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BackgroundData regarding the safety and efficacy of flow diverting stents (FDS) in the treatment of middle cerebral artery (MCA) bifurcation aneurysms are scarce and limited to small single center series, with particular concern for increased risk of ischemic complications with jailing one of the M2 branches.MethodsProspectively-maintained databases at six North American and European centers were queried for patients harboring MCA bifurcation aneurysms undergoing treatment with FDS (2011–2018). The pertinent clinical and radiographic data were collected and analyzed.Results87 patients (median age 60 years, 69% females) harboring 87 aneurysms were included. The majority of aneurysms were unruptured (79%); 75.9% were saccular with a median maximal diameter of 8.5 mm. Radiographic imaging follow-up was available in 88.5% of cases at a median of 16.3 months post-treatment, showing complete occlusion in 59% and near complete occlusion (90–99%) in 18% of aneurysms. The overall rate of ischemic and hemorrhagic complications was 8% and 1.1%, respectively. Symptomatic and permanent complications were encountered in 5.7% and 2.3% of patients respectively, with retreatment pursued in 2.3% of patients. Jailed branch occlusion was detected in 11.5% of cases, with clinical sequelae in 2.3%. Last follow-up modified Rankin Scale of 0–2 was noted in 96.8% of patients. On multivariate analysis, male sex was the only independent predictor of aneurysmal persistence at last follow-up imaging (p=0.019).ConclusionFDS treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms. Jailing of M2 branches was not associated with a higher risk of post-procedural ischemic complications.

BackgroundThe benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3.MethodsThis is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0–2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage.ResultsThe unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041).ConclusionsComplete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.

BackgroundEndovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited.MethodsThis was a retrospective study of patients undergoing EVT for stroke at 32 international centers. Patients were divided into LVOs (internal carotid artery/M1/vertebrobasilar), medium vessel occlusions (M2/A1/P1) and isolated DVOs (M3/M4/A2/A3/P2/P3) and categorized by thrombectomy technique. Primary outcome was a good functional outcome (modified Rankin Scale ≤2) at 90 days. Secondary outcomes included recanalization, procedure-time, thrombectomy attempts, hemorrhage, and mortality. Multivariate logistic regressions were used to evaluate the impact of technical variables. Propensity score matching was used to compare outcome in patients with DVO treated with aspiration versus stent retrieverResultsWe included 7477 patients including 213 DVOs. Distal location did not independently predict good functional outcome at 90 days compared with proximal (p=0.467). In distal occlusions, successful recanalization was an independent predictor of good outcome (adjusted odds ratio (aOR) 5.11, pConclusionsOutcomes following EVT for DVO are comparable to LVO with similar results between techniques. Techniques may exhibit different futility metrics; stent retriever thrombectomy was influenced by attempts whereas aspiration was more dependent on procedure time.

BackgroundFlow diversion is a common endovascular treatment for cerebral aneurysms, but studies comparing different types of flow diverters are scarce.ObjectiveTo perform a propensity score matched cohort study comparing the Pipeline Embolization Device (PED) and Flow Redirection Intraluminal Device (FRED) for posterior circulation aneurysms.MethodsConsecutive aneurysms of the posterior circulation treated at 25 neurovascular centers with either PED or FRED were collected. Propensity score matching was used to control for age, duration of follow-up imaging, adjunctive coiling, and aneurysm location, size, and morphology; previously ruptured aneurysms were excluded. The two devices were compared for the following outcomes: procedural complications, aneurysm occlusion, and functional outcome.ResultsA total of 375 aneurysms of the posterior circulation were treated in 369 patients. The PED was used in 285 (77.2%) and FRED in 84 (22.8%) procedures. Aneurysms treated with the PED were more commonly fusiform and larger than those treated with FRED. To account for these important differences, propensity score matching was performed resulting in 33 PED and FRED unruptured aneurysm pairs. No differences were found in occlusion status and neurologic thromboembolic or hemorrhagic complications between the two devices. The proportion of patients with favorable functional outcome was higher with FRED (100% vs 87.9%, p=0.04).ConclusionComparative analysis of PED and FRED for the treatment of unruptured posterior circulation aneurysms did not identify significant differences in aneurysm occlusion or neurologic complications. Variations in functional outcomes warrant additional investigations.

While the trend for endovascular therapy of posterior circulation aneurysms is permeating, cerebrovascular bypass remains essential in the armamentarium for complex lesions not amendable to these techniques. This review discusses the microsurgical anatomy of the posterior fossa intracranial circulation, as well as the techniques and outcomes related to cerebrovascular bypass.

Background Stent assistance for treatment of wide-based aneurysms is becoming rapidly accepted. Methods Cases of aneurysms arising in the paraclinoid location of the internal carotid artery treated with intracranial stents and/or bare platinum coils were analyzed retrospectively from our prospectively collected database. We identified 70 aneurysms treated with stent assistance (including one stenting-alone case) and 24 aneurysms treated with coiling alone. Stenting-assisted coiling was achieved either as a one-time treatment or as a two-step maneuver with the stent placed several weeks before coiling, or stent-assisted coiling was used as a second maneuver in aneurysms that recanalized after previous coiling. Results In aneurysms treated with stent assistance, 60% had ≥95% occlusion at treatment completion, a result comparing favorably with the 54.2% rate of ≥95% occlusion associated with coiling alone. At last follow-up, 60 aneurysms treated with stent assistance had a 66.7% incidence of ≥95% occlusion, with no in-stent stenosis; 75% of patients treated with coiling alone had ≥95% aneurysm occlusion. Thrombus occurred during stent deployment in two patients, one with and one without neurologic sequelae; stent displacement occurred in one patient without neurologic sequelae. At last follow-up, 57 of 62 patients (91.9%) treated with stent-assisted coiling experienced excellent/good outcomes (modified Rankin scale score ≤2). These results compared favorably with those for the coiling-alone group in which 23 of 24 (95.8%) had good outcomes. Conclusion Stent-assisted coiling of paraclinoid aneurysms did not add significantly to morbidity; overall effectiveness was comparable to that of bare coiling of paraclinoid aneurysms. These results require confirmation by a prospective controlled trial.

Background and purpose High in-stent restenosis (ISR) rates have been reported after treatment of intracranial atherosclerotic stenosis (ICAS). Balloon-mounted drug-eluting stent (DES) implantation has led to an ISR reduction in coronary vessels and may provide a solution to overcome this obstacle in the intracranial circulation. We present our initial experience with the everolimus-eluting stent (EES; Abbott Vascular, Abbott Park, Illinois, USA), a second-generation balloon-mounted DES, for ICAS treatment. Methods A retrospective review of prospectively collected endovascular data at our institution resulted in the identification of six patients with ICAS treated with EES. Data collected included patient demographics, presentation, comorbidities and lesion, intervention and follow-up details. Results These six patients had >70% angiographic ICAS and history of stroke or recurrent transient ischemic attacks, despite aspirin therapy and medical management of comorbidities. Lesions were located in the V4-vertebral artery segment (n=2), M1 middle cerebral artery segment (n=1), proximal basilar artery (n=1), supraclinoid internal carotid artery (n=1) and petrous internal carotid artery (n=1). Average stenosis severity was 82.8±6.6% (median, 80%); average lesion length was 10.2±2.2 mm. Stent placement was successful in all cases. Average postintervention stenosis was 5.5±4.4% (median, 7.5%). One patient had postintervention reperfusion hemorrhage that required urgent decompressive craniectomy. None of the five patients with angiographic follow-up (5–6 months) had ISR. The six patients had 4–10 months of clinical follow-up. Only the patient with reperfusion hemorrhage had decreased functional status after treatment (modified Rankin scale score=4) and is making a slow recovery. Conclusion This study confirms feasibility of use of a second-generation DES for ICAS and provides short-term follow-up results.

BackgroundThe Raymond–Roy Occlusion Classification (RROC) qualitatively assesses intracranial aneurysm occlusion following endovascular coil embolization. The Modified Raymond–Roy Classification (MRRC) was developed as a refinement of this classification scheme, and dichotomizes RROC III occlusions into IIIa (opacification within the interstices of the coil mass) and IIIb (opacification between the coil mass and aneurysm wall) closures.MethodsTo demonstrate in an external cohort the predictive accuracy of the MRRC, the records of 326 patients with 345 intracranial aneurysms treated with endovascular coil embolization from January 2007 to December 2013 were retrospectively analyzed.ResultsWithin this cohort, 84 (24.3%) and 83 aneurysms (24.1%) had MRRC IIIa and IIIb closures, respectively, during initial coil embolization. Progression to complete occlusion was more likely with IIIa than IIIb closures (53.6% vs 19.2%, p≤0.01), while recanalization was more likely with IIIb than IIIa closures (65.1% vs 27.4%, pConclusionsThis study confirms that the MRRC enhances the predictive accuracy of the RROC.

Objective Cerebral arteriovenous malformations (AVMs) are vascular lesions that are amenable to various treatment modalities including stereotactic radiosurgery, fractionated radiotherapy, endovascular embolization, microsurgical obliteration or combined modality treatment. A potential complication of endovascular therapy with embolization material is microcatheter entrapment. We report on a patient for whom surgery was combined with endovascular embolization to obliterate an AVM and retrieve an entrapped endovascular microcatheter. Participant A 52-year-old woman suffered a left parietal hemorrhage from an AVM. She underwent staged endovascular embolization of the lesion using Onyx material. During the second stage of the embolization, the microcatheter (Marathon Flow Directed Microcatheter; eV3 Neurovascular, Inc., Irvine, CA, USA) was retained in the Onyx plug. It was decided to section the microcatheter at the groin and proceed with microsurgical obliteration of the AVM, with removal of the entrapped microcatheter remnant. Intervention The AVM was dissected circumferentially allowing the meticulous obliteration of the feeding vessels. A single remaining feeding vessel originating from the distal anterior cerebral artery was identified and suspected to contain the entrapped microcatheter. The location was confirmed using stereotactic guidance (BrainLab, Munich, Germany) and the vessel was then sectioned allowing complete removal of the AVM. The microcatheter (102 cm) was then extracted cranially using gentle traction. Conclusion This demonstrates the first incidence of microcatheter removal after procedural entrapment in Onyx embolization material.

Purpose To evaluate the efficacy of n-butyl-2-cyanoacrylate (Trufill n-BCA) versus ethylene vinyl alcohol copolymer (ONYX) for the embolization of cranial dural arteriovenous fistulas (DAVF). Methods Fifty-three consecutive patients with cranial dural AVF were treated with liquid embolic agents from November, 2003 to November, 2008. These 53 patients had 56 lesions treated with arterial embolization. Patients embolized to completion underwent follow-up angiography at 3 months to assess for durable occlusion. Results Twenty-one lesions were treated with n-BCA. Seven patients treated with n-BCA had initial angiographic occlusion of their DAVF, which were durable at 3 months. Six patients had adjunctive treatment with coils and/or polyvinyl alcohol particles, but none of these were occluded by endovascular treatment alone. Eleven patients underwent post-embolization surgery for closure of their DAVF. There was one death related to intractable status epilepticus at presentation. One patient developed a major stroke from venous sinus thrombosis after embolization. Thirty-five lesions were treated with ONYX in 34 patients. Twenty-nine patients treated with ONYX had initial angiographic occlusion of their DAVF by embolization alone. One patient had recurrence at 3 months and was re-treated out of 27 total follow-ups. Four patients underwent post-embolization surgical obliteration of their lesions. No deaths or major strokes occurred in this cohort. Conclusion Initial angiographic occlusion (p=0.0004) and durable angiographic occlusion (p=0.0018) rates for embolization of cranial DAVF show a statistically significant higher efficacy with ONYX compared with n-BCA. Patients embolized with ONYX underwent surgery less frequently compared with those treated with n-BCA (p=0.0015).

Introduction Endovascular coiling has proven to be a safe and effective method of aneurysm treatment. However, its long-term durability remains unknown and difficult to predict. A previously published prediction score of various factors has been shown to reliably predict rates of recanalization across institutions. However, this prediction is dependent on treatment related outcomes. The present study attempts to predict the recanalization rate based on a modification of this scale using only aneurysm and patient factors rather than treatment related outcomes as well. Methods A retrospective single center analysis of of all endovascularly coiled aneurysms from 2009 to 2013 was undertaken using the previously published predication score criteria (size, presence of thrombus, rupture status) as well as smoking history. The primary outcome was evidence of increased Raymond Roy outcome, indicating recanalization. Results The outcomes will be analyzed using a multivariable logistic regression analysis and weighted similar to previously published recanalization prediction scores. Conclusions The ability to accurately predict which aneurysms will recanalize prior to treatment can greatly affect treatment decisions as well as follow up patterns. We aim to further clarify these relationships with a modification of a previously published prediction score. Disclosures M. Fusco: None. M. Chua: None. M. Froehler: None. A. Thomas: None. C. Ogilvy: None.

Onyx embolization is a well-established preoperative treatment of cerebrovascular arterio venous malformations and fistulae. We report four cases of hypervascular extraaxial tumor embolization using Onyx administration as an adjunct to traditional particle embolization and coils. We report three cases of meningioma and one case of hemangiopericytoma. These tumors are highly vascular tumor arising from the meninges, the core of the tumor predominantly supplied by the middle meningeal artery and the periphery supplied by parasatization by intracerebral branches. Hypervascular extraaxial tumor resection may cause very high volume blood loss during open surgery. Presurgical embolization of these lesions has been proven to significantly decrease intraopertaive blood loss and facilitate subsequent surgical resection. Various agents has been used in the past for embolization of these tumors including polyvinyl alcohol (PVA), gelfoam powder, gelatin microspheres, liquid adhesives and coils. For the last few decades until recently, PVA particle embolization has been the mainstay of embolization and has been widely used. Onyx is a nonpolymerizing liquid agent composed of ethylene-vinyl alcohol copolymer dissolved in dimethyl sufloxide. When injected, Onyx precipitates within vessels forming a spongy cast. We report the use of Onyx in the embolization of four cases of hypervascular extraaxial tumors. The average was 57 yrs of age and 2 males and 2 females. Technique included a guide catheter placement in the external carotid artery and a microcatheter in the distal branch of the middle meningeal artery. The guide catheter we used was a 6F Neuron catheter and the microcatheters used included marathon microcatheter and more recently a DUO catheter. A 0.38 DAC was also used in one of the cases. Advantages of Onyx embolization include a more controlled injection due to gradual precipitation in a centripetal fashion which allows for slower and more accurate injections as well as penetration of very small calibre vessels. It also has the advantages of penetrating into the branches supplied by other vascular territories. Special caution is recommended to make sure the onyx doesn’t reflux into the intracerebral arteries supplying the periphery of the tumor. In the first case we did not use the particles. During embolization using Onyx, there was occlusion of the catheter with onyx at the catheter tip and Onyx wouldn’t go forward and was only refluxing back and we had to abort the procedure. Although the major vessel supplying the tumor was thrombosed the tumor core itself was not embolised. In all the later cases we embolised initially with particles and then went on to complete the embolization with Onyx. This report furthers the growing body of literature confirming the safety and efficacy of Onyx in the preoperative embolization of Intracranial highly vascular extra axial tumors. Disclosures S. Reddy: None. A. Thomas: None. M. Fusco: None. D. DiNobile: None. C. Ogilvy: None.

Purpose To present trans-arterial venous sinus occlusion technique for dural arteriovenous fistulas of the transverse and sigmoid sinuses. Materials and Methods Nine cases of dural arteriovenous sinus fistula of the transverse and sigmoid sinuses were treated with trans-arterial closure of the arterial supply and the venous sinus using ethylene vinyl alcohol copolymer (ONYX). Five patients were male and four were female. Age range was30–73. Patients presented with stroke, intracranial haemorrhage, seizure, headache or memory changes. Six patients had patent sinuses and three patients had fistulas involving isolated sinus segments which were Cognard IIa + b and Cognard IIb respectively. Criteria for selection for this treatment included complex multi-hole fistulas involving a broad surface of the sinus. External carotid artery branches could be directly embolised when considered safe. High risk arterial supply from ICA parenchymal vessels of the brain or ECA cranial nerve were embolised via retrograde collaterals. The affected venous sinus was a non-dominant or co-dominant sinus. Vein of Labbe had to be spared. Results ONYX embolisation DAVF closure was accomplished in all nine patients with a total of 15 embolisation procedures. No cranial nerve neuropathies or strokes occurred related to arterial embolisation. No patients incurred strokes related to the venous sinus embolisation. DAVF closure was found to be durable at three months in eight patients with one patient pending follow up. Conclusion Trans-arterial closure of transverse and sigmoid sinus provides an alternative to venous sinus coil occlusion, surgical skeletonization or radiosurgery. High risk arterial collaterals can be closed via artery-artery or artery-sinus-artery embolisation. In this small cohort, closure of dural AV fistulas was durable at three months with low complication rates. Disclosures J. Rabinov: None. A. Yoo: None. T. Leslie-Mazwi: None. C. Ogilvy: None. J. Hirsch: None.

Edited by Anil Nanda, 1st Edition, 2012. Published by Thieme Medical Publishers, Inc., New York, pp 252 (hardcover). (Foreward by Peter J Jannetta). ISBN: 978-1588906632 Having authored one of the chapters, we have been familiar with this project during its evolution. This well-organized book fills a niche as a comprehensive but concise reference or vade mecum dedicated to the unique neuroanatomical compartment of the posterior fossa. It is well known to neurosurgeons that the range of disorders that include trauma, neoplastic lesions and vascular pathologies are managed differently by virtue of involving the infratentorial region, in contrast to analogous pathologies of the supratentorial region. In addition, there are …

Background Onyx is a non-adhesive liquid embolic agent that has gained wide acceptance in the treatment of intracranial pial AVMs. However, only a few series have addressed the results of Onyx embolization for the treatment of dural arteriovenous fistulas (DAVFs). We now report on the long term results of Onyx treatment for intracranial DAVFs. Methods We performed a retrospective analysis of 37 consecutive patients with intracranial DAVFs (a total of 39 lesions) who were treated with Onyx as the single treatment modality between March 2006 and April 2009. A trans-arterial approach was employed in all cases, and Onyx-18 or a combination of Onyx-18/Onyx-34 was used to embolize the DAVF. Patients underwent control angiography at 3 months and 12 months post-embolization to assess for recurrent or residual shunting. Results Mean age of these 37 patients was 56±11 years (median 56, range 30–76). There were 22 men and 15 women. 11 lesions (29.7%) were classified as Cognard IV/Borden 3; 14 lesions (37.8%) as Cognard III/Borden 3; four lesions (10.8%) as Cognard IIa + IIb/Borden 2; three lesions (8.1%) as Cognard IIb/Borden 2; one lesion (2.7%) as Cognard IIa/Borden 1; and four lesions (10.8%) as Cognard I/Borden 1. A total of 46 procedures were performed (three procedures in three patients; two in three patients; and one in 31 patients). Complete angiographic cure on immediate post-treatment angiography was achieved in 35 patients. One patient underwent surgical resection after partial embolization. The remaining patient had a residual fistula involving the jugular fossa below the skull base without evidence of any residual intracranial component. Complications included one asymptomatic extracranial vertebral artery dissection and two facial palsies. There was no other significant morbidity or mortality. Follow-up angiography is currently available in 34 patients. There was no evidence of residual or recurrent DAVF in 33 patients. One of the initially “cured” patients had evidence of a small recurrent DAVF on short-term follow-up. This was attributed to lack of penetration of the embolic agent into the proximal venous compartment. This patient was asymptomatic and was subsequently embolized with Onyx resulting in stable cure on follow-up angiogram performed 11 months later. Twenty-one patients have long term (>1 year) follow-up; 19 of these had follow-up angiography at both 3 and 12 months. In all these 19 cases, the angiographic results were stable across the two time epochs. Conclusion In our experience, the endovascular treatment of intracranial DAVFs with Onyx is safe and highly effective with no evidence of any significant recurrence in the long term follow-up. A single angiography at 3–6 months appears to be reasonable in the follow-up of these patients.