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Background: Cerebral venous thrombosis (CVT) accounts for 0.5-1% of all strokes. The role of endovascular therapy (EVT) in the management of CVT remains controversial and variations in practice patterns are not well known., Aims: Here, we present a comprehensive, international characterization of practice patterns and perspectives on the use of EVT for CVT.Methods A comprehensive 42-question survey was distributed to stroke clinicians globally from May-October 2023, asking about practice patterns and perspectives on the use of EVT for CVT., Results: The overall response rate was 31% (863 respondents of 2744 invited) across 61 countries. The majority of respondents (74%) supported the use of EVT for CVT in certain clinical situations. Key considerations for decision-making in using EVT favored clinical over radiographic/procedural factors and included worsening level of consciousness (86%) and worsening neurological deficits (76%). In the past three years, 56% of respondents used EVT for the treatment of CVT, with most (49.5%) involved in 2-5 cases. Among interventionalists, significant variability existed in the techniques used for EVT (p<0.001), with aspiration thrombectomy (56%) and stent retriever (51%) being the most used overall. Regionally, interventionalists from China predominately used intra-sinus heparin (56%), while this technique was most commonly ranked as "never indicated" throughout the rest of the world (23%). Post-procedure, low molecular weight heparin was the most used anticoagulant (83%), although North American respondents favored unfractionated heparin (37%), while imaging was primarily split between magnetic resonance (71.8%) and computed tomography (65.9%) arteriography or venography., Conclusions: Our survey reveals significant heterogeneity in approaches to EVT for CVT, and provides a comprehensive characterization of indications, techniques and long-term management used by clinicians internationally. This resource will aid in optimizing patient selection and endovascular treatments for future trials.

Background and Purpose: Two early basilar artery occlusion (BAO) randomized controlled trials (RCTs) did not establish the superiority of endovascular thrombectomy (EVT) over medical management. Yet many providers continued to recommend EVT. The goal of the present article is to compare physicians' diagnostic and management strategies of BAO among middle-income and high-income countries (MICs and HICs, respectively)., Methods: We conducted an international survey from January to March 2022 regarding management strategies in acute BAO, to examine clinical and imaging parameters influencing clinician management of patients with BAO. We compared responses between physicians from HIC and MIC., Results: Among the 1245 respondents from 73 countries, 799 (64.2%) were from HIC, with the remaining 393 (31.6%) from MIC. Most respondents perceived that EVT was superior to medical management for acute BAO, but more so in respondents from HIC (98.0% vs. 94.2%, p < 0.01). MIC respondents were more likely to believe further RCTs were warranted (91.6% vs. 74.0%, p < 0.01) and were more likely to find it acceptable to enroll any patient who met a trial's criteria in the standard medical treatment arm (58.8% vs. 38.5%, p < 0.01)., Conclusions: In an area where clinical equipoise was called into question despite the lack of RCT evidence, we found that respondents from MIC were more likely to express willingness to enroll patients with BAO in an RCT than their HIC counterparts., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Alemseged reported research grants from Medical Research Future Fund, Australian Heart Foundation, Sylvia & Charles Viertel Charitable Foundation. Dr Fischer reported research grants from Medtronic; consultant for Medtronic, Stryker, CSL Behring; advisory board for Alexion/Portola. Dr Kaesmacher reported grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, Clinical Trials Unit Bern, and the Swiss National Science Foundation. Dr Nagel reported consultancy for Brainomix, speaker bureaus with Boehringer Ingelheim and Pfizer. Dr Nguyen reported research support from Medtronic and SVIN. Dr Puetz reported fees as lecturer for Daiichi Sankyo. Dr Sacco reported research grants from Novartis and Uriach; fees for advisor or speaker from Abbott, Allergan-Abbvie, AstraZeneca, Lilly, Lundbeck, Novartis, Novo Nordisk, Pfizer, Teva. Dr Siegler reported consulting from Ceribell and speakers’ bureau with AstraZeneca. Dr Thomalla reported fees as a consultant from Acandis, Alexion, Amarin, Bayer, Bristol Myers Squibb/Pfizer, Boehringer Ingelheim, Portola, and Stryker. Dr Yamagami reported research grants from Bristol-Myers Squibb, lecturer’s fees from Bayer, Daiichi-Sankyo, Stryker, Bristol-Myers Squib; advisory boards for Daiichi-Sankyo. Dr Banerjee reported consultancy for RapidAI. Dr Marto reports consulting fees from Amicus Therapeutics and Boehringer Ingelheim; speaker fees from Boehringer Ingelheim. Dr Kaiser reported grants from the Joachim Herz Foundation and the Else Kröner Fresenius Center for Digital Health.

Background: The etiopathogenesis of venous sinus diverticulum is controversial. Conflicting evidence has been published suggesting that venous sinus diverticulum is either a congenital or acquired lesion., Methods: This is a case report of a single individual followed for 17 years within a single healthcare system., Results: An early middle-aged woman presented with unilateral pulsatile tinnitus, vertigo, and decreased hearing. Initial imaging was unrevealing. Interval imaging after 13 years revealed the development of an ipsilateral venous sinus diverticulum. The patient was treated via endovascular stenting and coiling of the lesion with complete resolution of symptoms., Conclusions: We demonstrate that a venous sinus diverticulum in a patient with pulsatile tinnitus is an acquired lesion. Further research is warranted to better elucidate the precise etiology and pathophysiology of acquired venous sinus diverticulum, potentially guiding management strategies., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: TNN reports institutional research support from Medtronic; advisory board membership for Idorsia, Brainomix; and is an Associate Editor of Stroke. The remaining authors report no conflicts.

Background: Recognition of neurovascular variants is crucial for safe endovascular and neurosurgical interventions. We aim to review and highlight various uncommon neurovascular variants and anomalies with a discussion of their relevant embryology and pathology., Methods: A retrospective review of a prospectively maintained neurovascular database was performed to identify uncommon neurovascular variants and anomalies. A pictorial review of these neurovascular findings is provided along with relevant embryological development, clinical significance, and potential pathological associations., Results: A pictorial review of selected neurovascular variants and anomalies is presented. These entities, divided between intra- and extra-cranial findings, include infra-optic origin of the anterior cerebral artery, meningo-ophtalmic artery, duplicated posterior cerebral artery, duplicate middle cerebral artery (MCA), MCA fenestration, twig-like MCA, pure arterial malformation, corkscrew basilar artery, persistent hypoglossal artery, persistent trigeminal artery and its variants, direct branches from the common carotid and cervical internal carotid arteries (ICA) (ascending pharyngeal artery from the ICA, thyroidal arteries from the CCA/brachiocephalic, arteria thyroidea ima), and extra-cranial carotid fenestration. The angiographic findings of these entities are presented with relevant 3D reconstruction and multimodal cross-sectional imaging correlation when available., Conclusions: This pictorial review highlights uncommon neurovascular variants and anomalies that neuroradiologists, interventionalists, and neurosurgeons should be aware of for accurate diagnosis and safe interventions., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The superiority of endovascular thrombectomy (EVT) over medical management was not established in two early basilar artery occlusion (BAO) randomized controlled trials. Despite this, many clinicians recommended EVT for acute BAO under certain circumstances. This paper aims to compare physicians' diagnostic and management strategies of BAO according to gender., Methods: From January to March 2022 an international survey was conducted regarding management strategies in acute BAO. We compared responses between clinicians by identifying gender. Questions were designed to examine clinical and imaging parameters influencing management of patients with BAO., Results: Among the 1245 respondents from 73 countries, 311 (25.0%) identified as female. This figure was 13.6% amongst interventionists. Geographically, female respondents were lowest in Asia (14.5%) and North America (23.9%). The proportion of respondents identifying as female was consistent regardless of their years of experience. Female respondents were more likely to choose time of onset as time of first estimated stroke like symptom (48.0% vs. 38.5%, p  < .01), were less likely to favor thrombectomy in the V4 segment of vertebrobasilar artery occlusions (31.5% vs. 43.3%, p  < .01), and were less likely to find it acceptable to enroll all patients who met trial criteria in the standard medical treatment arm of a clinical trial (41.2% vs. 47.0%, p  = .01). Male respondents were more likely to agree that thrombolysis would not alter their decision on proceeding with EVT (93.7% vs. 88.3%, p  < .01)., Conclusions: Female clinicians appear to be significantly underrepresented in stroke medicine. This is most pronounced amongst interventionists and in Asia. Although male and female opinions were closely aligned on many aspects of BAO management, differences in opinion were observed in a number of significant areas which influence decision making.

Introduction: Age is often used as a predictor in determining outcomes in large vessel occlusions treated with mechanical thrombectomy. However, limited data exist for octo/nonagenarian outcomes compared to younger individuals in acute basilar artery occlusions treated with thrombectomy., Methods: Patient data were obtained from the PC-SEARCH Thrombectomy Registry which consists of 444 acute basilar artery occlusions treated with mechanical thrombectomy. Individuals were dichotomized based on age (>80 and ≤80 years old). Primary outcome was defined as modified Rankin Scale of 0-3 at 90 days. Logistic and multivariate regression, as well as control-matched analysis, were performed., Results: There were 373 and 71 patients in the younger and older cohorts, respectively. Gender, ethnicity, smoking status, atrial fibrillation, and coronary artery disease were noted to be significantly different between cohorts. At 90 days, 178 (47.7%) and 23 (32.4%) patients achieved primary outcome at 90 days (p = 0.02), however, after controlling for potentially confounding factors this association lost significance (OR 0.50 95% CI 0.24-1.05; p = 0.07). There were 84 patients included in the control matched analysis and demonstrated no significant differences on multivariate analysis between cohorts (OR 0.68 95% CI 0.25-1.84; p = 0.45)., Interpretation: Octa/nonagenarians presenting with an acute basilar artery occlusion treated with mechanical thrombectomy can achieve acceptable rates of favorable functional outcomes compared to younger individuals with similar baseline demographic and stroke characteristics., Competing Interests: Authors’ contributionThe authors who have contributed to at least one of the key contributions that justify authorship, including (1) conception and design of the study (ATM, PPR, MJ), (2) acquisition and analysis of data (ATM, PPR, MJ) or (3) drafting a significant portion of the manuscript or figures (i.e., a substantial contribution beyond copy editing and approval of the final draft, which is expected of all authors) (ATM, PPR, MJ). Individuals who contributed data acquisition (including phenotyping and gathering information on patients) but not to the final analysis that is unique to this manuscript (e.g., site investigators in a large clinical trial or contributors to a large patient database) (PC-SEARCH Thrombectomy REGISTRY Group includes: NA, KG, EA, SZ, AN, SAK, SOG, JVS, MF, APJ, SD, GT, AA, TNN, PK, MA, ZW, SV, and NV). Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Mouhammad Jumaa has received general payments (<$1000) and academic funding from Chiesi USA, Genentech, Medtronic, and Stryker. Dr Sami Al Kasab has received general payments (<$1000) from AstraZeneca Pharmaceuticals, MicroVention, and Stryker. Dr Santiago Ortega Gutierrez has received general payments and academic funding from Medtronic, and Siemens Medical Solutions USA, Stryker. Dr Ashutosh P Jadhav has received general payments (<$1000) and academic funding from Medtronic, Viz AI, and Medical Device Business Services, Inc. Dr Toth Gabor has received general payments (<$1000) and academic funding from BioSense Webster, Medtronic, and Stryker. Dr Thanh Nguyen has received academic funding from AtriCure.

Background and Purpose: The diagnosis and management of acute fetal posterior cerebral artery occlusion are challenging. While endovascular treatment is established for anterior circulation large vessel occlusion stroke, little is known about the course of acute fetal posterior cerebral artery occlusions. We report the clinical course, radiological findings and management considerations of acute fetal posterior cerebral artery occlusion stroke., Methods: We performed a retrospective review of consecutive patients presenting with acute large vessel occlusion who underwent cerebral angiogram and/or mechanical thrombectomy between January 2015 and January 2021. Patients diagnosed with fetal posterior cerebral artery occlusion were included. Demographic data, clinical presentation, imaging findings and management strategies were reviewed., Results: Between January 2015 and January 2021, three patients with fetal posterior cerebral artery occlusion were identified from 400 patients who underwent angiogram and/or mechanical thrombectomy for acute stroke (0.75%). The first patient presented with concomitant fetal posterior cerebral artery and middle cerebral artery occlusions. Thrombectomy was performed with recanalisation of the fetal posterior cerebral artery but the patient died from malignant oedema. The second patient presented with isolated fetal posterior cerebral artery occlusion. No endovascular intervention was performed and the patient was disabled from malignant posterior cerebral artery infarct. The third patient presented with carotid occlusion and was found to have fetal posterior cerebral artery occlusion after internal carotid artery recanalisation. No further intervention was performed. The patient was left with residual contralateral homonymous hemianopia and mild left sided weakness., Conclusion: Fetal posterior cerebral artery occlusion is a rare, but potentially disabling, cause of ischaemic stroke. Endovascular treatment is feasible. Further investigation is needed to compare the efficacy of medical versus endovascular management strategies.

Introduction: Sigmoid sinus diverticulum (SSD) has been increasingly reported as a cause of pulsatile tinnitus (PT). While both endovascular and surgical treatments have been used, there is a lack of consensus on the treatment modality to treat SSD. We conducted a systematic review of the available literature to compare the clinical outcomes and safety of endovascular versus surgical approaches for treating SSD., Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify studies encompassing the management of SSD. Studies reporting the clinical outcomes and safety of endovascular or surgical treatments for SSD between January 2000 and January 2023 were included. Results were characterized using descriptive statistics., Results: Endovascular treatment (EVT) was reported by 17 articles, yielding 26 patients with 27 diverticula. Surgical treatment was reported by 20 articles, yielding 105 patients with 107 diverticula. EVT led to complete or near-complete resolution in all patients with SSD and PT. Complications occurred in 3.7% (1/27) with a return to baseline after 2 months. There were no permanent complications from EVT. Surgical treatment resulted in complete resolution in 77.6% (83/107) of cases, incomplete resolution in 11.2% (12/107), and no resolution in 11.2% (12/107). Significant complications occurred in 9.3% (10/107) of the surgical-treated patients., Conclusion: EVT in patients with PT and venous diverticulum appears more effective and safer than surgical treatment, but large studies are lacking. Studies directly comparing endovascular and surgical treatment are needed., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Aspiration mechanical thrombectomy traditionally includes use of an inner microcatheter and leading microwire to navigate an aspiration catheter (AC) to the site of occlusion. Early clinical experience suggests that a leading microwire is often not needed with the Tenzing 7 (T7, Route 92 Medical, San Mateo, CA), a soft tapered tip ledge-reducing delivery catheter. This multicenter experience aims to describe AC delivery success in single-pass thrombectomy using T7 with and without a leading microwire., Methods: A retrospective review was conducted of consecutive patients who underwent single-pass thrombectomy with T7 at six institutions between 2020 and 2022. We examined the percentage of successful AC delivery, puncture-to-revascularization time, and procedural complication rate., Results: A leading microwire with T7 was used in 19/89 (21%) of patients, and it was not used with T7 in 70/89 (79%) of patients. Successful AC delivery was similar with and without microwires (97% vs. 90%, p = 0.15). Median puncture-to-revascularization times were similar (17 min microwire vs. 16 min no-microwire, p = 0.12). No complications were associated with microwire use; one (1.4%) patient had a T7-related vasospasm resolved with verapamil during thrombectomy without a leading microwire. Differences in complication rates were not statistically significant (p = 0.46)., Conclusion: In our real-world clinical experience, leading microwire use was infrequently necessary with the T7 delivery catheter. Successful AC delivery and complication rates were similar with and without microwire use in single-pass T7 thrombectomies. Initial pass with T7 may be performed without use of leading microwire, reserving microwire use for refractory cases or known difficult-to-navigate vasculature., Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J. English is a consultant for Route 92 Medical and Stryker. He has equity in Route 92 Medical. F. Settecase is a consultant for Route 92 Medical and Stryker. He has received honorarium from Stryker. W. Kim is a consultant for Route 92 Medical and Stryker. He has equity in Route 92 Medical. A. Thomas is a consultant for Stryker, Medtronic, and CereVasc. T. Jovin is a consultant for Anaconda, Route 92 Medical,Viz.AI, FreeOx, Blockade Medical, and Methinks. He serves in an advisory capacity for Cerenovus and Contego Medical. He has equity in Cornidus. He receives research support from Medtronic and Stryker. R. Hanel is a consultant for Medtronic, Stryker, Cerenovous, Microvention, Balt, Phenox, Rapid Medical, and Q'Apel. He serves in an advisory capacity for MiVI, eLum, Three Rivers, Shape Medical, and Cornidus. He receives research support from National Institutes of Health, Interline Endowment, Microvention, Stryker, and CNX. He has equity in InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc., Scientia, RisT, BlinkTBI, and Cornidus. A. Aghaebrahim serves in an advisory capacity for iSchemaView. E. Sauvageau is a consultant for Stryker. T.N. Nguyen serves in an advisory capacity for Vesalio, National Institutes of Health, Avania, Idorsia, Brainomix, and SUMMIT Max PI. She serves as an editor, associate editor, or editorial advisory board member for the American Heart Association. She receives research support from Society of Vascular and Interventional Neurology and Boston Medical Center. All other authors have no disclosures to declare..

Research Design: In this study, we describe patients from a tertiary care safety-net hospital endocarditis registry with tricuspid valve infective endocarditis (TVIE), and concomitant acute or subacute ischemic stroke predominantly associated with injection drug use (IDU). We retrospectively obtained data pertinent to neurologic examinations, history of injection drug use (IDU), blood cultures, transthoracic/transesophageal echocardiography (TTE/TEE), neuroimaging, and Modified Rankin Scale (mRS) scores at discharge. Only those patients with bacteremia, tricuspid valve vegetations, and neuroimaging consistent with acute to subacute ischemic infarction and microhemorrhages in two cases were included in this series. Results: Of 188 patients in the registry, 66 patients had TVIE and 10 of these were complicated by ischemic stroke. Neurologic symptoms were largely non-specific, eight patients had altered mental status and only 3 had focal deficits. Nine cases were associated with IDU. Two patients had evidence of a patent foramen ovale on echocardiography. Blood cultures grew S. aureus species in 9 of the patients, all associated with IDU. Three patients died during hospitalization. The mRS score at discharge for survivors ranged 0-4. Conclusions: Patients with strokes from TVIE had heterogeneous presentations and putative mechanisms. We noted that robust neuroimaging is lacking for patients with TVIE from IDU and that such patients may benefit from neuroimaging as a screen for strokes to assist peri-operative management. Further inquiry is needed to elucidate stroke mechanisms in these patients., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background and Purpose: Intracranial arteriovenous shunts (IAVS) are rare vascular diseases in infants. They can be categorized into vein of Galen aneurysmal malformation (VGAM), pial arteriovenous fistula (PAVF), and dural arteriovenous fistula associated with dural sinus malformation (DAVF/DSM). We sought to review the clinical presentation, imaging characteristics, endovascular treatment (EVT), and outcomes of IAVS in infants presenting to a quaternary pediatric referral center over one decade., Methods: A retrospective review of a prospectively maintained database was performed of all infants diagnosed with IAVS between January 2011 and January 2021 in a quaternary pediatric referral center. For each patient, demographic data, clinical presentation, imaging findings, management strategies, and outcomes were reviewed and discussed., Results: Over the study period, 38 consecutive infants were diagnosed with IAVS. Patients with VGAM (23/38, 60.5%) presented with congenital heart failure (CHF) (14/23), hydrocephalus (4/23), and seizures (2/23), and three patients were asymptomatic. Eighteen patients with VGAM underwent EVT. Among those, 13 patients (72.2%) were successfully treated with an angiographic cure and three patients (3/18, 17%) died. Patients with PAVF (9/38, 23.7%) presented with CHF (5/9), intracranial hemorrhage (2/9), and seizures (2/9), and all of them were successfully treated endovascularly. Patients with Type I DAVF/DSM (4/6, 66.6%) presented with mass effect (2/4), cerebral venous hypertension (1/4), CHF (1/4), and cerebrofacial venous metameric syndrome (1/4). Patients with type II DAVF/DSM (2/6, 33.3%) presented with a thrill behind the ear. Patients with DAVF/DSM were treated endovascularly, five patients were cured, and one with type I DAVF/DSM died., Conclusion: Intracranial arteriovenous shunts are rare but potentially life-threatening neurovascular pathologies in infants. Endovascular treatment is challenging but feasible in carefully selected patients.

Background: Treatment of brain arteriovenous malformations (b-AVM) carries a risk of iatrogenic injury to eloquent brain regions. Intraoperative neuro-monitoring (IONM) has increasingly been used to monitor spontaneous or evoked neural activity during neurosurgery, but its use is not as well characterized in the endovascular treatment (EVT) of b-AVMs. We aimed to provide a systematic review and meta-analysis of studies reporting any neurological deficit after b-AVM embolization with IONM, with or without provocative test (PT), and no-IONM., Methods: This systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from conception until March 1, 2022 for studies evaluating EVT with IONM and PT. Primary outcome was the rate of postoperative neurological deficits in EVT with IONM versus no-IONM, while secondary outcome was the subanalysis of IONM with or without PT. Meta-analysis was performed using the Mantel-Haenszel method and random effects modeling., Results: Six studies reached synthesis. Out of a total of 192 EVT, 14 events occurred. Results demonstrated a nonsignificant trend favoring IONM compared to no-IONM to prevent neurological deficits (OR 0.09, 95% CI 0-4.68). Among the EVT with IONM, PT was done in 411 branches with 10 events (0.2%) despite a negative PT. There was a nonsignificant trend favoring IONM plus PT compared to IONM without PT (OR 0.16, 95% CI 0.02-1.07)., Conclusions: Our study suggests that b-AVM EVT with IONM plus PT might reduce rates of postprocedural neurological deficits compared with EVT without IONM. Further studies are needed to confirm these results.

Background: Challenging arterial anatomy delays, or prevents timely endovascular treatment (EVT) of acute ischemic stroke (AIS). We introduce a new technique called 'Balloon Gliding Technique (BGT)' to overcome difficult arterial anatomy during EVT of AIS, utilizing flow-assistance to access challenging circulations., Methods: Retrospective review of a prospectively collected database of all patients presenting to a single institution with AIS who underwent EVT was performed from January 2021 to June 2021. Patients in whom BGT was performed were assessed. BGT consists of advancing the balloon guide catheter in the cervical carotid artery while its balloon is inflated, and therefore carried by downstream flow., Results: Of 51 patients presenting with AIS secondary to large vessel occlusion during the study period, five patients underwent BGT. All five patients had anterior circulation large vessel occlusions. Mean age of the BGT patients was 92.2 years, and all patients were females. A type 3 arch was present in all patients. BGT was performed in all cases following initial failure of conventional techniques to cannulate the target circulation. BGT was successful in achieving distal cervical carotid access in 4 out of the 5 patients in whom BGT was attempted. Successful recanalization (modified treatment in cerebral ischemia 2b-3) was obtained in all cases with no complications., Conclusions: Balloon Gliding Technique (BGT) is a safe technique that can safely overcome challenging anatomy during endovascular treatment of acute ischemic stroke. Further studies can assist in demonstrating both its safety and effectiveness.

Foreign body embolization is a rare and potentially under-recognized complication of neuroendovascular procedures. This complication should be considered in the differential diagnosis for clinical or radiological deterioration following neurovascular interventions. We report a case of foreign body hydrophilic coating embolization that occurred following an attempted flow diversion of an intracranial aneurysm with dramatic flare-up after repeat exposure. We also provide a literature review of all reported cases of hydrophilic polymer embolization following flow diversion procedures.

Background: The COVID-19 pandemic led to profound changes in the organization of health care systems worldwide., Aims: We sought to measure the global impact of the COVID-19 pandemic on the volumes for mechanical thrombectomy, stroke, and intracranial hemorrhage hospitalizations over a three-month period at the height of the pandemic (1 March-31 May 2020) compared with two control three-month periods (immediately preceding and one year prior)., Methods: Retrospective, observational, international study, across 6 continents, 40 countries, and 187 comprehensive stroke centers. The diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases at participating centers., Results: The hospitalization volumes for any stroke, intracranial hemorrhage, and mechanical thrombectomy were 26,699, 4002, and 5191 in the three months immediately before versus 21,576, 3540, and 4533 during the first three pandemic months, representing declines of 19.2% (95%CI, -19.7 to -18.7), 11.5% (95%CI, -12.6 to -10.6), and 12.7% (95%CI, -13.6 to -11.8), respectively. The decreases were noted across centers with high, mid, and low COVID-19 hospitalization burden, and also across high, mid, and low volume stroke/mechanical thrombectomy centers. High-volume COVID-19 centers (-20.5%) had greater declines in mechanical thrombectomy volumes than mid- (-10.1%) and low-volume (-8.7%) centers (p < 0.0001). There was a 1.5% stroke rate across 54,366 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.9% (784/20,250) of all stroke admissions., Conclusion: The COVID-19 pandemic was associated with a global decline in the volume of overall stroke hospitalizations, mechanical thrombectomy procedures, and intracranial hemorrhage admission volumes. Despite geographic variations, these volume reductions were observed regardless of COVID-19 hospitalization burden and pre-pandemic stroke/mechanical thrombectomy volumes.

Background and Purpose: Early major recurrence (EMR) of cerebral aneurysms treated by coiling has not been investigated. The purpose of this study is to characterize the frequency and risk factors of this phenomenon., Materials and Methods: A retrospective review was performed of consecutive patients who presented with ruptured and unruptured cerebral aneurysms and underwent coiling from July 2009 to June 2019 at a university hospital. We defined EMR as recurrence of the aneurysm greater than its initial size within the first 6 months of an initial satisfactory coil embolization. Patient demographics, clinical information, aneurysm characteristics, angiographic and technical details were reviewed., Results: From July 2009 to June 2019, 338 aneurysms (190 unruptured aneurysms and 148 ruptured cerebral aneurysms) underwent coiling and satisfied our study criteria. Among these patients, 23 patients (19 ruptured and 4 unruptured aneurysms) were found to have recurrent aneurysm. Of those, 4 were found to have early major aneurysm regrowth occurring within 6 months after coiling (1.2%). The detection of the EMR was as early as 4 weeks and as late as 20 weeks after the initial coil embolization. The average detection time was 10 ± 7.2 weeks (mean ± SD, range:4-20 weeks). In each case, the recurrent aneurysm cavity was more than twice the initial size of presentation. All aneurysms with major recurrence were ruptured with low aspect ratios (dome height to neck ratio) and involved a communicating segment. All patients underwent successful retreatment of the recurrent aneurysm with good outcome., Conclusions: Early major recurrence of treated aneurysms is a rare but important complication that harbors an impending risk of re-rupture. Early control angiography after endovascular coiling may be warranted for small ruptured aneurysms, even in cases in which the initial result seems technically satisfactory.

The association of large mastoid emissary veins and pulsatile tinnitus has been reported. However, therapeutic options for this condition remain limited. We report a case of endovascular coiling of a large mastoid emissary vein in a patient with disabling pulsatile tinnitus with significant improvement of symptoms. To our knowledge, endovascular coiling of large mastoid emissary vein causing pulsatile tinnitus has not been reported.

Cerebral artery fenestrations are rare anatomical variants usually detected incidentally on cross-sectional imaging or cerebral angiography. Although considered benign findings, many reports have described their association with vascular abnormalities such as aneurysms or arteriovenous malformations, and to a lesser extent with ischemic or hemorrhagic complications. We report a case of middle cerebral artery fenestration associated with subarachnoid hemorrhage and middle cerebral artery thrombosis. To our knowledge, there has been no prior report of middle cerebral artery fenestration with a similar presentation.