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Endovascular treatment for isolated dural arteriovenous fistula (DAVF) in the middle cranial fossa (MCF) with pure cortical venous drainage poses challenges, including the absence of a safe access route for transvenous embolization (TVE) and the risk of ischemia to neuro feeding vessels and dangerous anastomosis at the sphenoid wing. Therefore, surgical treatment involving direct blockage of venous reflux via craniotomy is typically preferred. We describe the case of a 63-year-old woman presented with generalized seizures and was diagnosed with a Borden III left MCF-DAVF. Initial TVE was unsuccessful due to an occluded inferior petrosal sinus and a lack of connection between the cavernous sinus and the shunt point. After reducing the shunt flow with transarterial embolization, retrograde TVE through cortical drainage enabled successful treatment for the DAVF. We used a triple coaxial system (4-French guiding sheath, 3.2-French intermediate distal access catheter, and 1.5-French microcatheter) to retrogradely navigate a microcathter from the right jugular vein through the superior sagittal sinus, the vein of Trolard, and into the superficial middle cerebral vein, ultimately achieving shunt occlusion using several coils. This case demonstrates that TVE for MCF-DAVFs with pure cortical venous drainage is feasible when a safe anatomical route is established using appropriate strategies and instruments and provides a safe and effective treatment option for similar cases.

Peri-medullary arteriovenous fistula (PMAVF) is a rare spinal vascular malformation that manifests as progressive neurologic deficits or hemorrhage in the spinal canal. We report a case of high-flow PMAVF in a child, with a single feeder artery and a large venous pouch, which was successfully treated with transarterial endovascular intervention. A 2-year-old boy was referred with a progressive 2-year history of myelopathy. The MRI revealed a large venous pouch at the midthoracic spinal cord with segmental surrounding edema. A spinal angiogram confirmed high-flow PMAVF with a single feeder artery from the anterior radiculomedullary artery, draining into the peri-medullary vein. The patient underwent transarterial embolization at the distal feeder artery, resulting in gradual motor strength improvement. PMAVF is classified as type IV spinal vascular malformation, usually presenting as a large, high-flow fistula with multiple feeders, although there was only one in this case. PMAVFs are intradural and may cause severe neurologic deficits due to mass effect, venous congestion, or hemorrhage, hence requiring prompt treatment. Treatment options for PMAVF include microsurgery, endovascular intervention, or a combination of the 2. Endovascular intervention with coil or liquid embolic material is considered first-line treatment for IVc PMAVF, and effective in type IVb with good clinical outcome. PMAVF is a rare spinal vascular malformation commonly manifesting as severe neurologic deficits but has the potential of favorable outcomes with endovascular therapy. This case demonstrates a unique angioarchitecture of high-flow PMAVF with a single feeder artery and large venous pouch, treated successfully with endovascular therapy.

Brain arteriovenous malformations (AVM) present complex treatment decisions, particularly for low-grade AVM where surgical resection is often considered the standard. This case report emphasizes the importance of patient preferences and cultural considerations in selecting endovascular embolization over traditional surgical approaches for Spetzler-Martin Grade I AVM management, highlighting the evolving practice of patient-centered care in neurointervention. A 30-year-old male presented with recurrent seizures, characterized by a sudden onset of headache followed by speech arrest, without any preceding medical history of neurological deficits. Initial physical examination revealed no focal neurological deficits. Non-contrast computed tomography, magnetic resonance imaging, and magnetic resonance angiography suggested an AVM involving the cortical-subcortical regions of the left frontal lobe, measuring approximately 1.7 × 2.6 × 1.5 cm, fed by the left middle cerebral artery M3 segment, and draining into the superior sagittal sinus. Spetzler-Martin Grade I classification was confirmed via digital subtraction angiography. Given the patient's strong preference against invasive procedures, driven by personal and cultural beliefs, endovascular embolization was selected as the treatment strategy. Post-embolization, the patient showed marked symptomatic improvement with no evidence of residual AVM on follow-up imaging, and no postprocedure complications were reported. This case highlights the importance of considering patient preferences in AVM treatment planning, illustrating that endovascular embolization can be an effective and less invasive alternative to surgery in selected patients, reinforcing the need for personalized, patient-centered approaches in neurointerventional care.

We present the first case of endovascular treatment of a ruptured anterior circulation aneurysm via a transradial approach in a patient with undiscovered aortic coarctation (CoA).A 29 year old male patient presented to the emergency department with a 1 day history of sudden-onset headache and vomiting.CT and CTA confirmed presence of acute subarachnoid haemorrhage and an anterior communicating (ACOM) artery aneurysm.Transfemoral endovascular angiography with a view to coiling was performed, however resistance was encountered distal to the aortic arch. On-table chest radiography demonstrated bilateral inferior rib notching confirming suspicion of a CoA.The procedure was converted to transradial access. The ACOM aneurysm was successfully coiled.This case highlights several important learning number points with particular regard to the rising era of transradial neuroendovascular management.

Endovascular treatment for isolated dural arteriovenous fistula (DAVF) in the middle cranial fossa (MCF) with pure cortical venous drainage poses challenges, including the absence of a safe access route for transvenous embolization (TVE) and the risk of ischemia to neuro feeding vessels and dangerous anastomosis at the sphenoid wing. Therefore, surgical treatment involving direct blockage of venous reflux via craniotomy is typically preferred. We describe the case of a 63-year-old woman presented with generalized seizures and was diagnosed with a Borden III left MCF-DAVF. Initial TVE was unsuccessful due to an occluded inferior petrosal sinus and a lack of connection between the cavernous sinus and the shunt point. After reducing the shunt flow with transarterial embolization, retrograde TVE through cortical drainage enabled successful treatment for the DAVF. We used a triple coaxial system (4-French guiding sheath, 3.2-French intermediate distal access catheter, and 1.5-French microcatheter) to retrogradely navigate a microcathter from the right jugular vein through the superior sagittal sinus, the vein of Trolard, and into the superficial middle cerebral vein, ultimately achieving shunt occlusion using several coils. This case demonstrates that TVE for MCF-DAVFs with pure cortical venous drainage is feasible when a safe anatomical route is established using appropriate strategies and instruments and provides a safe and effective treatment option for similar cases., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Objective: Endovascular treatment of complex vascular pathologies in the pediatric population is often performed by nonpediatric subspecialists with adaptation of equipment and techniques developed for adult patients. We aimed to report our center's experience with safety and outcomes of endovascular treatments for pediatric vascular pathologies., Methods: We performed a retrospective review of our endovascular database. All patients ≤18 years who underwent endovascular treatment between January 1, 2004 and December 1, 2022 were included., Results: During the study time frame, 118 cerebral angiograms were performed for interventional purposes in 55 patients. Of these patients, 8(14.5%) had intracranial aneurysms, 21(38.2%) had intracranial arteriovenous malformations, 6(10.9%) had tumors, 5(9.1%) had arterial occlusions (n = 3) or dissections (n = 2), 8(14.5%) had vein of Galen malformations, and 7(12.7%) had other cerebrovascular conditions. Of the total 118 procedures, access-site complications occurred in 2(1.7%), intraprocedural complications occurred in 3(2.5%), and transient neurological deficits were observed after 2(1.7%). Treatment-related mortality occurred in 1(1.8%) patient., Conclusions: Neurointervention in pediatric patients was safe and effective in our experience., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: The clinical significance of iatrogenic diffusion-weighted imaging lesions following endovascular procedures is currently not well understood, partly because they do not result in immediate clinical deficits (“silent brain infarcts” [SBI]) and often remain undiagnosed. Conversely, access site complications are well-documented. With the SILENT survey, we sought to gain an understanding of physicians' opinions regarding the relative importance of SBI compared to the more commonly discussed access site complications. Methods: Seven scenarios of access site complications of varying severity were provided. Within each scenario, participants were asked whether they would choose the access site complication or an increasing number of periprocedural SBI. Logistic regression clustered by respondent was performed to assess participant and scenario factors associated with preferential choice of SBI versus access site complications. Results: 67 participants (13 women; 19.4%) provided 469 responses to the survey. The majority (45; 67.2%) were neurointerventionalists. Regardless of scenario, any number of SBI was deemed unacceptable in 42.4% of cases, whereas 10.5% of physicians would accept >15 SBI to avoid any access site complications. Significant group differences for career stage (p=0.001) and specialty (p=0.007) for the number of tolerated SBI were observed. Regression analyses revealed that only hematoma severity was significantly associated with the willingness to accept an increasing number of SBI. Conclusion: In this survey, 4/10 physicians would accept even severe access site complications to avoid any SBI. The perceived importance of SBI among experienced physicians, and the uncertainty regarding their long-term sequelae, support their systematic assessment and reporting.

Background: Neurosurgeons often use radiation to visualize blood vessels and implants intraoperatively. However, high exposure to radiation increases one's cancer risk. This study aims to investigate intraoperative ionizing radiation exposure awareness and associated morbidity among neurosurgeons., Methods: An anonymized 30-question survey about their intraoperative radiation exposure, protective measures, radiation knowledge, and any conditions that can arise from protracted radiation exposure was disseminated to 3344 American Association of Neurological Surgeons members., Results: A total of 227 (6.8%) neurosurgeons completed the survey. Most neurosurgeons (61, 27%) performed 2-4 surgeries per week necessitating radiation (61, 27%), did not use a dosimeter (134, 59%), and wore a lead apron (89%) and a thyroid shield (75%). Only 7 (3%) of respondents could correctly identify the safety limit for occupational radiation. One hundred and thirty-four (59%) respondents correctly identified the relationship between distance and radiation dose reduction. Two hundred and thirteen (94%) neurosurgeons reported concern about occupational radiation exposure. No significant association was found between occupational radiation exposure and the rate of cataracts, combined cancer, and skin cancer. Multivariate logistic regression adjusting for age and cancer history found that the likelihood of developing leukemia (P = 0.02) and nonmalignant thyroid nodular disease (P = 0.01) is positively associated with increased total occupational radiation exposure., Conclusions: There is a need for improved radiation safety awareness among neurosurgeons, especially in the context of rising usage of minimally invasive surgery. This can allow for a greater understanding of radiation-associated risks among neurosurgeons and guide the implementation of safer practices., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Peri-medullary arteriovenous fistula (PMAVF) is a rare spinal vascular malformation that manifests as progressive neurologic deficits or hemorrhage in the spinal canal. We report a case of high-flow PMAVF in a child, with a single feeder artery and a large venous pouch, which was successfully treated with transarterial endovascular intervention. A 2-year-old boy was referred with a progressive 2-year history of myelopathy. The MRI revealed a large venous pouch at the midthoracic spinal cord with segmental surrounding edema. A spinal angiogram confirmed high-flow PMAVF with a single feeder artery from the anterior radiculomedullary artery, draining into the peri-medullary vein. The patient underwent transarterial embolization at the distal feeder artery, resulting in gradual motor strength improvement. PMAVF is classified as type IV spinal vascular malformation, usually presenting as a large, high-flow fistula with multiple feeders, although there was only one in this case. PMAVFs are intradural and may cause severe neurologic deficits due to mass effect, venous congestion, or hemorrhage, hence requiring prompt treatment. Treatment options for PMAVF include microsurgery, endovascular intervention, or a combination of the 2. Endovascular intervention with coil or liquid embolic material is considered first-line treatment for IVc PMAVF, and effective in type IVb with good clinical outcome. PMAVF is a rare spinal vascular malformation commonly manifesting as severe neurologic deficits but has the potential of favorable outcomes with endovascular therapy. This case demonstrates a unique angioarchitecture of high-flow PMAVF with a single feeder artery and large venous pouch, treated successfully with endovascular therapy., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Background: Femoral access (TFA) for neuroendovascular procedures may present a challenge in very high body mass index (BMI) individuals. Whether radial access (TRA) confers a comparative benefit in this specific population has not been studied., Methods: We retrospectively identified all patients undergoing neuroendovascular procedures at our center between 2017 and 2021 with BMI ≥35 kg/m 2 . A total of 335 patients met our inclusion criteria, with 224 undergoing femoral access and 111 undergoing radial access. Electronic medical records were reviewed for baseline clinical and angiographic characteristics and procedural outcomes., Results: The primary outcome of any bleeding complication occurred in 7% of the femoral group and 2% of the radial group (odds ratio 4.2, 95% confidence interval 1.0-18.6, P = 0.0421). Radial access was also associated with significantly shorter mean procedure times (median 43 minutes for radial, median 58 minutes for femoral, P = 0.0009) and mean fluoroscopy exposure times (median 15 minutes for radial, median 20 minutes for femoral, P = 0.0003). There were no significant differences in nonaccess site complications, procedural failure, length of stay, or deaths during hospitalization., Conclusions: When compared to TRA, TFA was associated with a significantly greater rate of bleeding complications in very high BMI patients undergoing neuroendovascular procedures. Procedure time and fluoroscopy time were both significantly longer when using TFA compared to TRA in this patient population., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Despite advances in transcatheter aortic valve replacement (TAVR), periprocedural acute ischemic stroke remains a concern., Objectives: The aims of this study were to investigate acute ischemic stroke complicating TAVR (AISCT) and to describe the indications and outcomes of interventions to treat AISCT., Methods: An international multicenter registry was established focusing on AISCT within 30 days of TAVR. Stroke severity was assessed using the National Institutes of Health Stroke Scale. Primary outcomes were 1-year all-cause death and neurologic disability status at 90 days according to modified Rankin scale score., Results: Of 16,615 TAVR procedures, 387 patients with AISCT were included (2.3%). Rates of 1-year death were 28.9%, 35.9%, and 77.5% in patients with mild, moderate, and severe stroke, respectively (P < 0.001). Although 348 patients were managed conservatively, 39 patients (10.1%) underwent neurointervention (NI) with either mechanical thrombectomy (n = 26) or thrombolytic therapy (n = 13). In a subanalysis excluding patients with mild stroke, there was no clear 1-year survival benefit for NI compared with conservative management (47.6% vs 41.1%, respectively; P = 0.78). In a logistic regression model controlling for stroke severity, NI was associated with 2.9-fold odds (95% CI: 1.2-7.0; P = 0.016) of independent survival at 90 days., Conclusions: AISCT carries significant morbidity and mortality, which is correlated with stroke severity. The present findings suggest that neurologic disability for patients with moderate or worse stroke could potentially be improved by timely intervention and highlight the importance of collaboration between cardiologists and neurologists to optimize AISCT outcomes., Competing Interests: Funding Support and Author Disclosures Dr Pilgrim has received research grants to the institution from Edwards Lifesciences, Boston Scientific, and Biotronik; has received personal fees from Biotronik and Boston Scientific; has received other compensation from HighLife SAS and Medira; and is a proctor for Medtronic. Dr De Backer has received research grants and consulting fees from Abbott and Boston Scientific. Dr Søndergaard has received consulting fees and institutional research grants from Abbott, Boston Scientific, Edwards Lifesciences, and Medtronic. Dr Van Mieghem has received research grant support from Abbott, Boston Scientific, Edwards Lifesciences, Medtronic, PulseCath BV, and Daiichi Sankyo; and has received advisory fees from Abbott, Boston Scientific, Ancora, Medtronic, PulseCath BV, and Daiichi Sankyo. Dr Webb has been a consultant to and has received research funding from Edwards Lifesciences, Medtronic, and Boston Scientific. Dr Cockburn is a proctor for Boston Scientific. Dr Seiffert has served as a consultant for JenaValve and Boston Scientific; has received travel compensation from Edwards Lifesciences, JenaValve, Boston Scientific, and Biotronik; and has received speaker honoraria from Medtronic. Dr Mangieri has received a research grant (to the institution) from Boston Scientific; and has served on a medical advisory board for Boston Scientific. Dr Latib has served on advisory boards for Medtronic and Abbott; and has been a consultant to Edwards Lifesciences. Dr Akodad has received research funding from Medtronic, Biotronik, MUSE Explore, and Federation Française de Cardiologie. Dr Perl is a consultant for Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022. Published by Elsevier Inc.)

Background: The prevalence of carotid artery atherosclerosis and stroke is increasing. Carotid artery stenting (CAS), which treats carotid artery stenosis and prevents strokes, has benefited from advances in techniques and technology. In this study, we aimed to identify significant risk factors for major complications following contemporary CAS., Methods: Utilizing the National Surgical Quality Improvement Program registry, we investigated individuals who underwent CAS between the years 2015-2018. Multivariable logistic regression was performed to identify risk factors associated with stroke, myocardial infarction (MI), and death within 30 days of CAS., Results: Of the 770 patients within the National Surgical Quality Improvement Program registry who met study criteria, 3.2% experienced strokes, 1.6% experienced MIs, and 2.2% died within 30 days of CAS. A total of 6.1% of patients experienced any of these major complications. Of the 395 asymptomatic patients, 3.5% suffered a stroke, 1.5% experienced an MI, and 1.0% died for a total of 5.6% patients suffering from any event. Of the 375 symptomatic patients, there were 2.9% strokes, 1.6% MIs, and 3.5% deaths with 6.7% suffering any event. Age, race, and hyponatremia were significantly associated with stroke, and hyponatremia was associated with MI. Age, anemia, hypoalbuminemia, international normalized ratio, and emergency case were associated with death., Conclusions: These results suggest that preoperative risk stratification of CAS patients may not be straightforward as each adverse event has its own risk factors, precluding a generalized CAS risk stratification scoring system from being created. This paper can aid in patient selection for CAS by highlighting risk factors in modern CAS., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Studies about the transradial technique and experience with this approach abound in the neurointerventional literature, but studies focusing on patient perspectives and preferences with respect to transfemoral or transradial access are scarce., Methods: Patients from our center who underwent both transradial and transfemoral approaches for diagnostic and interventional cerebral angiograms on distinct occasions between January 2016 and January 2021 were identified and interviewed by phone regarding their experience with these access approaches. The first question was regarding the choice for an eventual next procedure (radial, femoral, or no preference). The second question addressed reasons (pain, bruising, complications, recovery time, mobility, failure of one approach, and comfort associated with puncture of the respective area)., Results: Forty-four patients were interviewed. Thirty-one (70.4%) preferred radial, 9 (20.5%) preferred femoral, and 4 (9.1%) had no preference. Most frequent reasons for radial preference were recovery time (67.7%), bruising (51.6%), and pain (48.4%). Most frequent reasons in femoral preference were pain (55.6%), mobility (33.3%), and failure of the other approach (33.3%). Recovery time (67.7% vs. 22.2%; P = 0.023) and comfort of puncturing the area (45.2% vs. 0%; P = 0.015) were significantly more frequent reasons for radial preference, whereas failure of the other approach (0% vs. 33.3%; P = 0.008) was a significantly more frequent reason for femoral preference., Conclusions: Most patients preferred the transradial approach. Evaluating the reasons behind their preference can help operators to better understand patient perspectives and improve quality of care., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Although studies have continued to demonstrate the advantages of transradial access (TRA) for neurointervention, radial artery spasm (RAS) has remained a frequent cause of TRA failure. Dotter and Judkins initially described a technique to dilate areas of peripheral vascular stenosis by advancing sequentially larger catheters across the lesion over a guidewire. We have presented our institutional experience with the use of a modified Dotter technique with long radial sheaths to dilate areas of proximal flow-limiting RAS. In the present study, we reviewed the use of the Dotter technique for alleviating RAS in patients undergoing TRA for neurointervention., Methods: We performed a retrospective review of all patients undergoing TRA for neurointervention at our institution from 2018 to 2020 to identify patients with proximal flow-limiting RAS. For the identified patients, a modified Dotter technique had been used to dilate the stenosis. The demographic and periprocedural data were assessed to identify any adverse outcomes., Results: Four patients with severe proximal flow-limiting RAS were identified. In each case, a hydrophilic long radial sheath and vascular dilator were sequentially advanced through the stenosis. In all cases, repeat angiography demonstrated improvement of the spasm, and the final radial angiograms demonstrated persistent improvement in caliber and regularity of the vessel. Each procedure was also completed via TRA with no periprocedural complications., Conclusions: Our modified Dotter technique was effective in bypassing areas of severe proximal flow-limiting RAS, obviating the need for access site conversion. Additional studies are warranted to understand the implication of the angioplasty-like effects seen within the radial artery after removal of the long radial sheaths., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The transradial approach using a Simmons-shaped catheter has been increasingly used for diagnostic cerebral angiography and neurointervention. In the transradial approach for neurointervention, the right radial artery is mainly used. However, in interventional cardiology, there are apparent clinical benefits with the left transradial approach for right-handed patients. To our knowledge, no studies have reported on neurointervention with the routine use of the left transradial approach. We therefore devised a novel technique for cases with an unachievable form of the Simmons shape using the standard technique, which we named the "interchange technique." The purpose of this study was to evaluate the technical feasibility of the left transradial neurointervention., Methods: This study is a retrospective review of our prospective database of consecutive patients who underwent a left transradial neurointervention, using a 6-French Simmons guiding sheath, performed from January through April 2021. The outcome variables studied were successful catheterization and procedure-related complications., Results: Twenty-one patients underwent a left transradial neurointervention including cerebral aneurysm coiling, carotid artery stenting, and meningioma embolization. The Simmons shape could not be formed with the standard technique for 3 patients, for whom we successfully formed the Simmons shape with our new interchange technique. The procedure was completely achieved in all 21 patients. No patients required crossover to the right radial or femoral arteries, and there were no radial artery spasms or occlusions or any procedural complications., Conclusions: The left transradial approach for neurointervention is a technically feasible, safe, and effective alternative while providing more comfort to right-handed patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Transradial access is an increasingly popular route for cerebral angiography and neurointerventions. However, obstacles to wider adoption remain, especially for complex interventions typically performed with larger, multiaxial systems such as flow diversion. We sought to analyze the published evidence for transradial flow diversion of intracranial aneurysms., Methods: Using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, a literature review was performed to identify all published reports and studies of transradial flow diversion for intracranial aneurysm. The search was limited from April 2011 to February 2021. Primary outcome was successful completion of the procedure via a transradial approach. Heterogeneity was analyzed with Q and I 2 statistics. Secondary outcomes were transradial access-site complications and other complications., Results: In total, 11 studies involving 290 treated aneurysms were identified; 90.7% of the procedures were completed via the transradial approach. The heterogeneity between studies was high, with an I 2 of 56.9%. There were no transradial access-site complications. The procedural complication rate was 2.41%., Conclusions: Transradial access has a high success rate for both anterior and posterior circulation flow-diversion embolizations. The success rate may be particularly high for posterior circulation and right anterior circulation aneurysms. It has a negligible access-site complication rate. Transradial access is a viable alternative to transfemoral access for flow diversion and should be considered as a first-line approach., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The COVID-19 pandemic is rapidly transforming the healthcare system, with telemedicine, or virtual health, being one of the key drivers of the change. Smart glasses have recently been introduced to the public and have generated interest with healthcare professionals as demonstrated by their early adoption in clinics and hospitals. Observing procedures is essential for young interventionalist-in-training, but sometimes it is difficult for them to be able to get the volume of exposure to procedures that they need. Here, we report the first experience using smart glasses for Neurointerventional procedures, highlighting potential benefits and limitations during different scenarios including invitro and life cases. This field is novel, innovative, and may have potential to improve both patient care and patient safety in other health care settings., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Transradial access (TRA) for neuroendovascular procedures has several clear benefits compared to transfemoral access. In this study, we report our initial experience with neuroendovascular procedures performed via transradial access using the novel Ballast 088 long sheath., Methods: We conducted a retrospective analysis and identified 91 consecutive patients who underwent neuroendovascular procedures via TRA using the Ballast 088 long sheath. Data collection was performed on indication for procedure, number of vessels selectively catheterized, fluoroscopy time, procedure duration, radiation exposure, failure of radial access and conversion to transfemoral access, periprocedural complications, and procedural outcomes., Results: Amongst 91 patients, the average age was 65.5 years ± 14.2 with 45 (49.5 %) female patients. 25 (27.5 %) patients underwent aneurysm treatment, 2 (2.2 %) AVM/AVF embolization, 28 (30.8 %) intracranial or extracranial stenting, 31 (34.1 %) stroke treatment, and 5 (5.5 %) underwent diagnostic angiogram. The mean number of target vessels catheterized was 1.07 ± 0.25, the mean procedure duration (minutes) was 96.5 ± 57.2, mean fluoroscopy time (minutes) was 21.9 ± 14.2, mean contrast dose (ml) was 112.7 ± 66.7, and mean radiation exposure (Gycm2) was 54.82 ± 41.37. The success rate of target vessel catheterization was 100 %. There were no complications resulting in long term sequelae. Access complications occurred in 1 (1.1 %) patients. Transfemoral conversion was required in 3 (3.3 %) patients., Conclusions: The Ballast 088 long sheath is safe and effective for TRA in neuroendovascular procedures with a low rate of complications and conversion., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Posterior circulation tandem occlusions are poorly characterized in current literature. Data regarding endovascular approaches and outcomes in this patient subgroup is extremely limited., Methods: We conducted a retrospective analysis of a prospectively maintained database and identified 17 patients with posterior circulation tandem occlusions who underwent mechanical thrombectomy between 2014 and 2019., Results: Of 17 patients with posterior circulation tandem occlusion, the mean age was 55.76 ± 11.8 with 35.3% female. The mean NIHSS score on presentation was 17.2 ± 9.2. Tissue plasminogen activator was administered in 7 (41.2%) patients, stent-retrievers alone were used in 2 (11.8%), aspiration catheters alone were used in 2 (11.8%), a combination was used 12 (70.6%), and a self-expandable stent in 5 (29.4%). The mean number of device passes was 2.24 ± 2.02, recanalization failure occurred in 4 (23.5%) patients, the mean time from stroke onset to puncture was 6.9 ± 2.4 h, and the mean time from puncture to recanalization was 59.3 ± 26.6 min. Postprocedural symptomatic ICH occurred in 1 (5.9 %) patient, periprocedural ICH/SAH occurred in 2 (11.8%), periprocedural distal emboli occurred in 0 (0%), periprocedural vessel dissection occurred in 1 (5.9%), and periprocedural vessel perforation occurred in 1 (5.9%) patient. TICI score>2b was achieved in 13 (76.5%) patients. An improvement in NIHSS>3 at discharge occurred in 10 (58.8%) patients, and good outcomes (mRS score < 2) occurred in 7 (41.2%). The mean length of stay was 11.6 ± 12.2 days, and the mortality rate was 41.2%., Conclusion: Endovascular intervention with mechanical thrombectomy is safe and feasible in patients with posterior circulation tandem occlusions., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: In cardiac intervention, the transradial approach (TRA) is increasingly used as the first-line approach owing to numerous advantages over the transfemoral approach. Neurointerventional TRA, especially in intracranial interventions, is predominantly restricted to an alternative approach, as transradial carotid cannulation using a conventional transfemoral system can be technically challenging for patients with unfavorable acute takeoff of the target common carotid artery. This study evaluated the feasibility and safety of first-line TRA with a radial-specific neurointerventional guiding sheath for a large series of consecutive intracranial anterior circulation aneurysm embolizations., Methods: We retrospectively analyzed our institutional database of first-line TRA for consecutive coil embolizations of anterior circulation aneurysms conducted between June 2018 and March 2020. A radial-specific 6-F Simmons guiding sheath (0.088-inch inner diameter) was engaged into the target common carotid artery, and subsequently a triaxial or quadraxial system was created for the embolization procedure. We assessed procedural success and procedure-related or vascular access site complications., Results: A total of 119 patients with intracranial anterior circulation aneurysms underwent 121 coil embolization procedures. Of these, 101 patients who underwent 103 (85.1%) embolization procedures treated with first-line TRA were included. After the triaxial or quadraxial system was constructed, the embolization procedure was successful for all 103 cases without catheter kinking, system instability, or complications., Conclusions: A transradial 0.088-inch triaxial or quadraxial system provided sufficient stability and kink resistance for intracranial aneurysm embolization. This method is feasible, highly successful, and safe for intracranial anterior circulation aneurysm embolization., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Surgical skills are generally acquired by watching the "hand movements" of experts. "Eye movements" are now attracting attention in skill-learning fields. Eye-tracking technology was introduced preliminarily to develop a better skill-learning system for neuroendovascular treatments., Methods: During a task to place a detachable coil into a silastic cerebral aneurysm model under biplane X-ray fluoroscopy, gaze points were recorded using a head-mount eye-tracking device., Results: During the task, 91% of fixations were allocated to the monitor displaying fluoroscopic images, and the others to the hands of operators or unspecified visual targets. More than 80% of fixations were located in frontal or lateral fluoroscopic images. Fixations were placed more frequently around the aneurysm than the microcatheter. One operator failed to recognize the timing when the proximal marker of the coil overlapped that of the microcatheter. The subject allocated most fixations to the frontal fluoroscopic image, whereas other subjects placed most fixations to the lateral fluoroscopic image. Furthermore, that operator put no fixations to the proximal marker of the microcatheter., Conclusions: The results of this preliminary study imply the feasibility of the eye tracking-based learning system for neuroendovascular treatments. The eye-tracking analysis has potential in investigating or preventing procedural failures in neuroendovascular treatments., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: In coronary intervention, the transradial approach (TRA) is increasingly used as the primary vascular access because of its numerous advantages over the transfemoral approach. However, in neurointerventions, conventional TRA with a straight-shaped guiding system is used as an alternative vascular access because transradial carotid cannulation can be technically challenging for right common carotid artery (CCA) lesions with steep angulation to the right subclavian artery or left CCA lesions with a nonbovine origin. The purpose of the present study was to evaluate the feasibility and safety of TRA as the primary vascular access with a pre-shaped Simmons guiding sheath for anterior circulation interventions., Methods: Between June 2018 and September 2019, 130 consecutive patients (75 carotid artery stenting and 55 cerebral aneurysm coiling cases) who underwent TRA as the primary vascular access were included in this study. A 6-Fr Simmons guiding sheath was introduced into the target CCA by selecting a cannulation technique based on preprocedural image assessment. We retrospectively analyzed the carotid cannulation success, procedural success, and periprocedural or vascular access site complications., Results: Carotid cannulation (69 right CCA, 6 left CCA with a bovine origin, and 55 left CCA with a nonbovine origin) and the subsequent procedure were successfully performed for all 130 patients without periprocedural or vascular access site complications., Conclusions: TRA with a 6-Fr Simmons guiding sheath for anterior circulation interventions is highly successful and safe for all target CCAs and aortic arch types. This method can be utilized as the primary vascular access for anterior circulation interventions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to assess the natural course of contrast-induced nephropathy (CIN) and to determine the predictive abilities of preprocedural high-sensitivity C-reactive protein (hs-CRP) and urine neutrophil gelatinase-associated lipocalin for CIN after neurointervention procedures., Methods: We prospectively enrolled 176 patients who underwent an elective neurointervention procedure (diagnostic angiography or endovascular surgery). CIN was defined as an increase in serum creatinine of more than 0.5 mg/dL or an increase of at least 25% from the baseline value within 48 hours of contrast media exposure. The predictive value of hs-CRP and serial urine NGAL (baseline, 6, 24, and 48 hours) for the risk of CIN was assessed using multivariate logistic regression., Results: CIN occurred in 17 patients (9.46%). Multivariate analysis revealed that the CIN incidence was significantly associated with high baseline hs-CRP. All patients with CIN had creatinine return to baseline levels within 7 days. No patients required dialysis or suffered permanent sequelae as a result of a creatinine increase. During the 3-year follow-up period, no cerebro- or cardiovascular events occurred in the CIN group. However, 3 patients in the non-CIN group suffered a vascular event. One was a myocardial infarction, and 2 were ischemic strokes., Conclusions: The incidence of CIN after neurointervention procedures was relatively high (9.46%). The natural course of CIN was favorable, however, and did not affect cerebrovascular events. Additionally, patients with CIN typically recovered with supportive care within 7 days. Elevated preprocedural hs-CRP levels (>5 mg/dL) were a significant and independent predictor of CIN after neurointervention procedures., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Hemostasis valves are commonly used in neurointerventions. We propose a novel concept for fixing hemostasis valves to the operating table during procedures. Moreover, we report our preliminary in vitro experience using these new devices created using a 3-dimensional printer., Methods: The hemostasis valve holder (HVH) comprises 2 components: an inner fixer and an outer socket. It was designed to be suitable for use with all rotational hemostasis valves commercially available. HVH contains magnets at the bottom that facilitate its attachment to a thin steel board beneath a sterilized drape on the working table. We evaluated the HVH's efficacy via in vitro experiments involving stent placement by a single operator., Results: HVH allowed easy attachment to and detachment from the rotational hemostasis valve. Moreover, the use of multiple HVHs facilitated operators to concentrate on the procedure because they continuously prevented the unexpected movement of devices at several points. Use of HVHs enables stent placement to be performed even by a single operator. We observed that forming a loop of the stent delivery catheter between 2 HVHs enhanced the device control., Conclusions: HVHs should be more useful than conventional methods, particularly in cases requiring fine complementary control of both a microcatheter and microguidewire., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Concerns exist that neurosurgery might fail to lead the field of endovascular surgical neuroradiology (ESN), as other specialties are allowed to train and practice ESN. This study aimed to assess the current breakdown of specialties and their relative academic productivity in accredited ESN fellowship programs., Methods: A list of fellowship programs was obtained from the Accreditation Council for Graduate Medical Education and Committee on Advanced Subspecialty Training directories. Primary specialty (i.e., residency) training for each faculty member in these programs was determined using information provided by the programs. A bibliometric search was performed for each member using Web of Science (Clarivate Analytics, Philadelphia, Pennsylvania, USA). Cumulative and ESN-specific h indices were calculated; h indices were compared between each specialty group and between international medical graduates and US medical graduates, regardless of specialty training., Results: Thirty-one ESN fellowship programs with 88 faculty members were included. Neurosurgeons constituted 61.4% (n = 54) of the total ESN faculty, followed by radiologists with 30.7% (n = 27), and neurologists with 7.9% (n = 7). The mean ESN-specific h index for neurosurgery-trained ESN faculty was 16.2 ± 14.6 compared with 14.4 ± 10.9 for radiologists and 13.0 ± 12.6 for neurologists (P = 0.76). There were 12 IMGs and 76 USMGs. The mean ESN-specific h index was greater for IMGs than USMGs, 24.7 ± 14.3 versus 14.0 ± 12.7 (P = 0.008), respectively., Conclusions: Neurosurgery is leading the ESN field in numbers; however, the h index is not significantly different among ESN faculty based on primary training. The number of IMGs is relatively small, yet IMGs have significantly higher mean h indices., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Endovascular treatment of neurovascular disorders is now well established as effective and safe; however, the nature of the intracranial vasculature poses unique challenges. The unintentional dislodgement or fracture of a device and its migration within cerebral vessels is a complication with serious potential morbidity that must be managed urgently. In this series, the authors describe 7 cases of a stentriever being used to remove foreign objects from within the cerebral vasculature., Methods: A retrospective search of all interventional neurovascular procedures performed in 2017 at a tertiary metropolitan hospital was performed to identify cases of dislodged devices., Results: Five dislodged endovascular coils, 1 microcatheter, and 1 fractured stentriever were technically successfully retrieved. In 6 of the cases, the foreign object was successfully removed with a stentriever alone, whereas 1 case used a J-tip wire and a "J-tip flick" to manipulate the coil and facilitate retrieval. Stentrievers, particularly when used alone, confer the advantages of speed, cost, as well as being tailor-made for cerebral vessels. They also allow continuous blood flow when deployed, a critical advantage when considering cerebral perfusion. Critical techniques include the gradual deployment of the stentriever alongside the foreign object to allow its entanglement and partial resheathing, so that the foreign object can become pinned within the microcatheter. Stentrievers do remain limited by vessel caliber and are less able to entangle larger, stiffer devices., Conclusion: The migration of foreign devices during neurointerventional procedures is a serious complication requiring urgent treatment. This case series highlights the efficacy and advantages of using a stentriever and suggests its consideration as a first-line technique in recovering dislodged foreign bodies in the cerebral vasculature., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Cerebral catheter angiography and endovascular neurointerventions (ENIs) were developed and refined by early pioneers in neuroradiology. Recently, with developments in the safety and efficacy of ENIs, other physician specialists have expressed strong interest in performing these procedures. Our purpose was to compare volume and utilization of ENIs, among the various specialties, from 2000 to 2013., Methods: Data from the Medicare Part B Physician/Supplier Procedure Summary Master Files for 2000 to 2013 were used to study ENI volume and utilization rates, by radiologists, neurosurgeons, neurologists, vascular surgeons, cardiologists, and other physicians., Results: From 2000 to 2013, the volume of intracranial ENIs increased: overall, from 2,439 to 7,424; for radiologists, from 1,956 to 3,993; and for neurosurgeons, from 237 to 2,900. Although cardiologists did not perform many intracranial ENIs in these years, they performed most of the carotid artery stenting procedures (4,097, which is 51% of the total 8,201 performed in 2013)., Conclusions: Radiologists continue to maintain a strong presence in the field of neurointerventional radiology, particularly in percutaneous intracranial interventions, performing 51% of all intracranial procedures in 2013, down from 80% in 2000. However, neurosurgeons have made substantial inroads into ENI procedures, with their volume increasing from 10% to 33%, from 2000 to 2013. The overall volume of ENIs rose steadily from 2000 to 2013., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)