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Background Endovascular embolization can effectively treat spinal dural arteriovenous fistulas (SDAVFs). One factor limiting the success and durability of endovascular treatments is reliably casting and occluding the draining vein. We sought to compare the efficacies of n‐butyl‐2‐cyanoacrylate (nBCA) and Onyx in the treatment of SDAVFs. Methods We retrospectively analyzed patients with SDAVFs treated with endovascular embolization for whether a “durable cure” was achieved, defined as complete obliteration, clinical improvement, and sustained radiologic cure on follow‐up. We compared the outcomes of patients treated with Onyx to those treated with nBCA. Results A total of 40 embolizations for SDAVFs were performed in 38 patients. All patients were treated exclusively with liquid embolysates: Onyx alone (n = 22), nBCA alone (n = 16), or nBCA and Onyx combined (n = 2). For 45% (10/22) of patients treated with Onyx only, complete obliteration of the fistula with casting of the vein was not achieved. These patients were referred for microsurgical ligation. For all 16 patients treated with nBCA only, complete obliteration of the fistula was achieved. All 16 patients exhibited a durable cure compared with 11 of 22 patients (50%) in the Onyx‐only group (P = 0.002). Conclusion nBCA may be superior to Onyx for the embolization of SDAVFs. nBCA embolization is safe and effective for a subset of SDAVFs. Prospective studies comparing SDAVF treatment strategies are warranted.

Background First described over 4 decades ago as a diffuse form of arteriovenous malformation, cerebral proliferative angiopathy (CPA) is now categorized as a distinct vascular anomaly. Unlike arteriovenous malformation, which typically forms a well‐developed vascular nidus with feeder vessels and distinct venous outflow, CPA is the product of disorganized angiogenesis; thus, it lacks a true nidus. Its characteristic cycle of ischemia, angiogenesis, and aberrant perfusion can lead to abnormal blood flow patterns that characterize the disease. Treatment of CPA has historically relied on conservative management (antiepileptic drugs), and efforts to effectively manage this pathology have been hindered by an incomplete understanding of its natural history. Methods A systematic search of 4 databases was performed. The following variables were extracted when present: study sample size, year of publication, age(s) of patient(s), sex, presenting signs and symptoms, neurological deficits (pre‐ and postoperative), type of intervention, average follow‐up time, and patient‐reported as well as functional outcomes at last follow‐up. Results Following the search and screen, 48 studies reporting 105 CPA cases remained eligible for inclusion. These studies consisted of 41 case reports, 6 case series, and 1 retrospective cohort study. The most common modality used in treatment of CPA was conservative management (53.4%). The second most common treatment modality was endovascular embolization (36.9%). The least common treatment modality was gamma knife radiosurgery, which was used in only 2 patients. Eleven patients experienced intracranial hemorrhage as a complication of CPA; 10 of the 11 patients underwent decompressive craniectomy. Finally, revascularization surgery was reportedly used in 5 patients (4.9%). Conclusion Although there remains a dearth of studies reporting CPA, several clearly defined traits have been identified that characterize this pathology and distinguish it from arteriovenous malformation. Nonetheless, the verdict has not yet been reached regarding the effectiveness of surgical interventions.

Background: Patients with supratentorial cavernous malformations (SCMs) commonly present with seizures. First-line treatments for cavernoma-related epilepsy (CRE) include conservative management (antiepileptic drugs (AEDs)) and surgery. We compared seizure outcomes of CRE patients after early (≤6 months) vs. delayed (>6 months) surgery. Methods: We compared outcomes of CRE patients with SCMs surgically treated at our large-volume cerebrovascular center (1 January 2010–31 July 2020). Patients with 1 sporadic SCM and ≥1-year follow-up were included. Primary outcomes were International League Against Epilepsy (ILAE) class 1 seizure freedom and AED independence. Results: Of 63 CRE patients (26 women, 37 men; mean ± SD age, 36.1 ± 14.6 years), 48 (76%) vs. 15 (24%) underwent early (mean ± SD, 2.1 ± 1.7 months) vs. delayed (mean ± SD, 6.2 ± 7.1 years) surgery. Most (32 (67%)) with early surgery presented after 1 seizure; all with delayed surgery had ≥2 seizures. Seven (47%) with delayed surgery had drug-resistant epilepsy. At follow-up (mean ± SD, 5.4 ± 3.3 years), CRE patients with early surgery were more likely to have ILAE class 1 seizure freedom and AED independence than those with delayed surgery (92% (44/48) vs. 53% (8/15), p = 0.002; and 65% (31/48) vs. 33% (5/15), p = 0.03, respectively). Conclusions: Early CRE surgery demonstrated better seizure outcomes than delayed surgery. Multicenter prospective studies are needed to validate these findings.

Racial and socioeconomic health disparities are well documented in the literature. This study examined patient demographics, including socioeconomic status (SES), among individuals presenting with aneurysmal subarachnoid hemorrhage (aSAH) and unruptured intracranial aneurysm (UIA) to identify factors associated with aSAH presentation. A retrospective assessment was conducted of all patients with aSAH and UIA who presented to a large-volume cerebrovascular center and underwent microsurgical treatment from January 2014 through July 2019. Race and ethnicity, insurance type, and SES data were collected for each patient. Comparative analysis of the aSAH and UIA groups was conducted. Logistic regression models were also employed to predict the likelihood of aSAH presentation based on demographic and socioeconomic factors. A total of 640 patients were included (aSAH group, 251; UIA group, 389). Significant associations were observed between race and ethnicity, SES, insurance type, and aneurysm rupture. Non-White race or ethnicity, lower SES, and having public or no insurance were associated with increased odds of aSAH presentation. The aSAH group had poorer functional outcomes and higher mortality rates than the UIA group. Patients who are non-White, have low SES, and have public or no insurance were disproportionately affected by aSAH, which is historically associated with poorer functional outcomes.

Background Endovascular thrombectomy is the gold‐standard treatment for large vessel occlusions (LVOs). A novel metric is introduced: the number needing review (NNR) to assess the triage efficiency of LVO detection systems. Methods Patients with suspected ischemic stroke and images processed by RapidAI LVO detection software over 6 months were reviewed. Only patients with LVOs of the M1 segment were included. The NNR was calculated for an M1 occlusion. Results Of 559 patients, M1 occlusion was detected in 42 patients (7.5%). RapidAI LVO had a sensitivity of 71%, specificity of 94%, positive predictive value of 49%, and negative predictive value of 92% for M1 occlusion. When gaze deviation and hyperdense sign were combined with RapidAI LVO, the specificity and positive predictive value increased to 100% for an M1 occlusion. A negative RapidAI LVO result combined with a low (6 seconds) or high (6 seconds) Tmax threshold was found to have a specificity and positive predictive value of 100% for no occlusion. The combination of gaze deviation, hyperdense sign, positive RapidAI LVO, and negative RapidAI LVO with low Tmax threshold yielded an NNR of 24 per 100 cases. When combined with a negative RapidAI LVO and a high Tmax threshold, the NNR was 16 per 100 cases. Adding National Institutes of Health Stroke Scale score 6 seconds threshold, the NNR is significantly reduced.

BackgroundApproximately 3.2%–6% of the general population harbor an unruptured intracranial aneurysm (UIA). Ruptured aneurysms represent a significant healthcare burden, and preventing rupture relies on early detection and treatment. Most patients with UIAs are asymptomatic, and many of the symptoms associated with UIAs are nonspecific, which makes diagnosis challenging. This study explored symptoms associated with UIAs, the rate of resolution of such symptoms after microsurgical treatment, and the likely pathophysiology.MethodsA retrospective review of patients with UIAs who underwent microsurgical treatment from January 1, 2014, to December 31, 2020, at a single quaternary center were identified. Analyses included the prevalence of nonspecific symptoms upon clinical presentation and postoperative follow-up; comparisons of symptomatology by aneurysmal location; and comparisons of patient demographics, aneurysmal characteristics, and poor neurologic outcome at postoperative follow-up stratified by symptomatic versus asymptomatic presentation.ResultsThe analysis included 454 patients; 350 (77%) were symptomatic. The most common presenting symptom among all 454 patients was headache (n = 211 [46%]), followed by vertigo (n = 94 [21%]), cognitive disturbance (n = 68[15%]), and visual disturbance (n = 64 [14%]). Among 328 patients assessed for postoperative symptoms, 258 (79%) experienced symptom resolution or improvement.ConclusionThis cohort demonstrates that the clinical presentation of patients with UIAs can be associated with vague and nonspecific symptoms. Early detection is crucial to prevent aneurysmal subarachnoid hemorrhage. It is imperative that physicians not rule out aneurysms in the setting of nonspecific neurologic symptoms.

Endovascular embolization is the primary strategy in the management for vein of Galen malformations (VOGM). However, despite significant advances in endovascular embolization technologies and techniques, VOGMs remain very technically challenging lesions largely due to the high-flow arteriovenous shunts present in these malformations. A variety of advanced flow-control techniques can be implemented to mitigate the risk of venous escape and increase the safety and efficacy of endovascular treatment. These techniques include regionally targeted strategies (transvenous embolization and balloon-assisted transarterial embolization) and global flow-control methods (pharmacologic cardiac arrest and rapid ventricular overdrive pacing). Each of these strategies are associated with unique advantages and disadvantages, highlighting the importance of a patient-specific approach when treating these challenging lesions.

Background Chronic subdural hematoma is associated with high rates of perioperative complications and recurrence. Methods The classic treatments are observation or surgical evacuation. Middle meningeal artery embolization is a recently emerging procedure that has evolved as the neuroendovascular community has gained collective experience. This review summarizes the pathophysiology of chronic subdural hematoma, reviews the classic treatment strategies, discusses the advent and use of middle meningeal artery embolization, and describes the contemporary technical approach to middle meningeal artery embolization. Results Embolization has the advantages of targeting the vascular supply of the neomembranes implicated in chronic subdural hematoma pathophysiology and avoiding surgical or bedside drainage in a population associated with significant comorbidities. Conclusions Middle meningeal artery embolization is increasingly used both as an adjunct treatment to surgical evacuation and as a stand‐alone method for managing this challenging entity.

Background The transradial artery (TRA) approach for neuroendovascular procedures is a safe and effective alternative to the transfemoral artery (TFA) approach. We compared the efficiency and periprocedural outcomes of TRA and TFA approaches for acute stroke interventions in patients receiving intravenous tissue plasminogen activator. Methods A retrospective cohort study analyzed data from patients at a large cerebrovascular center from January 1, 2014, to March 31, 2021. Baseline characteristics, periprocedural efficiency and efficacy, and in‐hospital outcomes were compared between intervention cohorts (TRA and TFA). Results Of 314 patients analyzed, 21 (7%) underwent a TRA approach and 293 (93%) underwent a TFA approach. Complications occurred in one (5%) of 21 patients in the TRA cohort and 20 (7%) of 293 patients in the TFA cohort. Access site complications were present in 12 (4%) patients with TFA, and no patients with TRA experienced access site complications. The mean length of stay was significantly longer for the TFA cohort (8.8 days [standard deviation, 8.5 days]) versus the TRA cohort (4.8 days [standard deviation, 2.9 days]) (P=0.02). Linear regression analysis showed that femoral access, Medicaid insurance, and discharge National Institutes of Health Stroke Scale score >10 predicted longer length of stay (P≤0.046). However, when the time to initial physical or occupational therapy session was added to the model, access site was no longer significant (P=0.42). Conclusion The TRA approach may reduce periprocedural complications and hospital length of stay compared with the TFA approach. The shorter length of stay associated with TRA access appeared to be associated with earlier initiation of physical or occupational therapies.

Background Neurocritical care is routinely provided to patients post‐endovascular thrombectomy (EVT) for anterior large vessel occlusion strokes. We aim to study the relationship between immediate improvement in National Institutes of Health Stroke Scale (NIHSS) score on outcomes post‐EVT and potential implications for postprocedural care. Methods We performed a retrospective review of anterior circulation large vessel occlusion (internal carotid/proximal middle cerebral artery) patients undergoing EVT. Demographic, clinical, and imaging information was analyzed. Ultra‐early functional improvement (UEFI) was defined as NIHSS score

Background: Indications for deep brain stimulation (DBS) are rapidly growing within functional neurosurgery. The objective of this study was to characterize national trends in demographics and complications across distinct populations of DBS patients. Methods: We identified patients from the 2008–2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File (PUF) who underwent an implantation or revision procedure for DBS. Summary statistics for postoperative infection rate, noninfectious complication rate, total hospital length of stay, discharge disposition, mortality, reoperation or readmission, and time from operation to readmission were obtained. Patients were categorized by diagnosis for DBS treatment. Outcomes for each diagnosis group were compared to outcomes for the total study population. Results: DBS patients who underwent primary implantation procedures had low rates of postoperative infections (1.2%), noninfectious complications (0.8%), and mortality (0.1%) and a high likelihood of discharge home (97.6%). In addition, a large percentage of patients presented for revision or removal of neurostimulators (34.2% of cases) or treatment of long-term hardware infection (4.5%). Compared with patients with other diagnoses, patients with Parkinson disease experienced lower rates of noninfectious complications (odds ratio 0.32; 95% CI, 0.15–0.63; p = 0.002) and fewer unplanned reoperations (odds ratio 0.60; 95% CI, 0.39–0.92; p = 0.02). Conclusion: Analysis of a national database suggests that DBS is a relatively safe treatment across several different patient populations. These overall favorable results support the continued practice of DBS surgery and provide encouraging validation for increasing access to DBS therapy for new indications that are being actively investigated.

Background Flow‐diverting stents (FDSs) are effective in treating complex intracranial aneurysms, including posterior communicating artery aneurysms. However, some studies have suggested FDSs have limited efficacy for posterior communicating artery aneurysms associated with a fetal posterior communicating artery (FPCoA). Methods A retrospective analysis of patients with FPCoA aneurysms treated using FDS intervention alone was performed. Only aneurysms in which the FPCoA originated from the neck or dome of the aneurysm, which were therefore not amenable to standard coil embolization, were included. Results Stand‐alone, single‐device FDSs were placed in 16 patients with unruptured posterior communicating artery aneurysms associated with an FPCoA. The device was sized to ensure excellent wall apposition, with a focus on expanding the device across the aneurysm neck to optimize flow diversion. Excellent angiographic results were achieved in 12 patients (75%), and all patients had satisfactory clinical outcomes, with complete obliteration of the aneurysm in 10 (62.5%). No patients required additional treatment. Nine patients had complete patency of the FPCoA, 4 had mildly decreased flow, 2 had markedly diminished flow, and 1 had FPCoA occlusion. In all 7 cases with decreased FPCoA flow, there was coincident increased flow in the P1 segment of the posterior cerebral artery. No patient developed posterior circulation ischemia. Mean follow‐up was 19.9 months. Conclusion Contrary to previous reports, the placement of FDSs was found to be a safe and effective treatment option for FPCoA aneurysms. The deployment technique of maximizing device expansion across the neck of the aneurysm may contribute to successful outcomes. Treatment using an FDS may be particularly useful for complex FPCoAs.

Chronic subdural hematoma (cSDH) is a common disease process associated with significant morbidity that occurs most often in elderly patients. Asymptomatic patients are typically treated conservatively, with surgical intervention reserved for patients with symptomatic and/or large hematomas that cause brain compression. However, conservatively managed cSDH cases frequently progress, and surgical evacuation of cSDH is associated with high rates of complication and recurrence. Recently, successful treatment of cSDH via middle meningeal artery (MMA) embolization has been reported in small case series and case reports. This article reviews the existing literature on MMA embolization for cSDH and discusses the need for randomized control trials and/or large prospective studies to establish the efficacy of MMA embolization for this disease.