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Introduction The Pipeline Embolization Device (PED) has greatly expanded the range of aneurysms amenable to endovascular treatment, including those with wide necks that incorporate branch vessels. Published occlusion rates of anterior circulation aneurysms treated with the PED typically exceed 85%1–7 with morbidity rates of less than 7%.7 8 Prompted by this success, the PED is being increasingly utilized for the off-label treatment of posterior circulation aneurysms with widely varying results.9 10 The purpose of this study was to examine the procedural, clinical, and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. Methods Retrospective review of the neurointerventional databases of three high-volume neurovascular centers was approved by respective institutional review boards to identify patients with vertebrobasilar aneurysms treated with the PED between 2012 and December 2016. Demographic, clinical, and angiographic data were collected from electronic medical records. Procedural details, including devices used and peri-procedural complications, were collected from operative reports. Preoperative digital subtraction angiography was reviewed to determine the morphological characteristics of treated aneurysms, including largest diameter in any dimension, location, shape, and incorporated branch vessels. Follow-up angiographic images were also reviewed for intra-PED stenosis and patency of branch vessels covered by the PED. Results During the study period, 27 patients with 29 vertebrobasilar aneurysms underwent 28 treatments with the PED. The patients were 37% (10/27) men and 63% (17/27) women with a mean age of 53.3 years (range, 32–75 years), 44% (12/27) of whom were previous or current smokers. 74% (20/27) of patients were asymptomatic at presentation. Six of the remaining patients presented with subarachnoid hemorrhage (SAH; 22%, 6/27) and one patient presented with stroke related to thrombosis of brainstem perforators incorporated into the aneurysm (3.7%, 1/27). Aneurysm locations included the basilar trunk (41%, 12/29), basilar tip (7%, 2/29), vertebral artery (VA) proximal to the posterior inferior cerebellar artery (PICA; 10%, 3/29), VA at the PICA origin (10%, 3/29), and post-PICA VA (17%, 5/29). There were 15 saccular aneurysms (50%) with a mean size of 8.1 mm (range, 1.7–38 mm), 13 fusiform aneurysms (47%) with mean size of 11.8 mm (range, 4.3–34 mm) and length of 11.4 mm (range, 3.4–33), and one 2.9 mm blister aneurysm. The overall procedural complication rate was 18% (5/28), and the neurologic morbidity and mortality rate was 11% (3/28). Excluding aneurysms in patients who died, angiographic follow up was available for 96% (26/27) of patients. Mean duration of follow up was 12 months (range, 3–59 months). At last angiographic follow up, 67% (18/27) of aneurysms were completely occluded and 81% (22/27) were completely or near-completely occluded. A total of 36 branch vessels in 21 patients were covered by at least one PED. At last angiographic follow up, 8% (3/36) of covered branch vessels were occluded, none of which were symptomatic. Conclusion Pipeline embolization of vertebrobasilar aneurysms is associated with a higher complication rate and lower occlusion rate compared with anterior circulation aneurysms, but may be a viable treatment option in select cases. Disclosures A. Wallace: None. M. Kamran: None. T. Madaelil: None. Y. Kayan: 2; C; Medtronic, Penumbra, MicroVention. A. Kansagra: None. J. Grossberg: None. J. Delgado Almandoz: 2; C; Medtronic, Penumbra, Microvention, Accriva Diagnostics. C. Moran: 2; C; Medtronic. A. Roy: None. D. Cross: None. B. Howard: None. C. Cawley: None. J. Dion: None. T. CreveCoeur: None. J. Osbun: 1; C; MicroVention.

Purpose Intracranial dural arteriovenous fistulas (dAVFs) constitute approximately 10%–15% of all intracranial vascular malformations. More rarely, these lesions can lead to intracranial hemorrhage. Early re-bleeding rates from unsecured, ruptured dAVFs have been reported as high as 50%. Therefore, early intervention is paramount. Our aim of this study was to investigate the angiographic and clinical outcomes of early endovascular intervention in this rare disease presentation. Methods A HIPPA compliant neuroendovascular procedural database was reviewed for all treated dAVFs from 1999 to 2017. Inclusion criteria for the study included: 1) hemorrhagic presentation and 2) early endovascular intervention defined as less than 48 hours from initial ictus. Clinical demographics, angiographic and procedural details (Anatomic location, Borden classification, route of embolization, material used during embolization, number of retreatments, and need for completion microsurgical ligation), as well as clinical and angiographic follow up outcomes (modified Rankin scale and occlusion status on last follow-up imaging) were recorded. Appropriate statistical analyses were performed on parametric and non-parametric variables as applicable (statistical significance, α=0.05). Results A total of 262 dAVFs were identified, of those only 18 patients met inclusion criteria. Overall, the majority of patients were male (12/18; 66%), with a median age of 56 years (IQR 46–68 years). Hemorrhagic presentations included isolated intraparenchymal hemorrhage (IPH) (8/18; 44%), isolated subarachnoid hemorrhage (SAH) (7/18; 39%), SAH with subdural hematoma/intraventricular hemorrhage (IVH) (2/18; 11%), and isolated IVH (1/18; 6%). Almost all the hemorrhagic dAVF were of the aggressive type (Borden type II/III, 17/18; 94%). Anatomically, the most common location was tentorial (8/18; 44%). The anterior fossa, torcula, superior sagittal sinus, and transverse/sigmoid sinus all proportionately were the next common location (2/18; 11%, each respective group). Foramen magnum and straight sinus were the least common locations (1/18; 6%, each respective group). Transarterial embolization was performed most commonly (15/18; 83%), followed by transvenous approach (3/18; 17%). nBCA glue or Onyx embolization was most commonly used (15/18; 83%) with coils used exclusively in all transvenous cases (3/18; 17%). At last clinical follow-up, two patients succumbed to complications related to initial hemorrhage with the majority of patients (14/16; 88%) achieving good clinical outcome (mRS=0–2). On imaging follow-up when residual dAVF or incomplete embolization was noted (5/12; 42%) all cases underwent endovascular retreatment. Overwhelmingly, endovascular re-treatment failed in the majority of the cases (3/5; 60%); requiring microsurgical ligation for completion therapy. In no instance was early or late re-bleeding observed on last clinical follow-up, median 5 months (IQR 2–19 months). Conclusion Early endovascular intervention for ruptured dAVFs is feasible and effectively secures these lesions with no re-bleeding. Attention must be paid to lesions, which are incompletely embolized/show residual filling, as microsurgical ligation is imperative for completion therapy. Disclosures T. Madaelil: None. J. Grossberg: None. M. Cawley: None. F. Tong: None. J. Dion: 5; C; Vice President, Scientific Affairs at MicroVention-Terumo. B. Howard: None.

Purpose Carotid web is an intimal variant of fibromuscular dysplasia that has been associated with recurrent ischemic strokes in the young. The accuracy of different diagnostic tests is unknown. The objective of the present study is to evaluate the diagnostic performance of different imaging modalities for the detection of carotid webs. Methods Using an institutional neurovascular database, we retrospectively identified consecutive patients diagnosed with carotid web and internal carotid artery atherosclerosis. Multimodality imaging including at minimum neck CT angiography (CTA) at baseline plus either Digital Subtraction Angiography (DSA) and/or carotid Ultrasound (US) was mandatory. CTA images were evaluated by two readers (neurointerventionist#1 and diagnostic neuroradiologist) in a consensus read for confirmation of diagnosis, and degree of stenosis based on NASCET criteria. DSA studies were evaluated by two blinded readers (neurointerventionists #2 and #3) to categorize the presence or absence of carotid web or atherosclerotic plaque in individual carotid arteries. US studies were evaluated by two blinded readers (two neurosonology-credentialed stroke neurologists) to characterize diagnosis (carotid web vs atherosclerosis vs normal), degree of certainty, and the degree of stenosis. In the setting of discrepancies, consensus read was obtained. The performance of DSA and of US was compared to CTA. Results Median age of the cohort was 57 years (IQR 46–61 years) with 36.4% (12/33) male gender. Overall comorbidities included 60.6% (20/33) hypertension, 33.3% (11/33) hyperlipidemia, 21.2% (7/33) diabetes mellitus, and 27.3% (9/33) smoking. Multimodal imaging was available for 33 carotid arteries. Twenty-eight carotids had CTA and DSA available for review. DSA readers identified correctly all normal vessels, but diagnosed carotid webs less frequently (43%, 12/28; DSA group vs 50%, 14/28; CTA group) and atherosclerosis more frequently (43%, 12/28; DSA group vs 36%, 10/28; CTA group) when compared to CTA. Inter-rater correlation for the two DSA readers (κ=0.86, p Conclusion CTA and DSA should be preferred imaging modalities to diagnose and characterize carotid webs. Disclosures T. Madaelil: None. R. Nogueira: None. J. Grossberg: None. A. Anderson: None. C. Barreira: None. D. Haussen: None.