative aneurysm rupture, intraprocedural thrombosis, hemorrhagic events (subarachnoid and intraparenchymal hemorrhage), and ischemic strokes (transient ischemic attacks [TIA], mild ischemia with National Institutes of Health Stroke Scale (NIHSS) score ≤ 4, and severe ischemia with NIHSS > 4). Severe functional impairment was also evaluated.[ 11 ] The blood laboratory data were collected within 6 days before surgery, including neutrophil count, lymphocyte count, monocyte count, and platelet count. The neutrophil-to-lymphocyte ratio (NLR) was defined as the number of neutrophils divided by the number of lymphocytes. Systemic inflammation response index (SIRI) was defined as the number of Monocyte count multiplied by the neutrophil-to-lymphocyte ratio. The systemic immune-inflammation index (SII) is defined as the product of platelet count multiplied by the neutrophil-to-lymphocyte ratio, divided by 1000. [ 9 , 12 ] Endovascular treatment procedure Before the procedure, patients were administered dual antiplatelet therapy (DAPT) comprising daily doses of aspirin (100 mg) and clopidogrel (75 mg) for at least three days. Preoperative assessment for platelet function testing conducted at least one day prior to the procedure. For those exhibiting clopidogrel resistance, ticagrelor was employed as an alternative antiplatelet agent. General anesthesia was administered, and patients were fully heparinized during the operation. The preferred method for accessing the target aneurysm was the transfemoral arterial approach utilizing a triaxial system. Stent deployment was generally achieved using the non-compacting technique, with the pushing–compaction operation employed infrequently. The stents were sized to extend at least 5mm beyond both the proximal and distal ends of the aneurysms. Balloon angioplasty was commonly used to correct severely poor wall apposition. Adjunctive coiling was considered under specific circumstances: (1) the potential risk of stent shortening or migration, and (2) an increased likelihood of aneurysm recurrence or rupture, which could be attributed to elevated blood flow velocities at the aneurysm neck. A group of neurointerventionalists, each boasting over 15 years of experience in treating aneurysms, made the decisions regarding the ultimate choice of stents and the approach to treatment. Post-procedure management involved continuing dual antiplatelet therapy for 6 to 12 months, followed by a single antiplatelet regimen of daily aspirin (100 mg) for an additional 6 to 9 months. Statistical analysis Statistical analysis was performed using R (v4.3.2), with normality assessed by the Kolmogorov-Smirnov test. Continuous variables were presented as mean ± SD or median (IQR) and analyzed with the t-test or Wilcoxon test. Categorical variables were reported as frequencies and proportions and analyzed using the Χ2 or Fisher’s exact test. The study cohort of 452 IAs was divided into derivation (70%) and validation (30%) subsets. Variables that had P value < 0.1 and demonstrated clinical significance were incorporated into three separate multivariate logistic regression models—Model 1, Model 2, and Model 3—each evaluating the NLR, SIRI and SII, respectively. Subgroup analyses were conducted to explore SII's association with complications in the elderly and those on dual antiplatelet regimens. The Decision Tree model was developed using 'caret' and 'rpart' packages, with feature selection guided by a P value < 0.1 and tenfold cross-validation. The model used the 'Gini' criterion and a maximum depth of 10. ROC analysis evaluated the predictive accuracy of the DT and multivariate models for complications. SII values were dichotomized based on Decision Tree outcomes to further investigate their association with periprocedural complications. Results Demographic and aneurysm characteristics In our study, we evaluated 488 IAs treated with FDs in 449 patients. Out of these, 452 IAs (92.6%) met our stringent inclusion criteria ( Supplemental Figure. 1 ). In the total cohort, the mean age was 56(IQR:46.8–64.0) years, and 306 patients (67.7%) were female, 19 patients (4.20%) presented with periprocedural complications and 433(95.8%) did not. The characteristics of 452 IAs from 418 patients in the derivation and validation cohorts have been compared in Supplemental Table 1 . No significant differences were noted between the derivation and validation cohort. The results of univariate analysis are shown in Table 1 . In the derivation cohort, compared with those without periprocedural complications, patients with periprocedural complications tended to have a diabetes (42.9% vs 11.9%, P = 0.005), hemorrhagic history (35.7% vs 6.9%, P = 0.003), larger neck width of the aneurysm (7.58 vs 4.27, P = 0.039), different dual antiplatelet regimen (P = 0.035) and worse preoperative mRS score (P < 0.001). Patients with complications also showed a trend towards increased neutrophil and platelet counts, though these did not statistically differ (p = 0.067, 0.350 respectively). Notably, preoperative SII differed significantly between two groups (0.54 vs 0.43 ×10 9 /L, P = 0.056). Other baseline characteristics were similar between the two groups. ROC analysis was performed to determine ability of SII index to distinguish patients who did or did not periprocedural complications (AUC of 0.651 on the derivation cohort and 0.758 on the validation cohort, Fig. 3 c, d). Table 1 Univariate analysis between periprocedural complications and no periprocedural complications group of 452 aneurysms in the derivation and validation cohort. Variable Derivation cohort Validation cohort Overall No PPC Group PPC Group p Overall No PPC Group PPC Group p 318 304 14 134 129 5 Age (years) 57.00 [47.00, 64.00] 56.00 [47.00, 63.00] 61.50 [55.25, 66.00] 0.107 56.00 [46.00, 63.50] 56.00 [46.00, 63.75] 51.00 [46.00, 57.00] 0.445 Gender, female 214 (67.5) 207 (68.3) 7 (50.0) 0.157 92 (68.1) 89 (68.5) 3 (60.0) 0.653 BMI (kg/m 2 ) 23.44 [21.51, 25.09] 23.44 [21.66, 25.12] 23.54 [20.43, 24.72] 0.916 23.44 [21.59, 25.55] 23.41 [21.59, 25.53] 23.52 [22.04, 28.04] 0.775 Hypertension 117 (36.9) 109 (36.0) 8 (57.1) 0.155 57 (42.2) 54 (41.5) 3 (60.0) 0.650 Hyperlipidemia 98 (30.9) 96 (31.7) 2 (14.3) 0.240 39 (28.9) 37 (28.5) 2 (40.0) 0.626 Diabetes 42 (13.2) 36 (11.9) 6 (42.9) 0.005* 16 (11.9) 14 (10.8) 2 (40.0) 0.107 Coronary disease 8 (2.5) 7 (2.3) 1 (7.1) 0.306 8 (5.9) 8 (6.2) 0 (0.0) > 0.999 History of smoking 40 (12.6) 36 (11.9) 4 (28.6) 0.085 14 (10.4) 13 (10.0) 1 (20.0) 0.427 History of drinking 31 (9.8) 29 (9.6) 2 (14.3) 0.636 12 (8.9) 11 (8.5) 1 (20.0) 0.377 Hemorrhagic history 26 (8.2) 21 (6.9) 5 (35.7) 0.003* 12 (8.9) 9 (6.9) 3 (60.0) 0.005 Ischemic stroke history 66 (20.8) 60 (19.8) 6 (42.9) 0.084 22 (16.3) 18 (13.8) 4 (80.0) 0.002 Preoperative mRS score < 0.001* 0.244 0 146 (46.1) 144 (47.5) 2 (14.3) 53 (39.3) 50 (38.5) 3 (60.0) 1 130 (41.0) 126 (41.6) 4 (28.6) 65 (48.1) 64 (49.2) 1 (20.0) 2 27 (8.5) 26 (8.6) 1 (7.1) 10 (7.4) 10 (7.7) 0 (0.0) 3 8 (2.5) 5 (1.7) 3 (21.4) 1 (0.7) 1 (0.8) 0 (0.0) 4 6 (1.9) 2 (0.7) 4 (28.6) 6 (4.4) 5 (3.8) 1 (20.0) Posterior circulation 36 (11.4) 33 (10.9) 3 (21.4) 0.204 22 (16.3) 21 (16.2) 1 (20.0) > 0.999 Regular aneurysm 256 (80.8) 247 (81.5) 9 (64.3) 0.156 97 (71.9) 94 (72.3) 3 (60.0) 0.620 Morphological feature, saccular 287 (90.5) 276 (91.1) 11 (78.6) 0.136 118 (87.4) 115 (88.5) 3 (60.0) 0.119 Tandem IAs† 81 (25.6) 78 (25.7) 3 (21.4) > 0.999 25 (18.5) 24 (18.5) 1 (20.0) > 0.999 Neck width (mm) 4.37 [3.20, 6.10] 4.27 [3.18, 5.90] 7.58 [3.76, 9.39] 0.039* 5.09 [3.77, 6.92] 5.04 [3.75, 6.89] 14.17 [4.58, 22.50] 0.113 Vessel diameter (mm)‡ 3.95 [3.48, 4.45] 3.95 [3.49, 4.48] 3.95 [3.36, 4.24] 0.728 3.95 [3.38, 4.50] 3.95 [3.38, 4.50] 4.21 [3.80, 4.25] 0.958 Dual antiplatelet regimen 0.035* 0.084 Clopidogrel 170 (53.6) 164 (54.1) 6 (42.9) 73 (54.1) 72 (55.4) 1 (20.0) Ticagrelor 94 (29.7) 92 (30.4) 2 (14.3) 45 (33.3) 43 (33.1) 2 (40.0) Others 53 (16.7) 47 (15.5) 6 (42.9) 17 (12.6) 15 (11.5) 2 (40.0) Stent type, TED 186 (58.7) 179 (59.1) 7 (50.0) 0.583 71 (52.6) 70 (53.8) 1 (20.0) 0.190 Nominal stent diameter (mm) 4.00 [3.75, 4.50] 4.00 [3.75, 4.50] 4.00 [3.75, 4.50] 0.903 4.00 [3.50, 4.50] 4.00 [3.50, 4.50] 4.00 [3.75, 4.25] 0.976 Nominal stent length (mm) 20.00 [20.00, 30.00] 20.00 [20.00, 30.00] 25.00 [20.00, 30.00] 0.224 20.00 [20.00, 30.00] 20.00 [20.00, 30.00] 30.00 [18.00, 35.00] 0.484 Balloon angioplasty 12 (3.8) 10 (3.3) 2 (14.3) 0.093 2 (1.5) 2 (1.5) 0 (0.0) > 0.999 Adjunctive coiling 58 (18.4) 54 (17.8) 4 (30.8) 0.268 31 (23.0) 29 (22.3) 2 (40.0) 0.324 Neutrophils, 10 9 /L 3.45 [2.65, 4.49] 3.43 [2.63, 4.44] 4.37 [3.36, 5.49] 0.067 3.78 [2.92, 5.14] 3.78 [2.92, 5.15] 3.78 [3.73, 4.44] 0.829 Lymphocytes, 10 9 /L 1.88 [1.51, 2.30] 1.88 [1.52, 2.30] 1.82 [1.37, 2.31] 0.704 1.98 [1.58, 2.48] 1.99 [1.59, 2.50] 1.18 [0.99, 1.93] 0.028 Monocytes, 10 9 /L 0.49 [0.39, 0.58] 0.49 [0.39, 0.58] 0.47 [0.41, 0.58] 0.911 0.50 [0.42, 0.65] 0.50 [0.41, 0.65] 0.54 [0.45, 0.57] 0.731 Platelets, 10 9 /L 239.00 [208.00, 279.00] 237.00 [208.00, 279.00] 269.00 [238.00, 276.00] 0.138 249.00 [204.00, 283.00] 247.50 [204.00, 280.75] 250.00 [198.00, 306.00] 0.889 NLR 1.76 [1.36, 2.56] 1.75 [1.35, 2.48] 2.23 [1.46, 3.22] 0.148 1.89 [1.47, 2.64] 1.85 [1.46, 2.59] 3.02 [2.25, 3.81] 0.037 SIRI, 10 9 /L 0.90 [0.59, 1.35] 0.90 [0.58, 1.35] 0.99 [0.76, 1.46] 0.384 0.98 [0.65, 1.52] 0.98 [0.64, 1.47] 1.71 [1.22, 2.06] 0.069 SII, 10 9 /L 0.44 [0.32, 0.66] 0.43 [0.32, 0.66] 0.54 [0.40, 0.87] 0.056 0.46 [0.35, 0.68] 0.45 [0.32, 0.67] 0.74 [0.66, 0.76] 0.050 Values are shown as median (IQR) or frequency (%) unless indicated otherwise. * Statistic difference. Abbreviations: PPC, periprocedural complications; No PPC, no periprocedural complications; NLR, neutrophil to lymphocyte ratio; SII, systemic immune-inflammation index; SIRI, Systemic inflammation response index. †Multiple IAs in close proximity to one another on the same or adjacent vascular segments that are not interconnected. ‡The mean diameter of the vessel at the proximal and distal ends of the aneurysms. In the entire cohort, the relationships between neutrophil count, lymphocyte count, platelet count, NLR, SIRI and SII with periprocedural complications were visualized using violin plots ( Fig. 1 ) . The conclusions drawn were consistent with those from the derivation cohort, with significant differences observed in NLR and SII between two groups (P = 0.022; P = 0.010), respectively. Characteristics of Periprocedural Complications in 19 Cases In this study, we investigated periprocedural complications in 19 patients treated with flow diverters (FDs) for cerebral aneurysms ( Table 2 ) . Complications were categorized as ischemic, hemorrhagic, and other types, and monitored during the periprocedural period. Ischemic complications were the most prevalent, occurring in 12 patients (63.16%). These included intraprocedural thrombosis in four cases (21.05%), which rapidly resolved following intraoperative administration of tirofiban, without subsequent adverse events. Transient ischemic attacks (TIAs) or minor strokes were observed in four patients (21.05%), and four cases (21.05%) were confirmed as major ischemic strokes. Hemorrhagic events were observed in 5 patients (26.32%), with subarachnoid hemorrhage (SAH) occurring in 4 patients (21.05%). These hemorrhages occurred either immediately or up to 11 hours post-procedure. Furthermore, intraparenchymal hemorrhage was recorded in 1 patient (5.26%). Other types of complications affected 2 patients (10.53%), including cranial nerve palsy and cerebellar edema, each identified within a day of the procedure. For a detailed overview of baseline characteristics, aneurysm locations, types of devices utilized, and pharmaceutical regimens are shown in Supplemental Table 2 . Table 2 Periprocedural complications in 19 patients. Event n % n Ischemic complications Intraprocedural thrombosis 4 21.05% 12 TIA/minor stroke 4 21.05% Major ischemic stroke 4 21.05% Hemorrhagic complications Subarachnoid hemorrhage 4 21.05% 5 Intraparenchymal hemorrhage 1 5.26% Other complications Other complications 2 10.53% 2 Total 19 100.00% Logistic regression and decision tree for prediction of periprocedural Complications The logistic regression analysis showed that, after adjusting for baseline differences (history of smoking, diabetes, hemorrhagic history, ischemic stroke history, neck width, stent type and balloon angioplasty), diabetes (OR: 5.885, 95%CI: 1.563–22.042; P = 0.007), and hemorrhagic history (OR: 15.102, 95%CI: 3.485–68.228; P < 0.001) as significant predictors of complications, with SII showing the highest odds ratio (OR) of 5.306 (95%CI:1.367–18.455; P = 0.009) across all models (Fig. 2 ). The model demonstrated reliable performance with an AUC of 0.792 in the derivation cohort and 0.898 in the validation cohort, achieving a sensitivity of 0.80 and a specificity of 0.986 at the optimal cutoff (Fig. 3 c, d). DT with four nodes and five leaves was constructed, using SII、neck of aneurysm as predictors, as shown in Fig. 3 a. According to the DT, participants with aneurysm neck diameters between 6.68 and 10.985 had a 33.0% chance of experiencing periprocedural complications if their SII exceeded 0.437. The DT model's AUC of 0.797 in the derivation cohort and 0.830 in the validation cohort (Fig. 3 c, d). SII index and periprocedural complication events in the overall population In this subgroup analysis from Table 3 , the SII demonstrates a significant association with periprocedural complications among patients aged ≥ 65, exhibiting a notably high adjusted OR of 36.979 (95% CI: 2.103-650.134; P = 0.014). Similarly, the SII serves as a significant predictor of complications in patients receiving clopidogrel, with an adjusted OR of 16.921 (95% CI: 2.733-104.746; P = 0.002). These findings underscore the substantial predictive value of SII for periprocedural risks within these specific patient cohorts. Table 3 Subgroup analysis for association between SII and periprocedural complications in the elderly and those on dual antiplatelet regimens. Factor Subgroup n total PPC case n (%) P value Adjusted OR (95% CI) SII Age < 65 350 13 (3.71%) 0.343 2.448 (0.384–15.601) Age ≥ 65 102 6 (5.88%) 0.014 36.979 (2.103-650.134) Clopidogrel 243 7 (2.88%) 0.002 16.921 (2.733-104.746) Ticagrelor 139 4 (2.88%) 0.355 4.269 (0.197–92.543) Others 70 8 (11.43%) 0.355 4.269 (0.197–92.543) Adjusted for baseline differences (history of smoking, diabetes, hemorrhagic history, ischemic stroke history, neck width, stent type and balloon angioplasty). Abbreviations: SII, systemic immune-inflammation index; PPC, periprocedural complications; OR, odds ratio; CI, confidence interval. Figure 3 b demonstrates the relationship between the SII and periprocedural complications. An elevated SII (> 0.437) is significantly correlated with increased periprocedural complications (p = 0.017). Although not statistically significant across all categories, the incidence of complications, especially ischemic ones (p = 0.063), is higher in the group with an SII > 0.437 compared to the group with an SII < 0.437. Discussion This is the first study to explore the prognostic value of the SII in patients undergoing FDs treatment for IAs. We found a significant association between SII and periprocedural complications, first validating SII as an independent prognostic factor through logistic regression and decision tree analysis. These findings not only offer a potential risk assessment tool for clinical applications but also underscore the important role of inflammation in periprocedural complications following endovascular treatment. The NLR is an established marker for heart failure, cardiovascular diseases, and chronic inflammatory conditions, offering a quick assessment of the inflammatory state.[ 13 ] However, NLR primarily focuses on the ratio between neutrophils and lymphocytes, potentially not fully reflecting the full scope of systemic inflammation. The SIRI has shown potential in predicting outcomes in stroke patients but may still miss other inflammatory parameters.[ 14 ] In contrast, the SII, which integrates neutrophil, lymphocyte, and platelet counts, provides a more comprehensive evaluation of the inflammatory state. Platelets play a crucial role in both inflammatory responses and thrombus formation, making SII potentially more sensitive in assessing vascular event risks.[ 9 , 15 ] An elevated SII may reflect a broader inflammatory and vascular response, which is particularly relevant in neurointerventional surgeries involving vascular manipulation and potential injury. Previous studies on FD treatment have identified major risk factors for periprocedural complications, such as basilar artery aneurysms, hypertension, ischemic stroke, and a history of subarachnoid hemorrhage.[ 3 , 16 ] However, limited research exists on the systemic immune-inflammatory state of patients. Emerging evidence indicates that inflammatory mechanisms play a significant role in periprocedural ischemic and bleeding events following endovascular treatments. Mechanical injuries from stenting can trigger cerebral vasospasm, leading to TIA,[ 17 ] and activate inflammatory pathways that promote thrombogenesis. Inflammatory responses, involving the release of various mediators, can hinder stent endothelialization and exacerbate thrombosis risk.[ 18 ] Thrombin amplifies this process by promoting leukocyte adhesion, smooth muscle cell proliferation, and the release of inflammatory cytokines, creating a feedback loop that furthers inflammation and thrombus formation. Even with dual antiplatelet therapy, these phenomena are challenging to completely avoid.[ 19 ] Meanwhile, Inflammation is increasingly recognized as a key factor in the pathogenesis and progression of IAs,[ 7 ] with inflammatory cell infiltration in the aneurysm wall significantly contributing to its vulnerability.[ 20 ] Neutrophils and lymphocytes produce enzymes and cytokines that degrade the extracellular matrix and elevate rupture risk. [ 21 , 22 ] The exacerbation of the inflammatory response intensifies the activity of these cells in the aneurysm wall, further destabilizing the structure. Platelets further support these inflammatory and immune responses, increasing the potential for aneurysmal instability and hemorrhagic events.[ 23 ] Based on the results of a Decision Tree analysis, further stratified analysis was conducted, revealing that patients with a SII exceeding 0.437 face a significantly increased risk of periprocedural complications, particularly ischemic events during the periprocedural period. This finding may offer new insights for clinical management, suggesting that SII could serve as a valuable biomarker for risk stratification in the periprocedural setting. In cerebrovascular diseases, age is a recognized risk factor, and DAPT affects periprocedural outcomes. Our exploratory subgroup analysis assessed the impact of age and DAPT regimens on periprocedural outcomes. We found that in patients over 65, high SII levels were significantly linked to increased periprocedural complications (adjusted OR = 36.979; P = 0.014), Likely due to age-related oxidative stress and chronic inflammation's impact on surgical outcomes. Age-related decline in antioxidant capacity and chronic inflammation accumulation may weaken the body's regulation and defense against inflammation, increasing periprocedural complications risk.[ 24 , 25 ] Further analysis of antiplatelet therapy outcomes revealed that patients treated with clopidogrel showed elevated SII levels and a correspondingly increased risk of periprocedural complications (adjusted OR = 16.921; P = 0.002), suggesting suboptimal antiplatelet efficacy under inflammatory stress compared to a baseline cohort risk (adjusted OR = 5.306). In contrast, ticagrelor was associated with a lower risk of complications (adjusted OR = 4.269), evidencing more robust platelet inhibition. Although the precise mechanisms are not yet clear, this phenomenon may be due to ticagrelor's more stable antiplatelet effects at elevated levels of systemic inflammation.[ 26 ] Moreover, the association of ticagrelor with reduced inflammatory indices during post-PCI follow-up suggests that its anti-inflammatory properties might contribute to the clinical benefits observed with antiplatelet therapy.[ 27 ] Therefore, we recommend a personalized approach for elderly patients with high inflammatory profiles, favoring ticagrelor for its stable antiplatelet effect and potential anti-inflammatory properties, to optimize endovascular treatment outcomes. Our multivariate analysis confirmed diabetes and a history of bleeding as independent predictors of complication risk, consistent with existing literature.[ 28 ] Following aneurysm rupture, vasospasms related to subarachnoid hemorrhage (SAH) and a hypercoagulable state further increase the risk of ischemic complications.[ 29 ] These pathological states warrant attention in treatment strategies. Following endovascular treatment in diabetic patients, the increased risk of ischemic events may be attributed to the high expression and aggregation of glycoprotein IIB/IIIA receptors, particularly under hyperglycemic conditions, and an enhanced inflammatory response. These findings underscore the importance of managing diabetes and a history of bleeding in treating IAs.[ 30 ] For patients with these risk factors, closer monitoring and more aggressive antiplatelet or anticoagulation therapy may be necessary. Limitations Despite valuable insights, this study's single-center, retrospective design may limit the generalizability of the findings. The SII is influenced by various factors, including age, gender, comorbidities, and other inflammatory conditions. Although efforts were made to exclude patients with such conditions, their potential impact cannot be entirely excluded. Thus, caution is warranted when applying SII as an independent predictive factor. Conclusions An elevated preoperative SII, along with a history of hemorrhage and diabetes, are independent risk factors for periprocedural complications in patients undergoing FDs for IAs, especially ischemic events. SII, a readily attainable indicator reflecting inflammation and immune status, is valuable for predicting and intervening early in complications. Older patients and those on clopidogrel may require more attention. Declarations Author contributions Jiwan Huang and Yaxian Huang make equal contributions to this research. Xin Feng and Chuanzhi Duan are co corresponding authors. Jiwan Huang: designed, conceptualized the study and drafted the manuscript; Yaxian Huang, Chi Huang, Mengshi Huang: analyzed and interpreted the data; Zhuohua Wen, Anqi Xu, Runze Ge, Hao Yuan, Hongyu Shi, Gengwu Ma, Can Li, Jiancheng Lin, Ruizhe Yi, Yuqi Hu, Yuheng Jin: collected the data; Shuyin Liang, Yiming Bi, Shixing Su, Xin Zhang and Xifeng Li: critically revised the study outcomes; Xin Feng and Chuanzhi Duan: funding, study supervision, and critical revision of the manuscript. Ethics approval and consent to participate This study has been approved by the Ethics Committee of Zhujiang Hospital of Southern Medical University (2023-KY-023-02) and conforms to the ethical standards as per the revised Declaration of Helsinki. The study is registered with ClinicalTrials.gov (NCT06446778). We retrospectively analyzed data collected through January 2023; however, all of these data were initially collected prospectively at the time of patient admission Data after January 2023 were collected in a prospective design. And participants gave informed consent to participate in the study before taking part. Consent for publication All authors of the manuscript agreed to its publication. Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Natural Science Foundation of China (82201427) and the Foundation of National Heath Commission Capacity Building and Continuing Education Center (GWJJ2022100102). Competing Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Availability of data and materials The supporting data of this study is available from the corresponding author on reasonable request. References Becske T, Brinjikji W, Potts MB, Kallmes DF, Shapiro M, Moran CJ, Levy EI, McDougall CG, Szikora I, Lanzino G, Woo HH, Lopes DK, Siddiqui AH, Albuquerque FC, Fiorella DJ, Saatci I, Cekirge SH, Berez AL, Cher DJ, Berentei Z, Marosfoi M, Nelson PK. (2017) Long-Term Clinical and Angiographic Outcomes Following Pipeline Embolization Device Treatment of Complex Internal Carotid Artery Aneurysms: Five-Year Results of the Pipeline for Uncoilable or Failed Aneurysms Trial. Neurosurgery, 80, 40-48. Hanel RA, Kallmes DF, Lopes DK, Nelson PK, Siddiqui A, Jabbour P, Pereira VM, Szikora II, Zaidat OO, Bettegowda C, Colby GP, Mokin M, Schirmer C, Hellinger FR, Given IC, Krings T, Taussky P, Toth G, Fraser JF, Chen M, Priest R, Kan P, Fiorella D, Frei D, Aagaard-Kienitz B, Diaz O, Malek AM, Cawley CM, Puri AS. (2020) Prospective study on embolization of intracranial aneurysms with the pipeline device: the PREMIER study 1 year results. J Neurointerv Surg, 12, 62-66. Kang H, Zhou Y, Luo B, Lv N, Zhang H, Li T, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Yang X, Liu J. (2021) Pipeline Embolization Device for Intracranial Aneurysms in a Large Chinese Cohort: Complication Risk Factor Analysis. Neurotherapeutics, 18, 1198-1206. Bhatia KD, Kortman H, Orru E, Klostranec JM, Pereira VM, Krings T. (2019) Periprocedural complications of second-generation flow diverter treatment using Pipeline Flex for unruptured intracranial aneurysms: a systematic review and meta-analysis. J Neurointerv Surg, 11, 817-824. Sweid A, Starke RM, Herial N, Chalouhi N, Das S, Baldassari MP, Alexander TD, Tjoumakaris S, Gooch MR, Hasan D, Rosenwasser RH, Romo V, Jabbour P. (2020) Predictors of Complications, Functional Outcome, and Morbidity in a Large Cohort Treated With Flow Diversion. Neurosurgery, 87, 730-743. Evans CE, Iruela-Arispe ML, Zhao YY. (2021) Mechanisms of Endothelial Regeneration and Vascular Repair and Their Application to Regenerative Medicine. Am J Pathol, 191, 52-65. Fang J, Cao Y, Ni J. (2024) Circulating inflammatory biomarkers and risk of intracranial aneurysm: a Mendelian randomization study. Eur J Med Res, 29, 17. Akboga MK, Inanc IH, Sabanoglu C, Akdi A, Yakut I, Yuksekkaya B, Nurkoc S, Yalcin R. (2023) Systemic Immune-Inflammation Index and C-Reactive Protein/Albumin Ratio Could Predict Acute Stent Thrombosis and High SYNTAX Score in Acute Coronary Syndrome. Angiology, 74, 693-701. Geraghty JR, Lung TJ, Hirsch Y, Katz EA, Cheng T, Saini NS, Pandey DK, Testai FD. (2021) Systemic Immune-Inflammation Index Predicts Delayed Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery, 89, 1071-1079. Morikawa S, Okumura K, Inoue N, Ogane T, Takayama Y, Murohara T. (2023) Systemic immune-inflammation index as a predictor of prognosis after carotid artery stenting compared with C-reactive protein. PLoS One, 18, e0288564. Huang C, Ma G, Tong X, Feng X, Wen Z, Huang M, Xu A, Yuan H, Shi H, Lin J, Li C, Ge R, Huang J, Peng C, Zhu Y, Wang T, Huang C, Guo Z, Liang S, Su S, Zhang X, Li X, Liu A, Duan CZ. (2024) Comparison of Pipeline embolization device versus Tubridge embolization device in unruptured intracranial aneurysms: a multicenter, propensity score matched study. J Neurointerv Surg. Wang RH, Wen WX, Jiang ZP, Du ZP, Ma ZH, Lu AL, Li HP, Yuan F, Wu SB, Guo JW, Cai YF, Huang Y, Wang LX, Lu HJ. (2023) The clinical value of neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR) and systemic inflammation response index (SIRI) for predicting the occurrence and severity of pneumonia in patients with intracerebral hemorrhage. Front Immunol, 14, 1115031. García-Escobar A, Vera-Vera S, Tébar-Márquez D, Rivero-Santana B, Jurado-Román A, Jiménez-Valero S, Galeote G, Cabrera JÁ, Moreno R. (2023) Neutrophil-to-lymphocyte ratio an inflammatory biomarker, and prognostic marker in heart failure, cardiovascular disease and chronic inflammatory diseases: New insights for a potential predictor of anti-cytokine therapy responsiveness. Microvasc Res, 150, 104598. Huang YW, Zhang Y, Feng C, An YH, Li ZP, Yin XS. (2023) Systemic inflammation response index as a clinical outcome evaluating tool and prognostic indicator for hospitalized stroke patients: a systematic review and meta-analysis. Eur J Med Res, 28, 474. Yang YL, Wu CH, Hsu PF, Chen SC, Huang SS, Chan WL, Lin SJ, Chou CY, Chen JW, Pan JP, Charng MJ, Chen YH, Wu TC, Lu TM, Huang PH, Cheng HM, Huang CC, Sung SH, Lin YJ, Leu HB. (2020) Systemic immune-inflammation index (SII) predicted clinical outcome in patients with coronary artery disease. Eur J Clin Invest, 50, e13230. Han J, Liu F, Chen J, Tong X, Han M, Peng F, Niu H, Liu L, Liu A. (2022) Periprocedural cerebrovascular complications and 30-day outcomes of endovascular treatment for intracranial vertebral artery dissecting aneurysms. J Neurosurg, 1-9. Zhu Y, Zhang H, Zhang Y, Wu H, Wei L, Zhou G, Zhang Y, Deng L, Cheng Y, Li M, Santos HA, Cui W. (2019) Endovascular Metal Devices for the Treatment of Cerebrovascular Diseases. Adv Mater, 31, e1805452. Xue J, Zhang Z, Sun Y, Jin D, Guo L, Li X, Zhao D, Feng X, Qi W, Zhu H. (2023) Research Progress and Molecular Mechanisms of Endothelial Cells Inflammation in Vascular-Related Diseases. J Inflamm Res, 16, 3593-3617. Croce K, Libby P. (2007) Intertwining of thrombosis and inflammation in atherosclerosis. Curr Opin Hematol, 14, 55-61. Hosaka K, Hoh BL. (2014) Inflammation and cerebral aneurysms. Transl Stroke Res, 5, 190-8. Frösen J, Piippo A, Paetau A, Kangasniemi M, Niemelä M, Hernesniemi J, Jääskeläinen J. (2004) Remodeling of saccular cerebral artery aneurysm wall is associated with rupture: histological analysis of 24 unruptured and 42 ruptured cases. Stroke, 35, 2287-93. Eliason JL, Hannawa KK, Ailawadi G, Sinha I, Ford JW, Deogracias MP, Roelofs KJ, Woodrum DT, Ennis TL, Henke PK, Stanley JC, Thompson RW, Upchurch GJ. (2005) Neutrophil depletion inhibits experimental abdominal aortic aneurysm formation. Circulation, 112, 232-40. Peng F, Xia J, Niu H, Feng X, Zheng T, He X, Xu B, Chen X, Xu P, Zhang H, Chen J, Tong X, Bai X, Li Z, Duan Y, Sui B, Zhao X, Liu A. (2023) Systemic immune-inflammation index is associated with aneurysmal wall enhancement in unruptured intracranial fusiform aneurysms. Front Immunol, 14, 1106459. Zuo L, Prather ER, Stetskiv M, Garrison DE, Meade JR, Peace TI, Zhou T. (2019) Inflammaging and Oxidative Stress in Human Diseases: From Molecular Mechanisms to Novel Treatments. Int J Mol Sci, 20. Li X, Li C, Zhang W, Wang Y, Qian P, Huang H. (2023) Inflammation and aging: signaling pathways and intervention therapies. Signal Transduct Target Ther, 8, 239. Jiang Z, Zhang R, Sun M, Liu Q, Wang S, Wang W, Zhao Q, Zhang H, Wang Y, Hou J, Yu B. (2018) Effect of Clopidogrel vs Ticagrelor on Platelet Aggregation and Inflammation Markers After Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction. Can J Cardiol, 34, 1606-1612. Adali MK, Buber I, Kilic O, Turkoz A, Yilmaz S. (2022) Ticagrelor improves systemic immune-inflammation index in acute coronary syndrome patients. Acta Cardiol, 77, 632-638. Zheng Y, Liu Y, Leng B, Xu F, Tian Y. (2016) Periprocedural complications associated with endovascular treatment of intracranial aneurysms in 1764 cases. J Neurointerv Surg, 8, 152-7. Geraghty JR, Testai FD. (2017) Delayed Cerebral Ischemia after Subarachnoid Hemorrhage: Beyond Vasospasm and Towards a Multifactorial Pathophysiology. Curr Atheroscler Rep, 19, 50. Dangas GD, Schoos MM, Steg PG, Mehran R, Clemmensen P, van T HA, Prats J, Bernstein D, Deliargyris EN, Stone GW. (2016) Early Stent Thrombosis and Mortality After Primary Percutaneous Coronary Intervention in ST-Segment-Elevation Myocardial Infarction: A Patient-Level Analysis of 2 Randomized Trials. Circ Cardiovasc Interv, 9, e003272. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterials.pdf Cite Share Download PDF Status: Published Journal Publication published 22 Oct, 2024 Read the published version in Neurosurgical Review → Version 1 posted Editorial decision: Revision requested 25 Sep, 2024 Reviews received at journal 19 Sep, 2024 Reviewers agreed at journal 17 Sep, 2024 Reviewers agreed at journal 13 Sep, 2024 Reviews received at journal 02 Sep, 2024 Reviewers agreed at journal 20 Aug, 2024 Reviewers agreed at journal 19 Aug, 2024 Reviewers invited by journal 18 Aug, 2024 Editor assigned by journal 11 Aug, 2024 Submission checks completed at journal 01 Aug, 2024 First submitted to journal 31 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4833682","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":345990884,"identity":"1386e31a-42c6-4d0a-8fd4-1ed73d01fa05","order_by":0,"name":"Jiwan Huang","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiwan","middleName":"","lastName":"Huang","suffix":""},{"id":345990885,"identity":"7dafb6e4-0df3-4def-a858-c59158d26350","order_by":1,"name":"Yaxian Huang","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yaxian","middleName":"","lastName":"Huang","suffix":""},{"id":345990886,"identity":"325743ce-8139-4abc-9bf0-2ddfd7fca3a8","order_by":2,"name":"Xin Feng","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Feng","suffix":""},{"id":345990887,"identity":"d7317560-842c-4d8a-9070-1c7984459805","order_by":3,"name":"Chi Huang","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chi","middleName":"","lastName":"Huang","suffix":""},{"id":345990888,"identity":"7016d29c-e15b-426e-982b-b2a68cd1a20b","order_by":4,"name":"Mengshi Huang","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mengshi","middleName":"","lastName":"Huang","suffix":""},{"id":345990889,"identity":"8fbb8a5b-d8d2-4d92-85d6-226fb09bd483","order_by":5,"name":"Zhuohua Wen","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhuohua","middleName":"","lastName":"Wen","suffix":""},{"id":345990890,"identity":"e428d0c3-4936-4193-86c0-5eef8268c09f","order_by":6,"name":"Anqi Xu","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Anqi","middleName":"","lastName":"Xu","suffix":""},{"id":345990891,"identity":"512729d8-6559-4b2a-9bcd-965e5520f69f","order_by":7,"name":"Runze Ge","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Runze","middleName":"","lastName":"Ge","suffix":""},{"id":345990892,"identity":"e4bfaca5-ff35-41f9-8172-8ed2c4704a77","order_by":8,"name":"Hao Yuan","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Yuan","suffix":""},{"id":345990893,"identity":"a09dbca0-a262-4c4e-bcc2-4218fdb01d3d","order_by":9,"name":"Hongyu Shi","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hongyu","middleName":"","lastName":"Shi","suffix":""},{"id":345990894,"identity":"7378bed9-338e-4f54-b96d-0b3f7461e067","order_by":10,"name":"Gengwu Ma","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Gengwu","middleName":"","lastName":"Ma","suffix":""},{"id":345990895,"identity":"22282e6d-7d7a-4ee1-8f98-616b0576909c","order_by":11,"name":"Can Li","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Can","middleName":"","lastName":"Li","suffix":""},{"id":345990896,"identity":"3e1224c3-1425-4a48-814d-0214f12d0499","order_by":12,"name":"Jiancheng Lin","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiancheng","middleName":"","lastName":"Lin","suffix":""},{"id":345990897,"identity":"8ec0a06e-9ad8-42ea-8788-ec3e7dcb7c79","order_by":13,"name":"Ruizhe Yi","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ruizhe","middleName":"","lastName":"Yi","suffix":""},{"id":345990898,"identity":"9a363f42-1066-4199-99b0-cb66ba1ca3dd","order_by":14,"name":"Yuqi Hu","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuqi","middleName":"","lastName":"Hu","suffix":""},{"id":345990899,"identity":"70033dea-1588-43bf-8d46-903201029b6e","order_by":15,"name":"Yuheng Jin","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuheng","middleName":"","lastName":"Jin","suffix":""},{"id":345990900,"identity":"dabb65fb-9e0c-4808-bd70-7ea6a7a25eaa","order_by":16,"name":"Shuyin Liang","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shuyin","middleName":"","lastName":"Liang","suffix":""},{"id":345990901,"identity":"abe075ca-e19d-4aec-96a2-7b0ba360251a","order_by":17,"name":"Yiming Bi","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yiming","middleName":"","lastName":"Bi","suffix":""},{"id":345990902,"identity":"f69a22e6-8d66-45bd-acfe-e56ce61858b4","order_by":18,"name":"Shixing Su","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shixing","middleName":"","lastName":"Su","suffix":""},{"id":345990903,"identity":"802f7bdf-4117-4e85-8f05-dc3c678a3e06","order_by":19,"name":"Xin Zhang","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Zhang","suffix":""},{"id":345990905,"identity":"d8b651f5-dcf7-470d-a2ae-548466fb4562","order_by":20,"name":"Xifeng Li","email":"","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xifeng","middleName":"","lastName":"Li","suffix":""},{"id":345990906,"identity":"fc657f21-13bd-4bb0-8f74-d9458d9fb414","order_by":21,"name":"Chuanzhi Duan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYDCCAxCKsQFESlRIyMkToQWsGqrljIWxYQNJWhjbKhJh9uIEfMebnz/4uIdBdsPxs4c/WM6TSGBsYH746AYeLZJnjhk2znjGYLzhTF6CgeQ2iTx2BjZj4xw8Wgxu5DA28xxgSNxwIMcgAailmLGBh02aOC3n3xgckJwjkdhwgGgtN3IMGyQbiNAC8svMGQcYjGfeeGPMIHFMwtiwmYBfgCH24MOHAwyyfedzjD9L1NTJybM3P3yMTwsU/AeTzBJgkrByBGD8QIrqUTAKRsEoGDEAAIgjUVbuf+snAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Cerebrovascular Surgery, Zhujiang Hospital, Southern Medical University","correspondingAuthor":true,"prefix":"","firstName":"Chuanzhi","middleName":"","lastName":"Duan","suffix":""}],"badges":[],"createdAt":"2024-07-31 08:29:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4833682/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4833682/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10143-024-03053-0","type":"published","date":"2024-10-22T15:57:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64144850,"identity":"48ad9522-53a5-48f7-a332-359d5d23dd63","added_by":"auto","created_at":"2024-09-08 19:46:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2808142,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e\u0026nbsp;a-f\u003c/strong\u003e The violin plot in distribution of neutrophil counts, lymphocyte counts, platelet counts, neutrophil-to-lymphocyte ratio (NLR), systemic inflammation response index (SIRI) and systemic immune inflammation index (SII) in the patients with and without periprocedural complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea.\u003c/strong\u003e The violin plot in distribution of neutrophil counts in the patients with and without periprocedural complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb.\u003c/strong\u003e The violin plot in distribution of lymphocyte counts in the patients with and without periprocedural complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec.\u003c/strong\u003e The violin plot in distribution of platelet counts in the patients with and without periprocedural complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed.\u003c/strong\u003e The violin plot in distribution of neutrophil-to-lymphocyte ratio (NLR) in the patients with and without periprocedural complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ee.\u003c/strong\u003e The violin plot in distribution of systemic inflammation response index (SIRI) in the patients with and without periprocedural complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ef.\u003c/strong\u003e The violin plot in distribution of systemic immune inflammation index (SII) in the patients with and without periprocedural complications.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4833682/v1/1a7c9235562f745702fc6051.png"},{"id":64144847,"identity":"0e9cb440-c1fa-4671-9d01-ff052e39d753","added_by":"auto","created_at":"2024-09-08 19:46:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2087802,"visible":true,"origin":"","legend":"\u003cp\u003eMultivariable logistics regression analysis and forest plot for the patients with and without periprocedural complications.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4833682/v1/5250fe6f4148a081f9a40d3b.png"},{"id":64145928,"identity":"ad77ddda-b0e1-45d7-baed-8d65afef2a4d","added_by":"auto","created_at":"2024-09-08 19:54:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1874143,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea-d\u003c/strong\u003e. Analysis of perioperative complications and predictive model performance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea.\u003c/strong\u003e Decision tree for the patients with and without perioperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb.\u003c/strong\u003e Bar chart of the incidence of periprocedural complications in all patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec.\u003c/strong\u003e Comparison of ROC curves for prediction models in derivative cohorts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed.\u003c/strong\u003e Comparison of ROC curves for prediction models in validation cohorts.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4833682/v1/e52aa738d9e90718fa0eec80.png"},{"id":67682577,"identity":"e968b47d-d953-4b8b-b0eb-5729658e74b5","added_by":"auto","created_at":"2024-10-28 16:14:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7124678,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4833682/v1/8ed22456-145c-49d9-9b82-4d745cb601f3.pdf"},{"id":64144851,"identity":"9494dfc9-9b5f-4774-b821-d9e15f1e12d3","added_by":"auto","created_at":"2024-09-08 19:46:18","extension":"pdf","order_by":16,"title":"","display":"","copyAsset":false,"role":"supplement","size":445689,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4833682/v1/5cf7480eb104a710763e575f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predictive Value of the Systemic Immune-Inflammation Index for Periprocedural Complications in Flow Diverter Treatment for Patients with Intracranial Aneurysms","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFlow-diverter devices (FDs) have gained global recognition for their safety and efficacy in aneurysm management, with occlusion rates ranging from 76\u0026ndash;90%.[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Despite these promising outcomes, flow-diversion treatment is associated with an overall complication rate of 10.1%.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Consequently, the identification of risk factors for such adverse events is paramount to optimize therapeutic outcomes.\u003c/p\u003e \u003cp\u003ePrevious studies have predominantly concentrated on demographic, clinical, and morphological determinants, with the role of immune-inflammatory status receiving less attention.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Inflammatory responses, mediated by immune cells and platelet activation, are crucial for aneurysm repair through endothelial proliferation, yet may also precipitate in-stent stenosis and thrombosis.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Moreover, heightened inflammation could destabilize aneurysms, increasing the risk of periprocedural hemorrhage.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] The significance of inflammation in periprocedural management has been well established in the context of percutaneous coronary intervention.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] However, the association between inflammation and periprocedural complications in FDs treatment remains unclear.\u003c/p\u003e \u003cp\u003eThe systemic immune-inflammation index (SII), which incorporates neutrophil, lymphocyte, and platelet counts, reflects the complex interactions among immunity, inflammation, and coagulation processes. This complexity suggests that SII may be more sensitive in assessing the risk of vascular events.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] While it shows promise in predicting complications in cardiovascular interventions and cerebrovascular incidents,[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] further research is needed to determine its prognostic value in cerebrovascular interventions. Hence, this study aims to elucidate the correlation between preoperative SII and periprocedural complications in patients treated with FDs, refining intervention strategies and enhancing patient prognosis.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective analysis of a prospectively maintained database at our center. Consecutive patients treated with FDs between February 2016 and August 2023 were retrospectively reviewed.\u003c/p\u003e \u003cp\u003eThe inclusion criteria included the following: (1) Aged over 18 years old; (2) IAs treated with FDs. Exclusion criteria for the study were: (1) patients complicated by other cerebrovascular diseases (e.g., Moyamoya disease, arteriovenous malformation, or arteriovenous fistula); (2) patients with other conditions affecting inflammatory cell counts, such as acute infectious inflammation (e.g., pneumonia or urinary tract infection), autoimmune diseases, or a history of cancer; (3) patients with inadequate venous blood samples collected upon admission, poor image quality, or incomplete medical records. This study received approval from the institutional review boards of centers, and informed consent was waived owing to the anonymous design of the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection and definitions\u003c/h2\u003e \u003cp\u003eOn the admission day, demographic and clinical characteristics were systematically recorded for all participants. These included age, gender, BMI, and medical history (hypertension, diabetes mellitus, dyslipidemia, history of smoking, drinking, hemorrhage, ischemic, and coronary artery disease). Angiographic evaluations of IAs such as location, morphology, neck width, tandem aneurysms (multiple IAs in close proximity to one another on the same or adjacent vascular segments that are not interconnected), regular aneurysms (without daughter sacs or lobulations), vessel diameter (the mean diameter of the parent vessel at the proximal and distal ends of the aneurysms) were conducted. The angiographic data was analyzed by two researchers, while three seasoned neurointerventionalists, each with over a decade of experience, supervised the measurements. Detailed procedural data were extracted from the electronic medical records, documenting dual antiplatelet therapy, FDs specifics, nominal stent diameter and length, coiling assistance, and balloon angioplasty usage.\u003c/p\u003e \u003cp\u003ePeriprocedural complications, defined as cerebrovascular incidents within 30 days post-procedure, included intraoperative aneurysm rupture, intraprocedural thrombosis, hemorrhagic events (subarachnoid and intraparenchymal hemorrhage), and ischemic strokes (transient ischemic attacks [TIA], mild ischemia with National Institutes of Health Stroke Scale (NIHSS) score\u0026thinsp;\u0026le;\u0026thinsp;4, and severe ischemia with NIHSS\u0026thinsp;\u0026gt;\u0026thinsp;4). Severe functional impairment was also evaluated.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe blood laboratory data were collected within 6 days before surgery, including neutrophil count, lymphocyte count, monocyte count, and platelet count. The neutrophil-to-lymphocyte ratio (NLR) was defined as the number of neutrophils divided by the number of lymphocytes. Systemic inflammation response index (SIRI) was defined as the number of Monocyte count multiplied by the neutrophil-to-lymphocyte ratio. The systemic immune-inflammation index (SII) is defined as the product of platelet count multiplied by the neutrophil-to-lymphocyte ratio, divided by 1000. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEndovascular treatment procedure\u003c/h2\u003e \u003cp\u003eBefore the procedure, patients were administered dual antiplatelet therapy (DAPT) comprising daily doses of aspirin (100 mg) and clopidogrel (75 mg) for at least three days. Preoperative assessment for platelet function testing conducted at least one day prior to the procedure. For those exhibiting clopidogrel resistance, ticagrelor was employed as an alternative antiplatelet agent. General anesthesia was administered, and patients were fully heparinized during the operation.\u003c/p\u003e \u003cp\u003eThe preferred method for accessing the target aneurysm was the transfemoral arterial approach utilizing a triaxial system. Stent deployment was generally achieved using the non-compacting technique, with the pushing\u0026ndash;compaction operation employed infrequently. The stents were sized to extend at least 5mm beyond both the proximal and distal ends of the aneurysms. Balloon angioplasty was commonly used to correct severely poor wall apposition. Adjunctive coiling was considered under specific circumstances: (1) the potential risk of stent shortening or migration, and (2) an increased likelihood of aneurysm recurrence or rupture, which could be attributed to elevated blood flow velocities at the aneurysm neck. A group of neurointerventionalists, each boasting over 15 years of experience in treating aneurysms, made the decisions regarding the ultimate choice of stents and the approach to treatment.\u003c/p\u003e \u003cp\u003ePost-procedure management involved continuing dual antiplatelet therapy for 6 to 12 months, followed by a single antiplatelet regimen of daily aspirin (100 mg) for an additional 6 to 9 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using R (v4.3.2), with normality assessed by the Kolmogorov-Smirnov test. Continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median (IQR) and analyzed with the t-test or Wilcoxon test. Categorical variables were reported as frequencies and proportions and analyzed using the Χ2 or Fisher\u0026rsquo;s exact test. The study cohort of 452 IAs was divided into derivation (70%) and validation (30%) subsets. Variables that had P value\u0026thinsp;\u0026lt;\u0026thinsp;0.1 and demonstrated clinical significance were incorporated into three separate multivariate logistic regression models\u0026mdash;Model 1, Model 2, and Model 3\u0026mdash;each evaluating the NLR, SIRI and SII, respectively. Subgroup analyses were conducted to explore SII's association with complications in the elderly and those on dual antiplatelet regimens. The Decision Tree model was developed using 'caret' and 'rpart' packages, with feature selection guided by a P value\u0026thinsp;\u0026lt;\u0026thinsp;0.1 and tenfold cross-validation. The model used the 'Gini' criterion and a maximum depth of 10. ROC analysis evaluated the predictive accuracy of the DT and multivariate models for complications. SII values were dichotomized based on Decision Tree outcomes to further investigate their association with periprocedural complications.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eDemographic and aneurysm characteristics\u003c/h2\u003e\n \u003cp\u003eIn our study, we evaluated 488 IAs treated with FDs in 449 patients. Out of these, 452 IAs (92.6%) met our stringent inclusion criteria (\u003cstrong\u003eSupplemental Figure. 1\u003c/strong\u003e). In the total cohort, the mean age was 56(IQR:46.8\u0026ndash;64.0) years, and 306 patients (67.7%) were female, 19 patients (4.20%) presented with periprocedural complications and 433(95.8%) did not. The characteristics of 452 IAs from 418 patients in the derivation and validation cohorts have been compared in \u003cstrong\u003eSupplemental Table\u0026nbsp;1\u003c/strong\u003e. No significant differences were noted between the derivation and validation cohort.\u003c/p\u003e\n \u003cp\u003eThe results of univariate analysis are shown in Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e. In the derivation cohort, compared with those without periprocedural complications, patients with periprocedural complications tended to have a diabetes (42.9% vs 11.9%, P\u0026thinsp;=\u0026thinsp;0.005), hemorrhagic history (35.7% vs 6.9%, P\u0026thinsp;=\u0026thinsp;0.003), larger neck width of the aneurysm (7.58 vs 4.27, P\u0026thinsp;=\u0026thinsp;0.039), different dual antiplatelet regimen (P\u0026thinsp;=\u0026thinsp;0.035) and worse preoperative mRS score (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients with complications also showed a trend towards increased neutrophil and platelet counts, though these did not statistically differ (p\u0026thinsp;=\u0026thinsp;0.067, 0.350 respectively). Notably, preoperative SII differed significantly between two groups (0.54 vs 0.43 \u0026times;10\u003csup\u003e9\u003c/sup\u003e/L, P\u0026thinsp;=\u0026thinsp;0.056). Other baseline characteristics were similar between the two groups. ROC analysis was performed to determine ability of SII index to distinguish patients who did or did not periprocedural complications (AUC of 0.651 on the derivation cohort and 0.758 on the validation cohort, Fig.\u0026nbsp;\u003cspan\u003e3\u003c/span\u003ec, d).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eUnivariate analysis between periprocedural complications and no periprocedural complications group of 452 aneurysms in the derivation and validation cohort.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"9\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eDerivation cohort\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eValidation cohort\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo PPC Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePPC Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo PPC Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePPC Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e318\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e304\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e134\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57.00 [47.00, 64.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56.00 [47.00, 63.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e61.50 [55.25, 66.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56.00 [46.00, 63.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56.00 [46.00, 63.75]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51.00 [46.00, 57.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.445\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender, female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e214 (67.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e207 (68.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92 (68.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89 (68.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.653\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.44 [21.51, 25.09]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.44 [21.66, 25.12]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.54 [20.43, 24.72]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.916\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.44 [21.59, 25.55]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.41 [21.59, 25.53]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.52 [22.04, 28.04]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.775\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e117 (36.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e109 (36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57 (42.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54 (41.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.650\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHyperlipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e98 (30.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e96 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39 (28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37 (28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.626\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.005*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14 (10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCoronary disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.306\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHistory of smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.427\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHistory of drinking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.636\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.377\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHemorrhagic history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIschemic stroke history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66 (20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60 (19.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative mRS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.244\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e146 (46.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e144 (47.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53 (39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e130 (41.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e126 (41.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65 (48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64 (49.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26 (8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10 (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePosterior circulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33 (10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21 (16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegular aneurysm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e256 (80.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e247 (81.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9 (64.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e97 (71.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e94 (72.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.620\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMorphological feature, saccular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e287 (90.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e276 (91.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11 (78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e118 (87.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e115 (88.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTandem IAs\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e81 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e78 (25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeck width (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.37 [3.20, 6.10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.27 [3.18, 5.90]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.58 [3.76, 9.39]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.039*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.09 [3.77, 6.92]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.04 [3.75, 6.89]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.17 [4.58, 22.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVessel diameter (mm)\u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.95 [3.48, 4.45]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.95 [3.49, 4.48]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.95 [3.36, 4.24]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.728\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.95 [3.38, 4.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.95 [3.38, 4.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.21 [3.80, 4.25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.958\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDual antiplatelet regimen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.035*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClopidogrel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e170 (53.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e164 (54.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e73 (54.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e72 (55.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTicagrelor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e94 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92 (30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43 (33.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e47 (15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStent type, TED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e186 (58.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e179 (59.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.583\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e71 (52.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e70 (53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.190\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNominal stent diameter (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.00 [3.75, 4.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.00 [3.75, 4.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.00 [3.75, 4.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.903\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.00 [3.50, 4.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.00 [3.50, 4.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.00 [3.75, 4.25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.976\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNominal stent length (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.00 [20.00, 30.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.00 [20.00, 30.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.00 [20.00, 30.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.224\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.00 [20.00, 30.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.00 [20.00, 30.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.00 [18.00, 35.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.484\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBalloon angioplasty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdjunctive coiling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58 (18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31 (23.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29 (22.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.324\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeutrophils, 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.45 [2.65, 4.49]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.43 [2.63, 4.44]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.37 [3.36, 5.49]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.78 [2.92, 5.14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.78 [2.92, 5.15]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.78 [3.73, 4.44]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.829\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLymphocytes, 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.88 [1.51, 2.30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.88 [1.52, 2.30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.82 [1.37, 2.31]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.704\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.98 [1.58, 2.48]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.99 [1.59, 2.50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.18 [0.99, 1.93]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMonocytes, 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.49 [0.39, 0.58]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.49 [0.39, 0.58]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.47 [0.41, 0.58]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.911\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.50 [0.42, 0.65]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.50 [0.41, 0.65]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.54 [0.45, 0.57]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.731\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlatelets, 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e239.00 [208.00, 279.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e237.00 [208.00, 279.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e269.00 [238.00, 276.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e249.00 [204.00, 283.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e247.50 [204.00, 280.75]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e250.00 [198.00, 306.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.889\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNLR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.76 [1.36, 2.56]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.75 [1.35, 2.48]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.23 [1.46, 3.22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.89 [1.47, 2.64]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.85 [1.46, 2.59]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.02 [2.25, 3.81]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSIRI, 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.90 [0.59, 1.35]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.90 [0.58, 1.35]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.99 [0.76, 1.46]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.384\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.98 [0.65, 1.52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.98 [0.64, 1.47]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.71 [1.22, 2.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSII, 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.44 [0.32, 0.66]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.43 [0.32, 0.66]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.54 [0.40, 0.87]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.46 [0.35, 0.68]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.45 [0.32, 0.67]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.74 [0.66, 0.76]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.050\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003eValues are shown as median (IQR) or frequency (%) unless indicated otherwise.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003e* Statistic difference.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003ePPC, periprocedural complications; No PPC, no periprocedural complications; NLR, neutrophil to lymphocyte ratio; SII, systemic immune-inflammation index; SIRI, Systemic inflammation response index.\u003c/p\u003e\n \u003cp\u003e\u0026dagger;Multiple IAs in close proximity to one another on the same or adjacent vascular segments that are not interconnected.\u003c/p\u003e\n \u003cp\u003e\u0026Dagger;The mean diameter of the vessel at the proximal and distal ends of the aneurysms.\u003c/p\u003e\n \u003cp\u003eIn the entire cohort, the relationships between neutrophil count, lymphocyte count, platelet count, NLR, SIRI and SII with periprocedural complications were visualized using violin plots \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. The conclusions drawn were consistent with those from the derivation cohort, with significant differences observed in NLR and SII between two groups (P\u0026thinsp;=\u0026thinsp;0.022; P\u0026thinsp;=\u0026thinsp;0.010), respectively.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003eCharacteristics of Periprocedural Complications in 19 Cases\u003c/h2\u003e\n \u003cp\u003eIn this study, we investigated periprocedural complications in 19 patients treated with flow diverters (FDs) for cerebral aneurysms \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. Complications were categorized as ischemic, hemorrhagic, and other types, and monitored during the periprocedural period. Ischemic complications were the most prevalent, occurring in 12 patients (63.16%). These included intraprocedural thrombosis in four cases (21.05%), which rapidly resolved following intraoperative administration of tirofiban, without subsequent adverse events. Transient ischemic attacks (TIAs) or minor strokes were observed in four patients (21.05%), and four cases (21.05%) were confirmed as major ischemic strokes. Hemorrhagic events were observed in 5 patients (26.32%), with subarachnoid hemorrhage (SAH) occurring in 4 patients (21.05%). These hemorrhages occurred either immediately or up to 11 hours post-procedure. Furthermore, intraparenchymal hemorrhage was recorded in 1 patient (5.26%). Other types of complications affected 2 patients (10.53%), including cranial nerve palsy and cerebellar edema, each identified within a day of the procedure. For a detailed overview of baseline characteristics, aneurysm locations, types of devices utilized, and pharmaceutical regimens are shown in \u003cstrong\u003eSupplemental Table\u0026nbsp;2\u003c/strong\u003e.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePeriprocedural complications in 19 patients.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eEvent\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eIschemic complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntraprocedural thrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.05%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTIA/minor stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.05%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMajor ischemic stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.05%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eHemorrhagic complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubarachnoid hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.05%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntraparenchymal hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.26%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.53%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003eLogistic regression and decision tree for prediction of periprocedural Complications\u003c/h2\u003e\n \u003cp\u003eThe logistic regression analysis showed that, after adjusting for baseline differences (history of smoking, diabetes, hemorrhagic history, ischemic stroke history, neck width, stent type and balloon angioplasty), diabetes (OR: 5.885, 95%CI: 1.563\u0026ndash;22.042; P\u0026thinsp;=\u0026thinsp;0.007), and hemorrhagic history (OR: 15.102, 95%CI: 3.485\u0026ndash;68.228; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) as significant predictors of complications, with SII showing the highest odds ratio (OR) of 5.306 (95%CI:1.367\u0026ndash;18.455; P\u0026thinsp;=\u0026thinsp;0.009) across all models (Fig.\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e). The model demonstrated reliable performance with an AUC of 0.792 in the derivation cohort and 0.898 in the validation cohort, achieving a sensitivity of 0.80 and a specificity of 0.986 at the optimal cutoff (Fig.\u0026nbsp;\u003cspan\u003e3\u003c/span\u003ec, d).\u003c/p\u003e\n \u003cp\u003eDT with four nodes and five leaves was constructed, using SII、neck of aneurysm as predictors, as shown in Fig.\u0026nbsp;\u003cspan\u003e3\u003c/span\u003ea. According to the DT, participants with aneurysm neck diameters between 6.68 and 10.985 had a 33.0% chance of experiencing periprocedural complications if their SII exceeded 0.437. The DT model\u0026apos;s AUC of 0.797 in the derivation cohort and 0.830 in the validation cohort (Fig.\u0026nbsp;\u003cspan\u003e3\u003c/span\u003ec, d).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003eSII index and periprocedural complication events in the overall population\u003c/h2\u003e\n \u003cp\u003eIn this subgroup analysis from Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e, the SII demonstrates a significant association with periprocedural complications among patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65, exhibiting a notably high adjusted OR of 36.979 (95% CI: 2.103-650.134; P\u0026thinsp;=\u0026thinsp;0.014). Similarly, the SII serves as a significant predictor of complications in patients receiving clopidogrel, with an adjusted OR of 16.921 (95% CI: 2.733-104.746; P\u0026thinsp;=\u0026thinsp;0.002). These findings underscore the substantial predictive value of SII for periprocedural risks within these specific patient cohorts.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSubgroup analysis for association between SII and periprocedural complications in the elderly and those on dual antiplatelet regimens.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSubgroup\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en total\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePPC case n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAdjusted\u003c/p\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eSII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u0026thinsp;\u0026lt;\u0026thinsp;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (3.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.343\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.448 (0.384\u0026ndash;15.601)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (5.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.979 (2.103-650.134)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClopidogrel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e243\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (2.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.921 (2.733-104.746)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTicagrelor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.269 (0.197\u0026ndash;92.543)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (11.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.269 (0.197\u0026ndash;92.543)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eAdjusted for baseline differences (history of smoking, diabetes, hemorrhagic history, ischemic stroke history, neck width, stent type and balloon angioplasty).\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e SII, systemic immune-inflammation index; PPC, periprocedural complications; OR, odds ratio; CI, confidence interval.\u003c/p\u003e\n \u003cp\u003eFigure \u003cspan\u003e3\u003c/span\u003eb demonstrates the relationship between the SII and periprocedural complications. An elevated SII (\u0026gt;\u0026thinsp;0.437) is significantly correlated with increased periprocedural complications (p\u0026thinsp;=\u0026thinsp;0.017). Although not statistically significant across all categories, the incidence of complications, especially ischemic ones (p\u0026thinsp;=\u0026thinsp;0.063), is higher in the group with an SII\u0026thinsp;\u0026gt;\u0026thinsp;0.437 compared to the group with an SII\u0026thinsp;\u0026lt;\u0026thinsp;0.437.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first study to explore the prognostic value of the SII in patients undergoing FDs treatment for IAs. We found a significant association between SII and periprocedural complications, first validating SII as an independent prognostic factor through logistic regression and decision tree analysis. These findings not only offer a potential risk assessment tool for clinical applications but also underscore the important role of inflammation in periprocedural complications following endovascular treatment.\u003c/p\u003e \u003cp\u003eThe NLR is an established marker for heart failure, cardiovascular diseases, and chronic inflammatory conditions, offering a quick assessment of the inflammatory state.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] However, NLR primarily focuses on the ratio between neutrophils and lymphocytes, potentially not fully reflecting the full scope of systemic inflammation. The SIRI has shown potential in predicting outcomes in stroke patients but may still miss other inflammatory parameters.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] In contrast, the SII, which integrates neutrophil, lymphocyte, and platelet counts, provides a more comprehensive evaluation of the inflammatory state. Platelets play a crucial role in both inflammatory responses and thrombus formation, making SII potentially more sensitive in assessing vascular event risks.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] An elevated SII may reflect a broader inflammatory and vascular response, which is particularly relevant in neurointerventional surgeries involving vascular manipulation and potential injury.\u003c/p\u003e \u003cp\u003ePrevious studies on FD treatment have identified major risk factors for periprocedural complications, such as basilar artery aneurysms, hypertension, ischemic stroke, and a history of subarachnoid hemorrhage.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] However, limited research exists on the systemic immune-inflammatory state of patients. Emerging evidence indicates that inflammatory mechanisms play a significant role in periprocedural ischemic and bleeding events following endovascular treatments. Mechanical injuries from stenting can trigger cerebral vasospasm, leading to TIA,[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and activate inflammatory pathways that promote thrombogenesis. Inflammatory responses, involving the release of various mediators, can hinder stent endothelialization and exacerbate thrombosis risk.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Thrombin amplifies this process by promoting leukocyte adhesion, smooth muscle cell proliferation, and the release of inflammatory cytokines, creating a feedback loop that furthers inflammation and thrombus formation. Even with dual antiplatelet therapy, these phenomena are challenging to completely avoid.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Meanwhile, Inflammation is increasingly recognized as a key factor in the pathogenesis and progression of IAs,[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] with inflammatory cell infiltration in the aneurysm wall significantly contributing to its vulnerability.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Neutrophils and lymphocytes produce enzymes and cytokines that degrade the extracellular matrix and elevate rupture risk. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] The exacerbation of the inflammatory response intensifies the activity of these cells in the aneurysm wall, further destabilizing the structure. Platelets further support these inflammatory and immune responses, increasing the potential for aneurysmal instability and hemorrhagic events.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Based on the results of a Decision Tree analysis, further stratified analysis was conducted, revealing that patients with a SII exceeding 0.437 face a significantly increased risk of periprocedural complications, particularly ischemic events during the periprocedural period. This finding may offer new insights for clinical management, suggesting that SII could serve as a valuable biomarker for risk stratification in the periprocedural setting.\u003c/p\u003e \u003cp\u003eIn cerebrovascular diseases, age is a recognized risk factor, and DAPT affects periprocedural outcomes. Our exploratory subgroup analysis assessed the impact of age and DAPT regimens on periprocedural outcomes. We found that in patients over 65, high SII levels were significantly linked to increased periprocedural complications (adjusted OR\u0026thinsp;=\u0026thinsp;36.979; P\u0026thinsp;=\u0026thinsp;0.014), Likely due to age-related oxidative stress and chronic inflammation's impact on surgical outcomes. Age-related decline in antioxidant capacity and chronic inflammation accumulation may weaken the body's regulation and defense against inflammation, increasing periprocedural complications risk.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Further analysis of antiplatelet therapy outcomes revealed that patients treated with clopidogrel showed elevated SII levels and a correspondingly increased risk of periprocedural complications (adjusted OR\u0026thinsp;=\u0026thinsp;16.921; P\u0026thinsp;=\u0026thinsp;0.002), suggesting suboptimal antiplatelet efficacy under inflammatory stress compared to a baseline cohort risk (adjusted OR\u0026thinsp;=\u0026thinsp;5.306). In contrast, ticagrelor was associated with a lower risk of complications (adjusted OR\u0026thinsp;=\u0026thinsp;4.269), evidencing more robust platelet inhibition. Although the precise mechanisms are not yet clear, this phenomenon may be due to ticagrelor's more stable antiplatelet effects at elevated levels of systemic inflammation.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Moreover, the association of ticagrelor with reduced inflammatory indices during post-PCI follow-up suggests that its anti-inflammatory properties might contribute to the clinical benefits observed with antiplatelet therapy.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Therefore, we recommend a personalized approach for elderly patients with high inflammatory profiles, favoring ticagrelor for its stable antiplatelet effect and potential anti-inflammatory properties, to optimize endovascular treatment outcomes.\u003c/p\u003e \u003cp\u003eOur multivariate analysis confirmed diabetes and a history of bleeding as independent predictors of complication risk, consistent with existing literature.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] Following aneurysm rupture, vasospasms related to subarachnoid hemorrhage (SAH) and a hypercoagulable state further increase the risk of ischemic complications.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] These pathological states warrant attention in treatment strategies. Following endovascular treatment in diabetic patients, the increased risk of ischemic events may be attributed to the high expression and aggregation of glycoprotein IIB/IIIA receptors, particularly under hyperglycemic conditions, and an enhanced inflammatory response. These findings underscore the importance of managing diabetes and a history of bleeding in treating IAs.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] For patients with these risk factors, closer monitoring and more aggressive antiplatelet or anticoagulation therapy may be necessary.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eDespite valuable insights, this study's single-center, retrospective design may limit the generalizability of the findings. The SII is influenced by various factors, including age, gender, comorbidities, and other inflammatory conditions. Although efforts were made to exclude patients with such conditions, their potential impact cannot be entirely excluded. Thus, caution is warranted when applying SII as an independent predictive factor.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAn elevated preoperative SII, along with a history of hemorrhage and diabetes, are independent risk factors for periprocedural complications in patients undergoing FDs for IAs, especially ischemic events. SII, a readily attainable indicator reflecting inflammation and immune status, is valuable for predicting and intervening early in complications. Older patients and those on clopidogrel may require more attention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJiwan Huang and Yaxian Huang make equal contributions to this research. Xin Feng and Chuanzhi Duan are co corresponding authors. Jiwan Huang: designed, conceptualized the study and drafted the manuscript; Yaxian Huang, Chi Huang, Mengshi Huang: analyzed and interpreted the data; Zhuohua Wen, Anqi Xu, Runze Ge, Hao Yuan, Hongyu Shi, Gengwu Ma, Can Li, Jiancheng Lin, Ruizhe Yi, Yuqi Hu, Yuheng Jin: collected the data; Shuyin Liang, Yiming Bi, Shixing Su, Xin Zhang and Xifeng Li: critically revised the study outcomes; Xin Feng and Chuanzhi Duan: funding, study supervision, and critical revision of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the Ethics Committee of Zhujiang Hospital of Southern Medical University (2023-KY-023-02) and conforms to the ethical standards as per the revised Declaration of Helsinki. The study is registered with ClinicalTrials.gov (NCT06446778). We retrospectively analyzed data collected through January 2023; however, all of these data were initially collected prospectively at the time of patient admission Data after January 2023 were collected in a prospective design. And participants gave informed consent to participate in the study before taking part. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors of the manuscript agreed to its publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Natural Science Foundation of China (82201427) and the Foundation of National Heath Commission Capacity Building and Continuing Education Center (GWJJ2022100102). \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe supporting data of this study is available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBecske T, Brinjikji W, Potts MB, Kallmes DF, Shapiro M, Moran CJ, Levy EI, McDougall CG, Szikora I, Lanzino G, Woo HH, Lopes DK, Siddiqui AH, Albuquerque FC, Fiorella DJ, Saatci I, Cekirge SH, Berez AL, Cher DJ, Berentei Z, Marosfoi M, Nelson PK. (2017) Long-Term Clinical and Angiographic Outcomes Following Pipeline Embolization Device Treatment of Complex Internal Carotid Artery Aneurysms: Five-Year Results of the Pipeline for Uncoilable or Failed Aneurysms Trial. Neurosurgery, 80, 40-48.\u003c/li\u003e\n\u003cli\u003eHanel RA, Kallmes DF, Lopes DK, Nelson PK, Siddiqui A, Jabbour P, Pereira VM, Szikora II, Zaidat OO, Bettegowda C, Colby GP, Mokin M, Schirmer C, Hellinger FR, Given IC, Krings T, Taussky P, Toth G, Fraser JF, Chen M, Priest R, Kan P, Fiorella D, Frei D, Aagaard-Kienitz B, Diaz O, Malek AM, Cawley CM, Puri AS. (2020) Prospective study on embolization of intracranial aneurysms with the pipeline device: the PREMIER study 1 year results. J Neurointerv Surg, 12, 62-66.\u003c/li\u003e\n\u003cli\u003eKang H, Zhou Y, Luo B, Lv N, Zhang H, Li T, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Yang X, Liu J. (2021) Pipeline Embolization Device for Intracranial Aneurysms in a Large Chinese Cohort: Complication Risk Factor Analysis. Neurotherapeutics, 18, 1198-1206.\u003c/li\u003e\n\u003cli\u003eBhatia KD, Kortman H, Orru E, Klostranec JM, Pereira VM, Krings T. (2019) Periprocedural complications of second-generation flow diverter treatment using Pipeline Flex for unruptured intracranial aneurysms: a systematic review and meta-analysis. J Neurointerv Surg, 11, 817-824.\u003c/li\u003e\n\u003cli\u003eSweid A, Starke RM, Herial N, Chalouhi N, Das S, Baldassari MP, Alexander TD, Tjoumakaris S, Gooch MR, Hasan D, Rosenwasser RH, Romo V, Jabbour P. (2020) Predictors of Complications, Functional Outcome, and Morbidity in a Large Cohort Treated With Flow Diversion. Neurosurgery, 87, 730-743.\u003c/li\u003e\n\u003cli\u003eEvans CE, Iruela-Arispe ML, Zhao YY. (2021) Mechanisms of Endothelial Regeneration and Vascular Repair and Their Application to Regenerative Medicine. Am J Pathol, 191, 52-65.\u003c/li\u003e\n\u003cli\u003eFang J, Cao Y, Ni J. (2024) Circulating inflammatory biomarkers and risk of intracranial aneurysm: a Mendelian randomization study. Eur J Med Res, 29, 17.\u003c/li\u003e\n\u003cli\u003eAkboga MK, Inanc IH, Sabanoglu C, Akdi A, Yakut I, Yuksekkaya B, Nurkoc S, Yalcin R. (2023) Systemic Immune-Inflammation Index and C-Reactive Protein/Albumin Ratio Could Predict Acute Stent Thrombosis and High SYNTAX Score in Acute Coronary Syndrome. Angiology, 74, 693-701.\u003c/li\u003e\n\u003cli\u003eGeraghty JR, Lung TJ, Hirsch Y, Katz EA, Cheng T, Saini NS, Pandey DK, Testai FD. (2021) Systemic Immune-Inflammation Index Predicts Delayed Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery, 89, 1071-1079.\u003c/li\u003e\n\u003cli\u003eMorikawa S, Okumura K, Inoue N, Ogane T, Takayama Y, Murohara T. (2023) Systemic immune-inflammation index as a predictor of prognosis after carotid artery stenting compared with C-reactive protein. PLoS One, 18, e0288564.\u003c/li\u003e\n\u003cli\u003eHuang C, Ma G, Tong X, Feng X, Wen Z, Huang M, Xu A, Yuan H, Shi H, Lin J, Li C, Ge R, Huang J, Peng C, Zhu Y, Wang T, Huang C, Guo Z, Liang S, Su S, Zhang X, Li X, Liu A, Duan CZ. (2024) Comparison of Pipeline embolization device versus Tubridge embolization device in unruptured intracranial aneurysms: a multicenter, propensity score matched study. J Neurointerv Surg.\u003c/li\u003e\n\u003cli\u003eWang RH, Wen WX, Jiang ZP, Du ZP, Ma ZH, Lu AL, Li HP, Yuan F, Wu SB, Guo JW, Cai YF, Huang Y, Wang LX, Lu HJ. (2023) The clinical value of neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR) and systemic inflammation response index (SIRI) for predicting the occurrence and severity of pneumonia in patients with intracerebral hemorrhage. Front Immunol, 14, 1115031.\u003c/li\u003e\n\u003cli\u003eGarc\u0026iacute;a-Escobar A, Vera-Vera S, T\u0026eacute;bar-M\u0026aacute;rquez D, Rivero-Santana B, Jurado-Rom\u0026aacute;n A, Jim\u0026eacute;nez-Valero S, Galeote G, Cabrera J\u0026Aacute;, Moreno R. (2023) Neutrophil-to-lymphocyte ratio an inflammatory biomarker, and prognostic marker in heart failure, cardiovascular disease and chronic inflammatory diseases: New insights for a potential predictor of anti-cytokine therapy responsiveness. Microvasc Res, 150, 104598.\u003c/li\u003e\n\u003cli\u003eHuang YW, Zhang Y, Feng C, An YH, Li ZP, Yin XS. (2023) Systemic inflammation response index as a clinical outcome evaluating tool and prognostic indicator for hospitalized stroke patients: a systematic review and meta-analysis. Eur J Med Res, 28, 474.\u003c/li\u003e\n\u003cli\u003eYang YL, Wu CH, Hsu PF, Chen SC, Huang SS, Chan WL, Lin SJ, Chou CY, Chen JW, Pan JP, Charng MJ, Chen YH, Wu TC, Lu TM, Huang PH, Cheng HM, Huang CC, Sung SH, Lin YJ, Leu HB. (2020) Systemic immune-inflammation index (SII) predicted clinical outcome in patients with coronary artery disease. Eur J Clin Invest, 50, e13230.\u003c/li\u003e\n\u003cli\u003eHan J, Liu F, Chen J, Tong X, Han M, Peng F, Niu H, Liu L, Liu A. (2022) Periprocedural cerebrovascular complications and 30-day outcomes of endovascular treatment for intracranial vertebral artery dissecting aneurysms. J Neurosurg, 1-9.\u003c/li\u003e\n\u003cli\u003eZhu Y, Zhang H, Zhang Y, Wu H, Wei L, Zhou G, Zhang Y, Deng L, Cheng Y, Li M, Santos HA, Cui W. (2019) Endovascular Metal Devices for the Treatment of Cerebrovascular Diseases. Adv Mater, 31, e1805452.\u003c/li\u003e\n\u003cli\u003eXue J, Zhang Z, Sun Y, Jin D, Guo L, Li X, Zhao D, Feng X, Qi W, Zhu H. (2023) Research Progress and Molecular Mechanisms of Endothelial Cells Inflammation in Vascular-Related Diseases. J Inflamm Res, 16, 3593-3617.\u003c/li\u003e\n\u003cli\u003eCroce K, Libby P. (2007) Intertwining of thrombosis and inflammation in atherosclerosis. Curr Opin Hematol, 14, 55-61.\u003c/li\u003e\n\u003cli\u003eHosaka K, Hoh BL. (2014) Inflammation and cerebral aneurysms. Transl Stroke Res, 5, 190-8.\u003c/li\u003e\n\u003cli\u003eFr\u0026ouml;sen J, Piippo A, Paetau A, Kangasniemi M, Niemel\u0026auml; M, Hernesniemi J, J\u0026auml;\u0026auml;skel\u0026auml;inen J. (2004) Remodeling of saccular cerebral artery aneurysm wall is associated with rupture: histological analysis of 24 unruptured and 42 ruptured cases. Stroke, 35, 2287-93.\u003c/li\u003e\n\u003cli\u003eEliason JL, Hannawa KK, Ailawadi G, Sinha I, Ford JW, Deogracias MP, Roelofs KJ, Woodrum DT, Ennis TL, Henke PK, Stanley JC, Thompson RW, Upchurch GJ. (2005) Neutrophil depletion inhibits experimental abdominal aortic aneurysm formation. Circulation, 112, 232-40.\u003c/li\u003e\n\u003cli\u003ePeng F, Xia J, Niu H, Feng X, Zheng T, He X, Xu B, Chen X, Xu P, Zhang H, Chen J, Tong X, Bai X, Li Z, Duan Y, Sui B, Zhao X, Liu A. (2023) Systemic immune-inflammation index is associated with aneurysmal wall enhancement in unruptured intracranial fusiform aneurysms. Front Immunol, 14, 1106459.\u003c/li\u003e\n\u003cli\u003eZuo L, Prather ER, Stetskiv M, Garrison DE, Meade JR, Peace TI, Zhou T. (2019) Inflammaging and Oxidative Stress in Human Diseases: From Molecular Mechanisms to Novel Treatments. Int J Mol Sci, 20.\u003c/li\u003e\n\u003cli\u003eLi X, Li C, Zhang W, Wang Y, Qian P, Huang H. (2023) Inflammation and aging: signaling pathways and intervention therapies. Signal Transduct Target Ther, 8, 239.\u003c/li\u003e\n\u003cli\u003eJiang Z, Zhang R, Sun M, Liu Q, Wang S, Wang W, Zhao Q, Zhang H, Wang Y, Hou J, Yu B. (2018) Effect of Clopidogrel vs Ticagrelor on Platelet Aggregation and Inflammation Markers After Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction. Can J Cardiol, 34, 1606-1612.\u003c/li\u003e\n\u003cli\u003eAdali MK, Buber I, Kilic O, Turkoz A, Yilmaz S. (2022) Ticagrelor improves systemic immune-inflammation index in acute coronary syndrome patients. Acta Cardiol, 77, 632-638.\u003c/li\u003e\n\u003cli\u003eZheng Y, Liu Y, Leng B, Xu F, Tian Y. (2016) Periprocedural complications associated with endovascular treatment of intracranial aneurysms in 1764 cases. J Neurointerv Surg, 8, 152-7.\u003c/li\u003e\n\u003cli\u003eGeraghty JR, Testai FD. (2017) Delayed Cerebral Ischemia after Subarachnoid Hemorrhage: Beyond Vasospasm and Towards a Multifactorial Pathophysiology. Curr Atheroscler Rep, 19, 50.\u003c/li\u003e\n\u003cli\u003eDangas GD, Schoos MM, Steg PG, Mehran R, Clemmensen P, van T HA, Prats J, Bernstein D, Deliargyris EN, Stone GW. (2016) Early Stent Thrombosis and Mortality After Primary Percutaneous Coronary Intervention in ST-Segment-Elevation Myocardial Infarction: A Patient-Level Analysis of 2 Randomized Trials. Circ Cardiovasc Interv, 9, e003272.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Systemic immunity-inflammation index, Flow diverter, Periprocedural complications, Intracranial aneurysms","lastPublishedDoi":"10.21203/rs.3.rs-4833682/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4833682/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eFlow-diverter devices (FDs) are effective in treating intracranial aneurysms (IAs) but carry substantial periprocedural risks, particularly ischemic complications. This study aimed to determine if elevated Systemic Immune-Inflammation Index (SII) can independently predict these risks and assess the impact of age and dual antiplatelet therapy on this association. We conducted a retrospective analysis of patients treated with FDs between February 2016 and August 2023, using blood samples taken within six days before surgery to calculate SII. Logistic regression and decision tree analyses assessed the link between SII and periprocedural complications, with subgroups exploring influencing factors. Multivariable analysis identified high SII as an independent predictor of periprocedural complications (OR=5.306, 95% CI: 1.367-18.455; P=0.009). The decision tree model confirmed SII \u0026gt; 0.437 as a critical threshold. Subgroup analysis showed a pronounced association of SII with periprocedural complications in patients ≥65 years (OR=36.979, 95% CI: 2.103-650.134; P=0.014) and in those on clopidogrel therapy (OR=16.921, 95% CI: 2.733-104.746; P=0.002). An elevated Systemic Immune-Inflammation Index (SII) \u0026gt;0.437 significantly correlates with increased periprocedural complications (6.5% vs. 1.8%, P=0.017). Although not statistically significant, higher SII is associated with a greater rate of ischemic events (3.9% vs. 0.9%). Elevated preoperative SII independently predicts periprocedural complications, particularly ischemic events, in patients undergoing FDs treatment for intracranial aneurysms. This association is especially significant in older patients and those on clopidogrel therapy.\u003c/p\u003e\n\u003cp\u003eTrial Registration: ClinicalTrials.gov (NCT06446778). Registered on May 22, 2024.\u003c/p\u003e","manuscriptTitle":"Predictive Value of the Systemic Immune-Inflammation Index for Periprocedural Complications in Flow Diverter Treatment for Patients with Intracranial Aneurysms","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-08 19:46:13","doi":"10.21203/rs.3.rs-4833682/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-25T10:47:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-19T21:51:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46018038313269490727383310150839361020","date":"2024-09-17T22:20:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275911017703707580332059116072397674639","date":"2024-09-13T20:44:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-02T10:10:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61611713569017022942628789998369566777","date":"2024-08-20T23:44:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89041230685531787702115664466165434769","date":"2024-08-19T13:12:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-18T21:54:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-11T23:10:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-01T17:03:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2024-07-31T08:28:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f2e530da-cbaf-43d3-af17-f08cd9398378","owner":[],"postedDate":"September 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T16:10:18+00:00","versionOfRecord":{"articleIdentity":"rs-4833682","link":"https://doi.org/10.1007/s10143-024-03053-0","journal":{"identity":"neurosurgical-review","isVorOnly":false,"title":"Neurosurgical Review"},"publishedOn":"2024-10-22 15:57:28","publishedOnDateReadable":"October 22nd, 2024"},"versionCreatedAt":"2024-09-08 19:46:13","video":"","vorDoi":"10.1007/s10143-024-03053-0","vorDoiUrl":"https://doi.org/10.1007/s10143-024-03053-0","workflowStages":[]},"version":"v1","identity":"rs-4833682","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4833682","identity":"rs-4833682","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}