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Background: No conventional surgical intervention has been shown to improve outcomes for patients with spontaneous intracerebral hemorrhage (ICH) compared with medical management., Objective: We report the initial multicenter experience with a novel technique for the minimally invasive evacuation of ICH using the Penumbra Apollo system (Penumbra Inc, Alameda, California)., Methods: Institutional databases were queried to perform a retrospective analysis of all patients who underwent ICH evacuation with the Apollo system from May 2014 to September 2014 at 4 centers (Medical University of South Carolina, Stony Brook University, University of California at San Diego, and Semmes-Murphy Clinic). Cases were performed either in the neurointerventional suite, operating room, or in a hybrid operating room/angiography suite., Results: Twenty-nine patients (15 female; mean age, 62 ± 12.6 years) underwent the minimally invasive evacuation of ICH. Six of these parenchymal hemorrhages had an additional intraventricular hemorrhage component. The mean volume of ICH was 45.4 ± 30.8 mL, which decreased to 21.8 ± 23.6 mL after evacuation (mean, 54.1 ± 39.1% reduction; P < .001). Two complications directly attributed to the evacuation attempt were encountered (6.9%). The mortality rate was 13.8% (n = 4)., Conclusion: Minimally invasive evacuation of ICH and intraventricular hemorrhage can be achieved with the Apollo system. Future work will be required to determine which subset of patients are most likely to benefit from this promising technology.

Background: The presence of intracerebral hematoma from aneurysm rupture is an indication for craniotomy for clot evacuation and aneurysm clipping. Some centers have begun securing aneurysms with coil embolization followed by clot evacuation in the operating room. This approach requires transporting a patient from the angiography suite to the operating room, which can take valuable time and resources., Objective: To report our experience with 3 cases in which a novel technique for minimally invasive evacuation of intracerebral hematomas after endovascular treatment of ruptured intracranial aneurysms was used. The Penumbra Apollo system can be used in the angiography suite in conjunction with neuroendovascular techniques to simultaneously address a symptomatic hematoma associated with a ruptured aneurysm., Methods: Standard preoperative computed tomography angiography was performed on arrival to the emergency department. The patients underwent diagnostic cerebral angiography followed by balloon-assisted coil embolization and then remained in the neurointerventional suite for intracerebral hematoma evacuation with the Apollo system., Results: All patients tolerated coil embolization and hematoma evacuation well. The combined procedures lasted <3 hours in both cases. Two patients were eventually discharged to acute rehabilitation facilities less than a month after their initial insult, and 1 has been cleared to return to work. The other patient was transferred to hospice care., Conclusion: The Apollo aspiration system appears to be a safe and effective minimally invasive option for intracerebral hematoma evacuation, particularly when coupled with endovascular embolization of ruptured intracranial aneurysms. Future work will address which patient population is most likely to benefit from this promising technique.

Background: Parent artery occlusion is sometimes required to treat cerebrovascular lesions., Objective: We evaluated the Nfocus LUNA parent vessel occlusion (PVO) device in comparison with the Vascular Plug (AVP) used in the peripheral vasculature for large-vessel occlusion in a canine animal model., Methods: The subclavian arteries were targeted for occlusion in 7 canines. Each animal received 1 LUNA and 1 AVP device sequentially rotated between the left and right subclavian arteries. Angiographic assessment was performed serially after device placement until vessel occlusion was observed and then again immediately before the animal was killed. Three animals were euthanized at 1 month and 4 at 2 months post-implantation, after which the native artery segments containing the implanted device were harvested and preserved for subsequent histological analysis., Results: The LUNA PVO device and the AVP were accurately positioned and deployed in all cases. Acute occlusion times for the devices were not statistically different. In no instance was there any evidence of device migration. At 28 and 55 days, the LUNA implants showed nearly complete occlusion with small recanalization channels, whereas the AVP devices were associated with low occlusion levels and large residual vascular channels within the occluder., Conclusion: The LUNA PVO device and delivery system can be accurately placed to occlude vessels without migration and with a performance that is similar to the AVP. The LUNA PVO device on average provided a higher degree of occlusion durability at both 1 and 2 months.

Objective: To describe a novel double-balloon trapping technique for endovascular embolization of a broad-based saccular aneurysm of the superior cerebellar artery., Clinical Presentation: A 62-year-old man with a history of diabetes, coronary artery disease, and smoking presented with a syncopal episode. Catheter angiography revealed a large (11.7 x 9.4 x 11.2 mm) right superior cerebellar artery (SCA) aneurysm with a 7-mm neck, incorporating the origin of the right SCA., Intervention: An endovascular double-balloon trapping technique was used. Using bilateral groin access and bilateral vertebral artery guide catheters, a 4 x 20 mm HyperGlide balloon (ev3 Neurovascular, Irvine, CA) was placed across the neck of the aneurysm, and a 4 x 7 mm HyperForm balloon (ev3 Endovascular Inc., Plymouth, MN) was placed within the aneurysm. The aneurysm was catheterized with an Echelon 14 microcatheter (ev3 Endovascular Inc.). The inflated HyperGlide balloon was used to protect the parent basilar artery and "trap" the smaller HyperForm balloon within the aneurysm. The HyperForm balloon was inflated within the aneurysm and gently retracted to protect the origin of the SCA at the aneurysm neck. The aneurysm was coiled with the balloons inflated. A 4.5 x 20 mm Neuroform stent (Boston Scientific, Natick, MA) was deployed across the aneurysm neck. Final procedural angiography showed near complete occlusion of the aneurysm and preservation of flow in the SCA. Follow-up angiography at 8 months showed progressive thrombosis with complete occlusion of the aneurysm, preserved patency of the SCA, and anatomic reconstruction of the native artery. The patient remained neurologically normal at the time of the follow-up evaluation., Conclusion: Double-balloon trapping is a novel endovascular technique that can be used to treat wide-necked aneurysms and maintain patency of side branches incorporated into the aneurysm neck.

Objective: Microcatheters retained after Onyx (eV3 Neurovascular, Inc., Irvine, CA) embolization represent a potential source of thromboembolic complications. Catheter retention depends on the degree of Onyx reflux and vessel tortuosity. To overcome this problem, we have adapted a previously described monorail snare technique for stretched coils to remove an adherent microcatheter from the occipital artery during Onyx embolization of a dural arteriovenous fistula., Clinical Presentation: We used this technique successfully in a 62-year-old man with a posterior fossa dural arteriovenous fistula. An Echelon-10 microcatheter (eV3 Neurovascular, Inc.) system became adherent in the right occipital artery because of reflux and vessel tortuosity. Significant stretching of the microcatheter was observed during attempted removal., Intervention: A 2-mm Amplatz Goose Neck microsnare (Microvena Corp., White Bear Lake, MN) was placed through a Rapid Transit microcatheter (Cordis Corp., Miami, FL). The hub of the indwelling Echelon microcatheter was cut off and the snare advanced over the outside of the microcatheter. The snare and Rapid Transit microcatheter were then advanced into the guiding catheter (6-French) as a unit over the indwelling Echelon microcatheter. Using the adherent Echelon as a "monorail" guide, the snare and Rapid Transit microcatheter were advanced distally into the occipital artery and the snare was retracted to engage the microcatheter. The microcatheters and snare were then easily removed because of the second vector of force placed by the snare system on the adherent microcatheter very close to the point of adherence., Conclusion: The monorail snare technique represents a simple and safe way to remove an adherent microcatheter from an Onyx cast during the embolization of dural arteriovenous fistulas. Prospective knowledge of this technique will facilitate more aggressive embolization without the reservation that a retained microcatheter could require surgical removal or anticoagulation.

Objective: To describe a novel technique for single stent reconstruction of wide-necked aneurysms arising from the circle of Willis., Methods: Neuroform stents (Boston Scientific/Target, Fremont, CA) were placed across the basilar apex (right P1 to left P1) via the posterior communicating artery in two patients, across the left carotid terminus (left A1 to left M1) via the anterior communicating artery in two patients, and across the anterior communicating artery (left A1 to right A1) in one patient for stent-supported coil embolization., Results: Five women underwent successful deployment of the Neuroform stent across the circle of Willis to support subsequent coil embolization of a wide-necked cerebral aneurysm. In two patients with subarachnoid hemorrhage, initial dome coiling was performed for short-term protection, and stents were applied across the circle of Willis to support completion of coil embolization during a second session. None of the patients experienced any periprocedural or delayed neurological complications., Conclusion: Stenting across the circle of Willis represents a novel adjuvant technique to support the coiling of selected wide-necked intracranial aneurysms. This technique is particularly useful for wide-necked terminal aneurysms that incorporate both branches of a bifurcation in a configuration unfavorable for Y-stent reconstruction.

Objective: Although cerebrospinal fluid shunting remains one of the most common neurosurgical procedures, it is fraught with high infection, blockage, and reoperation rates. It has been estimated that the economic cost of ventriculoperitoneal shunting exceeds $1 billion annually. A new laparoscopic technique that eliminates abdominal incisions overlying shunt hardware was applied to 111 patients requiring ventriculoperitoneal shunts in an effort to decrease the morbidity associated with shunting., Methods: All patients who required ventriculoperitoneal shunt insertion were eligible for this surgical technique. Patient selection was based on availability of both surgical teams (general surgery and neurological surgery) at the time of surgery. Using this technique, the distal shunt catheter is tunneled directly from the head into the peritoneal cavity under laparoscopic guidance without a skin incision directly overlying the distal catheter insertion site. Patients were followed prospectively for signs and symptoms related to shunt dysfunction, shunt infection, and incision morbidity., Results: One hundred eleven patients underwent 113 laparoscopic ventriculoperitoneal shunt surgeries between February 2003 and December 2004. The average follow-up period was 21.7 months (range, 12-34 mo). Nearly half of the patients (49%) were discharged the next morning and the majority (81%) was discharged within 2 days of surgery. Overall, 15 patients experienced complications requiring reoperation (13.5%) with a 1-year shunt survival rate of 91%. One patient (0.9%) acquired a new shunt infection, whereas two patients (1.8%) developed recurrence from a previous shunt infection. There were no abdominal incision-related complications., Conclusion: This simplified laparoscopic shunt placement technique, which requires no overlying abdominal incisions, can be performed quickly with high shunt survivability and low infection rates. Furthermore, the laparoscopic method has the advantage of fast recovery time, elimination of preperitoneal or misplaced catheters, and decreased abdominal incision morbidity. The procedure can be performed by either a multidisciplinary team or entirely by neurosurgeons.