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Background Non-galenic dural arteriovenous fistula (NGAVF) is a rare congenital vascular abnormality characterized by high flow connections between cerebral arteries and a dilated pial venous varix. These lesions have been reported mostly in the pediatric population. Objectives To examine the clinical features and treatment outcomes for adult (≥18 years) patients with NGAVFs. Methods We retrospectively reviewed the records of patients with NGAVFs who underwent endovascular treatment between 2008 and 2013. A PubMed literature search was conducted to identify reports of adult patients with these lesions. Results Two adults with NGAVFs were treated at our institution via transarterial embolization with a favorable outcome. The literature search revealed 24 adult NGAVF cases. Among these cases and ours, mean patient age was 33.4±13.3 years, and 13 were women. Most patients experienced protracted neurological symptoms at the time of treatment whereas 5 (19.2%) patients presented with acute hemorrhage. 18 patients had single hole fistulas; 8 had multi-hole fistulas. 11 patients were treated by microsurgical ligation, 10 by embolization, 4 by combined therapy, and 1 with observation. Two patients died of reperfusion hemorrhage. Women were more likely to have a favorable outcome than men (100% vs 75.0%; p=0.07). No statistical difference was found in terms of clinical outcome for patients with single hole versus multi-hole fistulas or those treated by surgery versus embolization. Conclusions NGAVFs are extremely rare in the adult population and present a similar clinical course as in older children. In our experience, transarterial embolization can be safely and effectively utilized for the treatment of these lesions in adults.

Background Thrombus characteristics, including Hounsfield unit (HU) value to measure density and thrombus volume and length, can predict successful recanalization following IV thrombolysis with recombinant tissue plasminogen activator. Conflicting and limited data exist regarding the value of assessing thrombus properties in acute stroke cases treated with endovascular IA approaches. Methods We retrospectively reviewed cases of anterior circulation acute ischemic stroke in which a Solitaire stent retriever (ev3-Covidien) was the primary treatment device. We measured the following thrombus characteristics: absolute and corrected HU values; thrombus length and volume; clot burden score; and vessel bifurcation involvement. Fisher9s exact test and the t test were used to study the association between these clot characteristics and successful recanalization (Thrombolysis in Cerebral Infarction (TICI) score 2b–3). Results We identified 41 patients with anterior circulation stroke treated with the Solitaire stent retriever as the primary treatment device. Successful recanalization (TICI score 2b–3) was achieved in 59% of cases. Higher absolute and corrected HU values were strongly predictive of successful recanalization (49.9±7.6 vs 43.8±6.6, p=0.01 for absolute HU values and 1.2±0.2 vs 1.0±0.1, p=0.03 for HU ratio in TICI 2b–3 and TICI 0–2a groups, respectively). There was no significant difference between recanalization and non-recanalization groups in the other thrombus characteristics studied. Conclusions In acute stroke treated with Solitaire stent retriever thrombectomy, higher thrombus HU values are predictive of successful recanalization. Such information can be used in decision making when estimating recanalization success rate with different endovascular treatment approaches.

BackgroundIntegration of data from clinical trials and advancements in technology predict a change in selection for treatment of patients with cerebral aneurysm.ObjectiveTo describe patterns of use and in-hospital mortality associated with surgical and endovascular treatments of cerebral aneurysms over the past decade.Materials and methodsThe data are 34 899 hospital discharges with a diagnosis of ruptured or unruptured cerebral aneurysm from 1998 to 2007 identified from the Nationwide Inpatient Sample (NIS). The rates of endovascular coiling and surgical clipping and in-hospital mortality among patients with an aneurysm are examined over a decade by hospital and patient demographic characteristics.ResultsFrom 1998 to 2007, 20 134 discharges with a ruptured aneurysm and 14 765 discharges with an unruptured aneurysm were identified. Over this decade, the number of patients discharged with a ruptured aneurysm was stable while the number discharged with an unruptured aneurysm increased significantly. The use of endovascular coiling increased at least twofold for both groups of patient (pConclusionsThe majority of unruptured aneurysms in the USA are now treated with endovascular coiling. Although surgical clipping is used for treatment of most ruptured aneurysms, its use is decreasing over time. Dissemination of endovascular procedures appears widespread across patient and hospital subgroups.

Diffusion- and perfusion-based imaging studies are regularly used in patients with ischemic stroke. Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and is primarily treated by systemic anticoagulation. Endovascular intervention can be considered in cases of failed medical therapy, yet the prognostic value of diffusion- and perfusion-based imaging for CVST has not been clearly established. We present a patient with CVST whose abnormal findings on MRI and CT perfusion images were largely reversed after endovascular treatment.

Objective Utilization of the Pipeline embolization device (PED) in complex ruptured aneurysms has not been well studied. We evaluated the safety and effectiveness data from five participating US centers. Methods Records of patients with ruptured cerebral aneurysms who underwent PED treatment between 2011 and 2013 were retrospectively reviewed. Results 26 patients with ruptured aneurysms underwent PED treatment (mean age 51.4±13.2 years;16 women). At presentation, 8 patients (30.8%) had a Hunt–Hess grade of IV or above; 11 required extraventricular drain placement. Aneurysm morphologies were: 8 dissecting, 8 blister-like, 6 fusiform, and 4 saccular. There were 22 anterior circulation and 4 posterior circulation aneurysms. PED deployment was successful in all patients, with adjunctive coiling utilized in 12. Periprocedural complications occurred in 5 (19.2%), including 3 inhospital deaths. 23 patients (88.5%) had postoperative angiography at a mean of 5.9 months: 18 aneurysms (78.3%) were completely occluded, 3 (13.0%) had residual neck filling, and 2 (8.7%) had residual dome filling. All blister-type aneurysms were completely occluded at follow-up. Clinical follow-up was available for an average of 10.1 months (range 2–21 months), with one asymptomatic in-stent stenosis and one asymptomatic thromboembolic stroke noted. Good outcome (modified Rankin Scale (mRS) score of 0–2) was achieved in 20 patients (76.9%), fair (mRS 3–4) in 3 (11.5%), and 3 died (11.5%). Conclusions The PED can be utilized for ruptured aneurysms and is a good option for blister-type aneurysms. However, due to periprocedural complications, it should be reserved for lesions that are difficult to treat by conventional clipping or coiling.

Thrombus characteristics, including Hounsfield unit (HU) value to measure density and thrombus volume and length, can predict successful recanalization following IV thrombolysis with recombinant tissue plasminogen activator. Conflicting and limited data exist regarding the value of assessing thrombus properties in acute stroke cases treated with endovascular IA approaches.We retrospectively reviewed cases of anterior circulation acute ischemic stroke in which a Solitaire stent retriever (ev3-Covidien) was the primary treatment device. We measured the following thrombus characteristics: absolute and corrected HU values; thrombus length and volume; clot burden score; and vessel bifurcation involvement. Fisher's exact test and the t test were used to study the association between these clot characteristics and successful recanalization (Thrombolysis in Cerebral Infarction (TICI) score 2b-3).We identified 41 patients with anterior circulation stroke treated with the Solitaire stent retriever as the primary treatment device. Successful recanalization (TICI score 2b-3) was achieved in 59% of cases. Higher absolute and corrected HU values were strongly predictive of successful recanalization (49.9±7.6 vs 43.8±6.6, p=0.01 for absolute HU values and 1.2±0.2 vs 1.0±0.1, p=0.03 for HU ratio in TICI 2b-3 and TICI 0-2a groups, respectively). There was no significant difference between recanalization and non-recanalization groups in the other thrombus characteristics studied.In acute stroke treated with Solitaire stent retriever thrombectomy, higher thrombus HU values are predictive of successful recanalization. Such information can be used in decision making when estimating recanalization success rate with different endovascular treatment approaches.

Introduction/purpose Introduction of the stent retrievers in 2012 has revolutionized the constant evolution of stroke intervention. However, analysis regarding nationwide utilization of mechanical thrombectomy and associated outcomes after approval of the stent retrievers has yet to be performed. Using Nationwide Inpatient Sample (NIS) database, our study analyzed the clinical outcome and trend of national utilization of interventional treatment for acute ischemic stroke over three periods, from 2006 to 2007, from 2008 to 2011, and 2012. Material and methods Data for 2006 to 2012 were extracted from NIS database provided by the Agency for Healthcare Research and Quality (AHRQ). Patient selection was based on the International Classification of Diseases, 9 th revision, clinical modification (ICD-9-CM: 433 to 437.1, 39.74 and 99.10) and diagnosis related group (DRG: 543) codes. Patient outcome was evaluated by discharge status, in-hospital mortality, length of stay, and in-hospital complications. Outcomes were grouped by three time periods (Post-MERCI: 2006–07; Post-Penumbra: 2008–11 and Stent Retrievers: 2012). Statistical analysis was performed using Chi-square, ANOVA and multivariate logistic regression accordingly. Results The average acute stroke admissions per year are: 723,327 during 2006–07 (Post-MERCI); 737,125 during 2008–11 (Post-Penumbra) and 738,490 (Stent Retrievers). Incremental trend was shown for the utility of intravenous tissue plasminogen activator (IV-tPA) administration (1.5%, 2.5% and 3.5% respectively), mechanical thrombectomy (0.2%, 0.5% and 0.7%) and combination of both (0.1%, 0.4% and 0.5%) for corresponding duration. The rate of mortality was significantly lower during 2012 ([IV-tPA: 6.7%; p = 0.007]; [Mechanical thrombectomy: 17.1%; p The age specific mortality following the stroke intervention was significantly decreased for ≥ 80 years (20%; p Conclusion Introduction of stent retrievers for mechanical thrombectomy in acute stroke intervention has significantly decreased the overall mortality as well as age-specific mortality, especially in patients with 65–79 and ≥80 years-of-age. Our findings suggest that age alone should not be an exclusion criterion for mechanical thrombectomy in an appropriate clinical setting. Disclosures S. Boddu: None. X. Sun: None. M. Crimmins: None. D. Kimball: None. J. Knopman: None. A. Patsalides: None. P. Gobin: None. N. Lin: None.

Diffusion- and perfusion-based imaging studies are regularly used in patients with ischemic stroke. Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and is primarily treated by systemic anticoagulation. Endovascular intervention can be considered in cases of failed medical therapy, yet the prognostic value of diffusion- and perfusion-based imaging for CVST has not been clearly established. We present a patient with CVST whose abnormal findings on MRI and CT perfusion images were largely reversed after endovascular treatment.

Endovascular embolization has become increasingly favored over microsurgical resection for treatment of complex dural arteriovenous fistulas (DAVFs). However, endovascular treatment can be restricted by tortuous transarterial access and a transvenous approach is not always feasible. We present a Borden III DAVF treated by direct access to the middle meningeal artery (MMA) and Onyx embolization performed in a hybrid operating room-angiography suite. A middle-aged patient with pulsatile headaches was found to have left transverse sinus occlusion and DAVF with retrograde cortical venous drainage fed by multiple external carotid artery (ECA) feeders. Endovascular attempts via conventional transvenous and transarterial routes were unsuccessful, and the major MMA feeder was accessed directly after temporal craniotomy was performed under neuronavigation. Onyx embolization was performed; complete occlusion of the fistula was achieved. Three-month follow-up angiography showed no residual filling; the patient remains complication-free. A combined surgical-endovascular technique in a hybrid operating room-angiography suite can be an effective treatment for DAVFs complicated by inaccessible arterial and transvenous approaches.

Introduction/Purpose Catheter-based cerebral angiography and embolization are important tools in managing cerebrovascular diseases in the pediatric population. We concurrently present data on the safety of pediatric neurointervention, demonstrating an overall low complication rate associated with such procedures in children, regardless of age group. However, radiation exposure during neurointerventional procedures in the pediatric population is of particular importance and merits dedicated study. Materials and Methods Records for all pediatric patients who underwent cerebral angiography and/or neuroembolization from 2007 through 2009 were retrospectively reviewed. Radiation skin entry dose data were obtained from fluoroscopic suites equipped with built-in cumulative dose (air kerma) and dose-area-product (DAP) measurement capability. Results Of the 357 consecutive procedures performed from 2007 through 2009, 214 were diagnostic angiograms and 143 involved embolization. Mean age was 9.5 years (range: 4 days to 18 years), and 193 were female. The interventional procedures included intracranial (77), extracranial (57), and spinal (9) embolizations. The pathology requiring neurointervention included intracranial arteriovenous malformation (AVM, 15), spinal AVM (8), aneurysms (15), Vein of Galen Malformation (VOGM, 19), intracranial arteriovenous fistula (AVF, 21), facial and extracranial AVM (46), tumor (11), stroke (2), and others (6). Overall, the observed cumulative dose and DAP correlated well (r=0.87). The average cumulative skin entry dose for the cohort was 365.9 mGy (range: 21–2707 mGy). Radiation exposure during neurointervention was significantly higher than during diagnostic angiography (566.3 and 191.0 mGy, respectively, p Conclusion Relative to previous reports related to neurointerventions in adults and to complex, non-neuro pediatric interventions, radiation exposure during cerebral angiography and embolization was moderate, and the short-term risk associated with radiation was low. It will be of importance, going forward, to track the long-term effects of radiation exposure related to pediatric neurointerventions in this cohort, requiring conversion of skin entry doses to brain organ dose. Competing interests None.

Introduction/purpose Catheter-based cerebral angiography and embolization and related techniques are important tools in the management of cerebrovascular diseases in the pediatric population. While two series reporting complication rates for pediatric diagnostic cerebral angiography have been published, a similar analysis for neurointerventional procedures in children is not available. Materials and Methods Records for all pediatric patients who underwent cerebral angiography and/or neurointerventions from January 1, 2007 to December 31, 2010 were retrospectively reviewed to identify both intra-procedural and post-procedural complications. Events were categorized as transient non-neurological, long-term non-neurological, transient neurological and long-term neurological complications. Demographic and clinical risk factors for developing a complication were analyzed with a multivariate logistic regression model. Results Of the 509 consecutive procedures performed by the senior author from 2007 through 2010, 304 were diagnostic angiograms and 205 were interventions. Mean age was 9.2 years (range: 4 days – 18 years), and the female to male ratio was 1.02. The interventional procedures included intracranial (85), extracranial (80), and spinal (13) embolizations, as well as sclerotherapy (27). Underlying pathology for the transarterial/transvenous interventions included Vein of Galen Malformation (23), intracranial AVM (21), intracranial AVF (17), aneurysms (16), spinal AVM (11), tumor (13), acute stroke (5), facial and extracranial AVM (53), extracranial AVF (10) and others (9). Pathologies for the sclerotherapy included venous and lymphatic malformations of the head and neck (27). Overall, zero intra-procedural and three post-procedural complications (0.99%) occurred in the diagnostic group, all of which were short-term, non-neurological events. In the interventions group, eight intra-procedural and six post-procedural complications (6.8%) were observed. There were four purely technical complications, with no clinical consequence (1.9%), four short-term non-neurological events (1.5%), three short-term neurological events (0.98%), and two long-term neurological events (0.98%): one patient developed intracerebral hemorrhage after embolization of an intracranial AVM, and another patient (a syndromic dwarf with moyamoya) had an acute infarct during aneurysm coiling. Multivariate analysis revealed that tumor embolization was associated with higher likelihood of complication than other groups of patients. There was no association between the age of the patient and the likelihood of adverse events. There were no vessel dissections or ruptures and no long-term femoral artery sequelae. Conclusions We report safety data on the largest pediatric neurointerventional cohort to date. At a high volume pediatric neurovascular center, the complication rates for neuroangiography and embolization are low; in particular, non-transient adverse events are rare. Competing interests None.