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BACKGROUND Catheter-based endovascular neurointerventions require deep neuromuscular blocks during the procedure and rapid subsequent recovery of strength to facilitate neurological evaluation. We tested the primary hypothesis that sugammadex reverses deep neuromuscular blocks faster than neostigmine reverses moderate neuromuscular blocks. METHODS Patients having catheter-based cerebral neurointerventional procedures were randomized to: (1) deep rocuronium neuromuscular block with posttetanic count 1 to 2 and 4-mg/kg sugammadex as the reversal agent or (2) moderate rocuronium neuromuscular block with train-of-four (TOF) count 1 during the procedure and neuromuscular reversal with 0.07-mg/kg neostigmine to a maximum of 5 mg. Recovery of diaphragmatic function was assessed by ultrasound at baseline before the procedure and 90 minutes thereafter. The primary outcome-time to reach a TOF ratio ≥0.9 after administration of the designated reversal agent-was analyzed with a log-rank test. Secondary outcomes included time to successful tracheal extubation and the difference between postoperative and preoperative diaphragmatic contraction speed and distance. RESULTS Thirty-five patients were randomized to sugammadex and 33 to neostigmine. Baseline characteristics and surgical factors were well balanced. The median time to reach TOF ratio ≥0.9 was 3 minutes (95% confidence interval [CI], 2-3 minutes) in patients given sugammadex versus 8 minutes (95% CI, 6-10 minutes) in patients given neostigmine. Sugammadex was significantly faster by a median of 5 minutes (95% CI, 3-6 minutes; P < .001). However, times to tracheal extubation and diaphragmatic function at 90 minutes did not differ significantly. CONCLUSIONS Sugammadex reversed deep rocuronium neuromuscular blocks considerably faster than neostigmine reversed moderate neuromuscular blocks. However, times to extubation did not differ significantly, apparently because extubation was largely determined by the time required for awaking from general anesthesia and because clinicians were willing to extubate before full neuromuscular recovery. Sugammadex may nonetheless be preferable to procedures that require a deep neuromuscular block and rapid recovery.

This meeting abstract was removed due to the OA licensing requirements of this journal. The full abstract is listed here : https://www.svin.org/files/SVIN_2021_Abstracts_for_Web.pdf

Background Intracerebral hemorrhage (ICH) is associated with a significant mortality of up to 50%, with almost all survivors suffering from debilitating functional compromise. In most cases, open craniotomy has failed to yield significant survival benefit. However, emerging evidence suggests that minimally invasive surgery (MIS) may yield clinically significant improvements in patient survival and quality of life in cases where open craniotomy has not shown benefit. Case presentation We report the first documented usage of a side-cutting-aspiration device via an endoscopic approach for the evacuation of a 56cc hematoma, which was a technical modification on previous MIS techniques. The patient is a 50-yr-old female who was transferred emergently to our center with a National Institutes of Health Stroke Scale score of 27 and found to have a large hematoma involving her left basal ganglia. A minimally-invasive approach was elected due to evidence on the risks and suboptimal outcomes of open craniotomy in ICH evacuation. Neuronavigation was used to plan the surgical trajectory for ICH access. Evacuation took place in three main steps: 1) beginning at the center of the clot to remove bulk; 2) mobilizing clots from parenchymal walls to a safe zone via aspiration, followed by clot homogenization; and 3) re-expansion of the cavity via continuous irrigation to allow visualization of further clots. A final inspection was performed to ensure removal of all clots that could be safely removed. The dual functionalities of the device, namely, suction only and suction plus side-cutting functions, enabled key maneuvers, such as clot homogenization and controlled aspiration strength, to be safely performed. A near-total evacuation of the hematoma was achieved without damage to surrounding parenchyma. The patient experienced a rapid clinical course from comatose to discharge-ready in 5 d. At 30-d follow-up, the patient had residual expressive aphasia and was able to ambulate with the assistance of a quad cane. There are no radiographical signs of recurrent hemorrhage or parenchymal injury. Clinical follow-up with this patient is ongoing. Conclusion This is the first ICH evacuation with a side-cutting-aspiration device via an endoscopic approach. In our patient, this technique proved to be safe and efficacious, suggesting that this technique may be a promising addition to the armamentarium of MIS for ICH evacuation.

BACKGROUND Prospective evidence to support mechanical thrombectomy (MT) for mild ischemic stroke with large vessel occlusion (LVO) is lacking. There is uncertainty about using an invasive procedure in patients with mild symptoms. OBJECTIVE To evaluate the safety and feasibility of MT in patients with mild symptoms and LVO. METHODS Our single-arm prospective pilot study recruited patients with LVO and initial National Institute of Health Stroke Scale (NIHSS)

IntroductionSince the publication of the ARUBA trial, interventional management of cerebral arteriovenous malformations has become an area of debate. Treatment practices may have changed based on data from this recent trial which suggested that the risk of AVM treatment is greater than medical management in unruptured AVMs. To assess the ‘real world’ experience with interventional AVM outcomes, we compared outcomes of ARUBA eligible patients from the NVQI-QOD registry database to the ARUBA trial results.MethodsIn an IRB approved study, the NVQI-QOD AVM registry database was queried for treated patients between 2017 to present with the following inclusion criteria: age > 18 years, baseline mRS> 1, unruptured AVMs. 174/364 patients were ARUBA eligible and were included in the analysis. Patients were divided into embolization alone, microsurgery with or without embolization, and gamma knife radiation therapy with or without embolization. Primary outcomes of ischemic/hemorrhagic stroke or death were analyzed with a mean follow up time of 5.8 months (range 1 to 128 months).ResultsA total of 14 (8.0%) of patients that underwent any type of intervention suffered stroke or mortality. The risk of stroke or death was 6.8% (5 of 74) for microsurgery, 5.4% (2 of 37) for gamma knife, and 10.9% (7 of 64) for embolization alone. Annual stroke or death rates for all treatments were 7.5% (13 of 174) at one year and 0.57% (1 of 174) at 2 years.ConclusionARUBA eligible patients from the NVQI-QOD registry demonstrate a significantly lower risk of stroke or death with intervention of 8.0% (N=174) compared to the 30.7% (N=114) ARUBA trial interventional risk, and is nearly equivalent to the ARUBA trial medical management risk of 10.1% (N=109) over 33 months.DisclosuresN. Moore: 1;C;SNIS Joe Niekro Research Grant. R. Abdalla: None. T. Patterson: None. Y. Moazeni: None. P. Rasmussen: 2;C;Blockade Medical, Covidien/Medtronic, Stryker Neurovascular, Perflow Medical. 4;C;Perflow Medical. G. Toth: None. M. Bain: 2;C;Stryker Neurovascular. S. Ansari: None. S. Hussain: 2;C;Pulsar Inc.

Background Intracranial hemorrhage (ICH) results in devastating neurological injury as a result of both mass effect and the pro-inflammatory response to erythrolysis. Minimally invasive surgical techniques for hematoma evacuation are promising for improving functional outcome. The NICO BrainPath 13.5 mm tubular retractor system has been used as a minimally invasive approach to subcortical intracranial hemorrhages. Here we report the first ever use of the novel 11 mm BrainPath retractor system to evacuate a subcortical intracerebral hematoma. Case Description: 52 year-old man presented to our hospital with expanding left basal ganglia hemorrhage and declining neurological exam. The patient underwent minimally invasive NICO (Indianapolis, IN) BrainPath evacuation using an 11 mm tubular retractor system. Near total evacuation was successfully achieved. The patient did well postoperatively, with a favorable 90-day functional outcome. Conclusion In this case, using an 11 mm NICO (Indianapolis, IN) BrainPath system for basal ganglia ICH provided early, near-total hematoma evacuation and favorable functional outcome at 90-day check-in. Here, we demonstrate the technical feasibility of utilizing an 11 mm BrainPath tubular retractor instead of the traditional 13.5 mm system for evacuating ICH. It is the hope that the smaller 11 mm access port more closely matches endoscopic evacuation access techniques and could potentially mitigate the impact of a MIS approach on surrounding parenchyma while still achieving optimal evacuation.

Like all DNA viruses, human cytomegalovirus (HCMV) infection is known to result in profound effects on host cell cycle. Infection of fibroblasts with HCMV is known to induce an advance in cell cycle through the G(0)-G(1) phase and then a subsequent arrest of cell cycle in early S-phase, presumably resulting in a cellular environment optimum for high levels of viral DNA replication whilst precluding replication of cellular DNA. Although the exact mechanisms used to arrest cell cycle by HCMV are unclear, they likely involve a number of viral gene products and evidence points to the ability of the virus to prevent licensing of cellular DNA synthesis. One viral protein known to profoundly alter cell cycle is the viral immediate early 86 (IE86) protein--an established function of which is to initially drive cells into early S phase but then inhibit cellular DNA synthesis. Here we show that, although IE86 interacts with the cellular licensing factor Cdt1, it does not inhibit licensing of cellular origins. Instead, IE86-mediated inhibition of cellular DNA synthesis requires mini-chromosome-maintenance 3 (MCM3) associated protein (MCM3AP), which can cause subsequent inhibition of initiation of cellular DNA synthesis in a licensing-independent manner.

As capabilities for endovascular treatment of intracranial vascular pathologies continue to expand, the need for access to the distal internal carotid artery with rigid support catheter systems continues to increase. One of the dominant factors limiting this access is patient anatomy, specifically vessel tortuosity. Increased tortuosity of the carotid siphon is a frequently encountered anatomic variant and may complicate endovascular procedures in adults and children.1,2 Failed attempts to navigate the carotid siphon with a distal access catheter carry a risk of vessel injury and treatment failure. For this reason, techniques that aid in supporting safe advancement of a distal access catheter across a tortuous carotid siphon are essential.3,4 In this video, we demonstrate 2 ways in which this may be accomplished. The first technique uses a larger diameter microcatheter, such as the AXS Offset catheter (Stryker, Kalamazoo, Michigan), to increase support for the distal access catheter, while the second uses a buddy wire technique to accomplish this increased support. Both of these techniques can help increase the safety of navigating a tortuous carotid siphon and increase the likelihood of successful treatment. The procedures shown were performed with the informed consent of the patients.

Introduction The Sofia Plus aspiration catheter (Microvention; Tustin, CA) is a recently introduced 0.070-inch inner diameter catheter designed to provide distal intracranial access and engage thrombus to facilitate thrombectomy for acute ischemic stroke. Methods This single-center retrospective study assessed technical outcomes of mechanical thrombectomy using the Sofia Plus aspiration catheter. Utilizing a prospective database of all acute stroke interventions at our institution, cases utilizing SOFIA Plus on the first pass were identified. Patient characteristics, procedural details, and radiographic outcomes were analyzed. Results Sofia Plus was utilized as a first pass aspiration catheter in 138 cases. Patients presented with a median NIHSS of 17 (IQR 10–22), ASPECT of 10 (IQR 8–10), and had target occlusions involving the ICA (n=30), M1 (n=73), M2 (n=22), or basilar artery (n=13). The aspiration catheter was used for first-pass direct aspiration alone in 86 patients (62%), and in conjunction with a stent retriever in 52 patients (38%). A recanalization grade of TICI 2b or better was achieved in 118 patients (86%), which was accomplished with a single pass in 88 (64%). Median time from groin puncture to recanalization was 44 minutes (IQR 30–68). Comparison of direct aspiration alone versus with stent retrievers demonstrated no difference in recanalization grade (p=0.64) or rates of first-pass recanalization (p=0.28), but direct aspiration was associated with faster recanalization (41 vs 53 minutes, p=0.02). There were two cases of vessel perforation (both involving stent retrievers), and two additional patients had symptomatic ICH on follow-up CT. Conclusions Our experience demonstrates that the SOFIA Plus aspiration can facilitate safe and effective revascularization for acute ischemic stroke, either using a direct aspiration technique or in conjunction with a stent-retriever. However, reperfusion was achieved faster with direct aspiration alone. Disclosures A. Witek: None. T. Patterson: None. L. Sheikhi: None. M. Bain: 2; C; Medtronic PLC, Stryker Corp. M. Hussain: 2; C; Johnson & Johnson. G. Toth: None.

Introduction Cerebral arteriovenous malformation (AVM) rupture risk is thought to be approximately 3% peryear, but varies with high risk anatomic features. Recent studies have raised the question about whether treatment is indicated for unruptured AVMs. The important decisions about treatment versus conservative management is largely based on a collection of outcome studies that may not match a patient’s particular AVM. The ultimate purpose of this research is to create a predictive computational model for a patient’s specific AVM anatomy to give them a lifetime risk of rupture profile. Our hypothesis is that the flow and pressure patterns within the nidus of the AVM can be determined by creating a 3D printed model of a simple AVM with internal imbedded pressure and flow sensors. This information can then be incorporated into a fluid structure interaction model of a simple arteriovenous malformation. Methods In an IRB approved study, unruptured Spetzler Martin Grade I and II AVMS were evaluated to select an AVM that demonstrated a relatively de-compact nidus and simple inflow and outflow vessels with cerebral angiography imaging with at least 4 frames/second anterior-posterior and lateral runs. This AVM was then processed in Matlab as well as manually segmented to create a 3D printing stereolithography file. The AVM was then printed in the Cleveland Clinic 3D printing laboratory with hollow lumens within the vessels and was fitted with inline flow probes within the inflow, outflow and nidus vessels and pressure transducers. This AVM was then inserted into a flow circuit connected to a cardiac cycle pump. The pump was then run with fluid that mirrors the viscosity of blood and cycled for 10 repetitions to verify stability of the pressure and flow readings at each 10 mmHg increment of output pressure between 100 mmHg to 260 mmHg. The model was then imaged in a cerebral angiography machine and connected to a pressure injector to compare transit time between the flow model and the previously obtained cerebral angiogram data from the patient. Results We successfully built and measured flow and pressure from a 3D printed replica of a simple brain AVM incorporated into a cardiac cycle fluid circuit. This data is currently being compared to cerebral angiography transit rates to validate the data and fit the projected flow and pressure measurements to clinically obtained data. The data additionally is being incorporated into inflow and outflow parameters in the ANSYS fluid structure interaction model of the same simple AVM to compare predicted pressure and flow through the simulation compared to the 3D printed AVM measurements. Conclusions We have made progress in the multistep task of building a fluid structure interaction model of a simple AVM by measuring flow rate and pressure measurements in an anatomically correct 3D printed model of a simple AVM. This data allows for more accurate simulation and for further evaluation of whether flow and pressure characteristics can be simplified for a compact AVM nidus with the goal of developing a predictive model of the natural history of AVM rupture. Disclosures N. Moore: 1; C; Joe Niekro/SNIS Research Grant. R. Klatte: None. A. Erdemir: None. T. Masaryk: None. N. Parkar: None. M. Bain: None. M. Hussain: None.

Supplemental Digital Content is available in the text., Background and Purpose: Stent-assisted coil embolization using the new generation Neuroform Atlas Stent System has shown promising safety and efficacy. The primary study results of the anterior circulation aneurysm cohort of the treatment of wide-neck, saccular, intracranial, aneurysms with the Neuroform Atlas Stent System (ATLAS trial [Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System]) are presented. Methods: ATLAS IDE trial (Investigational Device Exemption) is a prospective, multicenter, single-arm, open-label study of wide-neck (neck ≥4 mm or dome-to-neck ratio 50%) at the target location. The primary safety end point was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary end points was performed by an independent Imaging Core Laboratory and the Clinical Events Committee. Results: A total of 182 patients with wide-neck anterior circulation aneurysms at 25 US centers were enrolled. The mean age was 60.3±11.4 years, 73.1% (133/182) women, and 80.8% (147/182) white. Mean aneurysm size was 6.1±2.2 mm, mean neck width was 4.1±1.2 mm, and mean dome-to-neck ratio was 1.2±0.3. The most frequent aneurysm locations were the anterior communicating artery (64/182, 35.2%), internal carotid artery ophthalmic artery segment (29/182, 15.9%), and middle cerebral artery bifurcation (27/182, 14.8%). Stents were placed in the anticipated anatomic location in all patients. The study met both primary safety and efficacy end points. The composite primary efficacy end point of complete aneurysm occlusion (Raymond-Roy 1) without parent artery stenosis or aneurysm retreatment was achieved in 84.7% (95% CI, 78.6%–90.9%) of patients. Overall, 4.4% (8/182, 95% CI, 1.9%–8.5%) of patients experienced a primary safety end point of major ipsilateral stroke or neurological death. Conclusions: In the ATLAS IDE anterior circulation aneurysm cohort premarket approval study, the Neuroform Atlas stent with adjunctive coiling met the primary end points and demonstrated high rates of long-term complete aneurysm occlusion at 12 months, with 100% technical success and

Background Clinical trials of extracranial-intracranial (EC-IC) bypass surgery studied patients in subacute and chronic stage after ischemic event. Objective To investigate the short-term outcomes of EC-IC bypass in progressive acute ischemic stroke or recent transient ischemic attacks. Methods The study was a retrospective review at a single tertiary referral center from 2008 to 2015. Inclusion criteria consisted of EC-IC bypass within 1 yr of last ischemic symptoms ipsilateral to atherosclerotic occlusion of internal carotid or middle cerebral artery. Early bypass group who underwent surgery within 7 d of last ischemic symptoms were compared to late bypass group who underwent surgery >7 d from last ischemic symptom. The primary endpoint was perioperative ischemic or hemorrhagic stroke or intracranial hemorrhage within 7 d of surgery. Results Of 126 patients who underwent EC-IC bypass during the period, 81 patients met inclusion criteria, 69 (85%) persons had carotid artery occlusion, 7 (9%) had proximal MCA occlusion, and 5 (6%) had both. Early surgery had a 31% (9/29) perioperative stroke rate compared to 11.5% (6/52) of patients undergoing late bypass (P = .04). Of patients with acute stroke within 7 d of surgery, 41% (7/17) had perioperative stroke within 7 d (P = .07). Six of nine patients (67%) with blood pressure dependent fluctuation of neurologic symptoms had perioperative stroke (P = .049). Conclusion EC-IC bypass in setting of acute symptomatic stroke within 1 wk may confer higher risk of perioperative stroke. Patients undergoing expedited or urgent bypass for unstable or fluctuating stroke symptoms might be at highest risk for perioperative stroke.

Robert J. White is probably best known as the first neurosurgeon to perform successful "cephalic exchange" on monkeys in 1971. However, he was also a pioneer in the field of neurosurgery and contributed tremendously to the field of neuroanesthesia and bioethics. White received medical training at the University of Minnesota, Harvard University, Peter Bent Brigham Hospital, and Mayo Clinic before becoming the first Chief of Neurosurgery at Metrohealth Hospital in Cleveland, Ohio. He made significant strides in the field of spinal cord cooling and hypothermia. White and his team was also the first to successfully isolate the monkey brain with retention of biological activity. In 2004 and 2006, White and colleagues were nominated for the Nobel Prize in Physiology and Medicine, with Harvey Cushing and Wilder Penfield being the only other 2 neurosurgeons ever to be nominated for the award. Aside from his career as a neurosurgeon, he was also an advisor to 2 popes and an advocate for animal research. By the end of his career, White performed over 10 000 brain operations and published over 1000 articles, which has pushed the frontiers of neurosurgical research.

Acute carotid terminus occlusion (CTO) is responsible for up to 5% of acute ischemic strokes secondary to emergent large vessel occlusion (ELVO) and up to 20% of acute internal carotid artery (ICA) occlusions.1 The term "CTO" has also been used to describe occlusions in the supra-clinoid segment or at the bifurcation of the ICA. Compared to other ELVOs, patients with CTO present with higher stroke severity and larger infarct volume, likely to be a result of disruption of direct Circle of Willis collaterals across the anterior communicating artery (AComA) and posterior communicating artery (PComA).2,3 Similary, CTO is usually associated with worse prognosis compared to other ELVOs in general. With regard to response to treatment, previous studies have reported significantly lower recanalization rates with intravenous alteplase with CTO compared to M1 segment occlusion. With regard to the safety and efficacy of mechanical thrombectomy, prior reports provide conflicting results with some reporting lower successful recanalization rates with CTO compared to M1 occlusion, and others reporting similar results. In our experience, we have found that successful recanalization of CTO can be achieved with a similar approach to M1 occlusions utilizing a direct aspiration first pass technique (ADAPT).3,4 Herein, we present a case of CTO for which we performed mechanical thrombectomy using ADAPT. This procedure was an emergent standard of care procedure for which a consent was not required and so not obtained.

Background Anterior inferior cerebellar artery (AICA) aneurysms are rare lesions whose treatment can involve microsurgical and/or endovascular techniques. Such treatment can be challenging and may carry a significant risk of neurological morbidity. Objective To demonstrate a case involving a complex AICA aneurysm that was treated with a unique microsurgical approach involving trapping the aneurysm and performing in Situ bypass from the posterior inferior cerebellar artery (PICA) to the distal AICA. The nuances of AICA aneurysms and revascularization strategies are discussed. Methods The aneurysm and the distal segments of AICA and PICA were exposed with a retrosigmoid and far lateral approach. A side-to-side anastomosis was performed between the adjacent caudal loops of PICA and AICA. The AICA aneurysm was then treated by trapping the aneurysm-bearing segment of the parent vessel between 2 clips. Results A postoperative angiogram demonstrated a patent PICA-AICA bypass and complete occlusion of the AICA aneurysm. There were no complications, and the patient made an excellent recovery. Conclusion The combination of parent vessel sacrifice and bypass remains an excellent option for certain difficult-to-treat aneurysms. This case involving PICA-AICA bypass to treat an AICA aneurysm serves as an example of the neurosurgeon's ability to develop unique solutions that take advantage of individual anatomy.

Introduction Reversible cerebral vasoconstriction syndrome (RCVS) can occur spontaneously or may be a secondary response. RCVS is rarely reported in literature following carotid revascularization and thought to be a possible result of chronic cerebral hypoperfusion with disturbance of cerebral autoregulation. There is no standard treatment for this condition. Here we report occurrence and management of cerebral vasoconstriction following unique combined neurosurgical and endovascular carotid revascularization for symptomatic carotid occlusion. Methods We review a patient’s clinical and imaging characteristics following carotid artery revascularization. Results A female patient in her 70 s with history of hypertension, controlled type 2 diabetes mellitus, and current smoker presented with recurrent episodes of transient left sided limb shaking. She was found to have a right internal carotid artery (ICA) occlusion at the cervical origin with a non-flow limiting 40% stenosis of the left ICA associated with an acute infarct in the right frontal white matter. A diagnostic cerebral angiogram confirmed the occlusion of the right ICA with limited and delayed retrograde filling from the vertebrobasilar system via the right posterior communicating artery and smaller collateral contribution via right external carotid to ophthalmic artery. Notably, there was no anterior communicating artery for contralateral cross-filling. She had several outpatient visits and hospital admissions for hypotensive episodes associated with recurrent stereotypic symptoms. Repeat imaging demonstrated overall small stroke burden and no hemorrhage. Upon careful discussion and review of possible options, a combined neurosurgical-endovascular carotid revascularization was performed with endarterectomy of an occlusive plaque involving the distal common carotid to the proximal ICA, and direct mechanical thrombectomy with aspiration and stentriever of the cervical ICA to the terminus. Additional angioplasty and stenting of proximal petrous ICA segment was performed via femoral access after closure of the surgical site. She clinically was doing well until 5 days post-operatively, when she developed recurrent symptoms. Imaging showed small new ischemic strokes without hemorrhage. Continuous video-EEG monitoring was negative for seizures. Transcranial doppler monitoring over the next few days demonstrated worsening velocities, with a repeat angiogram confirming severe focal segmental irregularities isolated to the right anterior territory. The surgical and stenting site remained widely patent. Her vasospasm was successfully treated with intra-arterial verapamil with improvement in vessel caliber and clinical symptoms. Conclusions Post carotid revascularization cerebral vasoconstriction may be an unusual cause of clinical worsening after revascularization for chronic carotid stenosis or occlusion. Intra-arterial treatment with verapamil can be a safe and effective mode of therapy. Disclosures L. Sheikhi: None. J. Tsai: None. M. Bain: 2; C; Stryker. 4; C; Rebound Therapeutics. G. Toth: None.

Background: Lumbar spine surgery with or without intraoperative dural tear (DT) may contribute to postoperative subdural hematomas and/or cerebellar intracranial hemorrhages (ICHs). Here, we present two patients, one with and one without an intraoperative DT occurring during lumbar surgery, both of whom developed acute postoperative supratentorial ICHs. Case Description: Two patients developed supratentorial lobar ICH following lumbar decompressions and fusion. The first patient, without an intraoperative DT, developed multiple ICHs involving the left cerebellum and left temporal lobe. The second patient, following an L4-5 decompression/instrumented fusion involving a DT, postoperatively developed a large right frontal ICH. Conclusion: Here, two patients undergoing lumbar spine surgery with/without DT subsequently developed significant ICH.

Introduction: Mycotic aneurysms are a serious complication of infective endocarditis with increased risk of intracranial hemorrhage. Patients undergoing open heart surgery for valve repair or replacement are exposed to anticoagulants, increasing the risk of aneurysm bleeding. These patients may require endovascular or surgical aneurysm treatment prior to heart surgery, but data on this approach are scarce. Methods: Retrospective review of consecutive patients with infectious endocarditis and mycotic aneurysms treated endovascularly with Trufill n-butyl cyanoacrylate (n-BCA) at the Cleveland Clinic between January 2013 and December 2015. Results: Nine patients underwent endovascular treatment of mycotic aneurysms with n-BCA (mean age of 39 years). On imaging, 4 patients had intracerebral hemorrhage, 2 had multiple embolic infarcts, and the rest had no imaging findings. Twelve mycotic aneurysms were detected (3 patients with 2 aneurysms). Seven aneurysms were in the M4 middle cerebral artery segment, 4 in the posterior cerebral artery distribution, and 1 in the callosomarginal branch. n-BCA was diluted in ethiodized oil (1:1 to 1:2). Embolization was achieved in a single rapid injection with immediate microcatheter removal. Complete aneurysm exclusion was achieved in all cases without complications. All patients underwent open heart surgery and endovascular embolization within a short interval, 2 with both procedures on the same day. There were no new hemorrhages after aneurysm embolization. Conclusions: Endovascular embolization of infectious intracranial aneurysms with liquid embolics can be performed successfully in critically ill patients requiring immediate open heart surgery and anticoagulation. Early embolization prior to and within a short interval from open heart surgery is feasible.

Spontaneous intracerebral hemorrhage (ICH) is the most common type of hemorrhagic stroke, ≈4 times more common than subarachnoid hemorrhage and accounting for 15% of all strokes.1 ICH is associated with higher rates of morbidity and mortality than all stroke subtypes. Overall, mortality rates for ICH are estimated to be as high as 40% to 50%, with the vast majority of survivors disabled at 6 months. When ICH is associated with intraventricular hemorrhage (IVH), outcomes are even worse, with estimated rates of mortality between 50% and 80%.1 Current standards recommend that patients with cerebellar hemorrhages measuring >3 cm with associated neurological deterioration or significant mass effect be managed with emergency surgical decompression. Similarly, patients with supratentorial hemorrhage and impending herniation are frequently taken for surgical decompression with or without hematoma evacuation. ICH patients who do not fall into either of these 2 categories are, in the vast majority of cases, managed medically.2 With the exception of aggressive blood pressure normalization, no medical therapy has been shown to improve outcomes or reduce mortality in patients with ICH.2 In the absence of clinical evidence to guide therapy, many aspects of medical management are based on local practice patterns with significant variations between institutions. Spontaneous supratentorial ICH may be divided into 2 general categories based on anatomic location—deep (involving the deep gray matter nuclei) or lobar. Deep hemorrhages are generally caused by hypertension, whereas lobar hemorrhages are most often caused by either hypertension or amyloid angiopathy.3 Either type of hemorrhage may be caused or exacerbated by an inherent or pharmacologically induced coagulopathy.1 Brain injury caused by spontaneous ICH is believed to be a biphasic process. The initial hemorrhage dissects through the brain parenchyma, creating a direct traumatic injury to the regional neurons. Although some neurons are irreversibly injured …

Vascular access for cerebral angiography has traditionally been performed via the common femoral artery. It is crucial to obtain safe access to prevent complications that could lead to limb ischemia, groin hematoma, or retroperitoneal hematoma. This is especially true in neurointervention as many patients are anticoagulated or have received intravenous thrombolytics prior to their intervention. Special attention to anatomic landmarks, both grossly and radiographically, can help to assure safe access. The patient consented for this procedure. This video details rapid but safe femoral artery access in a patient undergoing emergent thrombectomy.

Background: F 2 -Isoprostanes (F 2 -IsoP) and Isofurans (IsoF), specific markers of lipid peroxidation in vivo, have been reported to be elevated and have prognostic implications in aneurysmal subarachnoid hemorrhage (aSAH). We examined associations between these biomarkers and the risk of delayed cerebral ischemia (DCI) following aSAH. Methods: Eighteen patients with aSAH and 7 controls with normal neuroimaging and CSF analysis results underwent CSF sampling and abstraction of clinical, demographic, and laboratory data. Samples (two) of CSF were collected on day 1 and once on days 5-8 post-bleed. F 2 -IsoP and IsoF assays were performed at Vanderbilt Eicosanoid Core Lab by gas chromatography/mass spectroscopy. Levels are expressed in median (IQR) for non-parametric data. Repeated sample measurement were compared using the Wilcoxon signed-rank test, whereas the Mann Whitney test was used for other non-parametric data. Results: Mean age was 62 + 15 (aSAH cases) vs. 52 + 14 (controls) years, p =0.07, and 80% were female. Median Hunt-Hess score was 3 (2-4) and modified Fisher scale 3 (3-4). Thirty five percent of patients developed DCI. F 2 -IsoP were significantly higher in cases than controls 47.5 (30.2-53.5) vs. 26.0 (21.2-34.5) pg/mL, p 0.01. No significant differences were observed in patients with or without DCI (41 (33.5-52) vs. 44 (28.5-55.5) pg/mL). IsoF were elevated in the second CSF sample (41.5 (34-72) pg/mL) in 9 patients, but undetectable in the remainder cases and all controls. Cases who developed DCI had significantly higher IsoF than cases who did not (57 (34-72) vs. 0 (0-34) pg/mL, p= 0.001). Median PaO2 in both groups was similar (130.5 (89.2-189.7) vs. 115 (77.5-176) mmHg). Conclusions: F 2 -IsoP and IsoF serve as overall indicators of oxidative injury following aSAH, but IsoF may also be related to the development of DCI and cerebral vasospasm. Whether IsoF serve as mediators of vasospasm/ischemia or are merely favored byproducts of oxidative damage warrants further investigation. In the absence of higher oxygen tensions, we hypothesize the possibility of neuronal mitochondrial dysfunction in patients with elevated IsoF.

Introduction: Endovascular therapy (EVT) for emergent large vessel occlusion (ELVO) is standard of care for disabling strokes. There is no sufficient prospective data evaluating EVT for mild ischemic stroke with ELVO. Retrospective data suggests that many patients may not have favorable outcomes without intervention. We present our initial data investigating safety and outcomes of EVT in patients with ELVO and initial NIHSS of < 6. Methods: Our single arm prospective study (Mild acute Ischemic Stroke With lArge Vessel occlusion - MISTWAVE) recruited patients in 2 large tertiary care centers. Inclusion criteria included anterior circulation or basilar artery ELVO within 24 hours of onset. We excluded patients with ASPECTS score ≤ 6 on pre-intervention imaging, prior intracranial hemorrhage, or current anticoagulant use. Our primary endpoints were symptomatic cerebral hemorrhage within 24 hours, and/or change in NIHSS by ≥ 4 points within 72 hours or during hospitalization. Secondary endpoints included angiographic recanalization grade, NIHSS and disability assessment at discharge, 30 days, or on last follow-up. Results: We screened over 50 patients, and enrolled 20 as of November 2018 (mean age 65.6 ± 12.3 years; 55% males; 12 M1 occlusions, 8 M2 occlusions). Main reasons for exclusion were: outside treatment window, worsening NIHSS to >5, tandem or extracranial carotid occlusion, and inability to obtain consent. TICI 2B/3 thrombectomy was achieved in 95% of patients. The median NIHSS on presentation was 3 (range 0-5), and at last available follow-up it was 0 (0-10). The majority of patients (85%) were discharged home with minimal or no residual deficits. The average follow-up was 60.9 days (range 9-210 days), and mRS 0-2 was achieved in 90%. None of the patients suffered symptomatic cerebral hemorrhage. One patient (5%) had neurologic worsening within 24 hours despite TICI 3 recanalization. There were no other periprocedural complications. Conclusion: This is one of the first truly prospective studies designed to assess the safety and feasibility of EVT in patients with low NIHSS and ELVO. Our results are preliminary, but suggest excellent radiographic and clinical outcomes, and no significant procedural complications.

Brain arteriovenous malformations (BAVM) are some of the most complex lesions treated by clinical neuroscientists. The recent publication of the ARUBA trial, showing higher complication rates with treatment compared with the natural history over a short period of follow-up, puts even more pressure on the physician to achieve complete BAVM eradication without complication. These lesions are often treated by multimodality therapy with some combination of endovascular embolization, radiosurgery, and microsurgical resection; however, multimodality therapy involves the additive risk of procedural complication with each procedure. While surgical resection has long been accepted as monotherapy with good cure rates, staged pre-operative endovascular embolization has facilitated microsurgical resection with lower blood loss. Endovascular embolization is more often utilized in conjunction with surgical resection, and often the portions of the AVM and feeders that are completely embolized with Onyx or glue may not be surgically resected since they have been “internally obliterated.” We present a case where the AVM was preoperatively embolized with Onyx and subsequently partially surgically resected. Post-operative angiography showed complete obliteration or “cure” of the AVM with no filling of the nidus or early venous drainage. The patient presented 12 months later with seizures and imaging showed volume loss in the residual Onyx cast and recanalization of the AVM nidus. The patient subsequently underwent repeat resection with complete removal of the residual AVM and Onyx cast. To our knowledge this is the first published report of volume loss within the Onyx cast leading to recanalization of the AVM nidus. This suggests that extreme care should be taken with partial resection of the AVM nidus or with embolization for cure, as late recanalization may occur.

A study of the views of the chief communications officers (CCOs) at large organizations revealed views about “high performance” of the communication function is considered more in terms of the entire organization than evaluation only of the communications or public relations function. Depth interviews followed by a survey showed that top CCOs see high performance most important in IT and finance, but that high performance in communications is more vital to organizational success than it is in marketing, legal and the human resources function. Key drivers and impediments to high-performance of corporate communications were identified. The study matters to the profession by going beyond other research on communications and public relations evaluation that is focused more within the function than in the broader organizational context. It also extends recent research on public relations and leadership. Finally, the study shows a distinction in viewpoint between top communications executives and other professionals, and indicates a mindset necessary to be successful as a function as well as to gain respect across the enterprise.

Delivery wire fracture of flow-diverter stents are rare but have been described. We describe a video case of a successful technique to retrieve such a fractured delivery wire by using a balloon microcatheter and the intermediate catheter when other proven methods may fail.

Acute ischemic stroke (AIS) is the fifth leading cause of death, and remains the leading cause of disability in the USA.1 There are an estimated 680 000 new strokes per year in the USA, with a mortality rate of 53–94%, and with an even greater morbidity.2 It is estimated that 3–22% of these patients are candidates for endovascular therapy.3–6 In addition to baseline stroke severity, emergent large vessel occlusion (ELVO) has been shown to be an independent predictor of poor outcome at 6 months.3 4 While intravenous recombinant tissue plasminogen activator (IV r-tPA) has proven efficacious predominantly for small cerebral vessel occlusions, endovascular therapies, including stent retriever based, aspiration based mechanical thrombectomy techniques, and intra-arterial administration of thrombolytic agents, have been shown to achieve higher rates of recanalization in patients with ELVO.7–10 The purpose of this document is to provide an update and critical assessment of technical aspects of the mechanical thrombectomy procedure. This document was prepared by the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery (SNIS), a multidisciplinary society representing the leaders in the field of endovascular therapy for cerebrovascular disease. A review of the English language literature published between January 1998 and March 2016 was conducted using search terms that included: ‘stroke,’ ‘ischemic stroke,’ ‘large vessel occlusion,’ ‘thrombectomy,’ ‘mechanical thrombectomy,’ ‘neurointerventional,’ ‘tPA,’ and ‘technique.’ Additionally, we incorporated already existing guidelines published by the American Heart Association (AHA) and the SNIS.11–15 The strength of the evidence supporting each recommendation was summarized using a scale previously described by the AHA guideline panels, and by the University of Oxford, Centre for Evidence Based Medicine.13 15–18 Much of our current practice in mechanical thrombectomy derives from recent randomized controlled trials (RCTs) which provide a foundation for treatment goals. The online supplementary tables 1-3 provide details of these thrombectomy trials, and …

This study explored the current state of performance evaluation and talent management in corporate communication from the perspective of senior communication leaders including the members of the Arthur W. Page society. The findings of a national survey underscore several opportunities for communication leaders to elevate performance and importance of their function. In addition to actionable insights, key trends and best practices in measuring communication effectiveness, the study also concludes with recommendations on developing high performing teams that also deliver higher value.

Background The guideline for treating unruptured brain arteriovenous malformations (ubAVMs) remains controversial. A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) reported lower risk of stroke or death with conservative management compared to interventional treatment. There were numerous limitations to the study, including short follow-up period and disproportionate number of patients treated with surgery and embolization. Objective To evaluate whether treatment of ARUBA-eligible patients have acceptable outcomes at our institution. Methods Retrospective analysis was performed on 673 patients with brain AVMs treated at our institution between 2001 and 2014. One hundred five patients were ARUBA eligible and included in the study. Patients were divided into the microsurgery or Gamma Knife Radiosurgery (GKS; Elekta, Stockholm, Sweden) arm depending on their final treatment. Mean follow-up period was 43 mo (range 4-136 mo). Primary outcome was stroke or death. Results A total of 8 (7.6%) patients had a stroke or died. The overall risk of stroke or death was 11.4% (5 of 44 patients) for the microsurgery arm and 4.9% (3 of 61 patients) for the GKS arm. The annual rates of stroke or death were 2.1%, 4.0%, and 1.2% for the entire patient cohort, microsurgery arm, and GKS arm, respectively. AVM obliteration rates at the end of the follow-up period were 95.5% and 47.5% for the microsurgery and GKS arms, respectively. Conclusion We report a lower overall risk of stroke or death in our ARUBA-eligible patients following treatment than ARUBA. Our results suggest that microsurgery and GKS may be appropriate treatments for patients with ubAVM.

This video demonstrates the diagnosis and surgical ligation of a C1 dural arteriovenous fistula via a far lateral, transcondylar approach. The patient’s dural arteriovenous fistula was identified by MRI signal changes in the spinal cord and a cerebrospinal angiogram demonstrating an abnormal hypertrophied early venous drainage pattern suggestive of a C1 vessel origin. Indocyanine green was used to verify surgical treatment of the fistula intraoperatively. A postoperative angiogram and MR image demonstrate fistula occlusion and resolution of the spinal cord edema. Anatomic details and technical nuances of the approach are demonstrated.The video can be found here: https://youtu.be/zSd0vuov8xk.

Background and Purpose— The failure of recent trials to show the effectiveness of acute endovascular stroke therapy (EST) may be because of inadequate patient selection. We implemented a protocol to perform pretreatment MRI on patients with large-vessel occlusion eligible for EST to aid in patient selection. Methods— We retrospectively identified patients with large-vessel occlusion considered for EST from January 2008 to August 2012. Patients before April 30, 2010, were selected based on computed tomography/computed tomography angiography (prehyperacute protocol), whereas patients on or after April 30, 2010, were selected based on computed tomography/computed tomography angiography and MRI (hyperacute MRI protocol). Demographic, clinical features, and outcomes were collected. Univariate and multivariate analyses were performed. Results— We identified 267 patients: 88 patients in prehyperacute MRI period and 179 in hyperacute MRI period. Fewer patients evaluated in the hyperacute MRI period received EST (85 of 88, 96.6% versus 92 of 179, 51.7%; P P =0.01), and when taken for EST (6 of 63, 9.5% versus 17 of 71, 23.9%; P =0.03). On adjusted multivariate analysis, the EST in the hyperacute MRI period was associated with a more favorable outcome (odds ratio, 3.4; 95% confidence interval, 1.1–10.6; P =0.03) and reduced mortality rate (odds ratio, 0.16; 95% confidence interval, 0.03–0.37; P Conclusions— Implementation of hyperacute MRI protocol decreases the number of endovascular stroke interventions by half. Further investigation of MRI use for patient selection is warranted.

Coil embolization of oblong aneurysms is difficult because the majority of commercially available coils are manufactured with a helical or spherical tertiary structure. While adopting framing strategies for oblong aneurysms (aspect ratio ≥ 2: 1), traditional coils may be undersized in the long axis but oversized in the short axis, resulting in increased aneurysmal wall stress, risk of re-rupture, and difficulty creating a basket that respects the aneurysmal neck. We review three cases in which versatile filling coils (VFCs) were used as the initial coils for embolization of oblong aneurysms and report coil distribution characteristics and clinical outcomes. Packing density after VFC implantation was assessed using the software AngioSuite-Neuro edition and AngioCalc. Illustrative case: a 58-year-old woman experienced a subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm (7.5 mm × 3.5 mm). A 3–6 mm × 15 cm VFC was selected as the first coil because the flexibility of its wave-loop structure facilitates framing of an irregularly shaped aneurysm. The loop portions of the structures tend to be pressed to the extremes of the aneurysmal sac by the wave component. The VFC was introduced smoothly into the aneurysmal sac without catheter kickback. We were then able to insert detachable filling coils without any adjunctive technique and achieved complete occlusion. Complete occlusion without severe complications was achieved in all three cases in our study. Average packing density after the first coil was 15.63%. VFC coils may have a specific role in framing oblong aneurysms given their complex loop-wave design, allowing spacing of the coils at the dome and neck while keeping sac stress to a minimum.

Introduction: Multiple clinical trials have failed to show that surgical intervention leads to better outcomes than medical management for patients with intracerebral hemorrhage (ICH). Newer and less invasive surgical techniques have been reported to be safe and technically effective for evacuation of ICH. The purpose of this study is to evaluate clinical outcomes following ICH evacuation using the BrainPath system (NICO, Indianapolis, IN), a tool that allows minimally invasive access to the subcortical space. Methods: IRB-approved prospective data were collected on patients who underwent ICH evacuation using BrainPath at the Cleveland Clinic from August 2013 to April 2016. Glasgow Coma Score (GCS) was collected upon admission and discharge. NIH stroke score (NIHSS) and modified Rankin score (mRS) were collected upon admission and discharge, and at the 3- and 6-month months follow-up visits. Results: Thirty-five patients underwent BrainPath-assisted ICH evacuation, with a mean age of 57 ± 16 years and average ICH volume of 50.4 ± 23.5mL. Complications included two patients requiring re-operation due to hematoma re-accumulation (6%), both of whom had serum creatinine greater than 1.5, and one case of wound infection (3%). Eight (23%) patients died during the follow-up period, of which four (11%) died within 30 days of hemorrhage. GCS was 10.1 ± 3.7 on admission and improved to 11.9 ± 2.9 at discharge. NIHSS of surviving patients at pre-operation, discharge, 3-month follow-up, and 6-month follow-up were 18.6 ± 7.7 (n=35), 19.0 ± 8.7 (n=26), 7.8 ± 5.9 (n=19), and 3.7 ± 3.8 (n=12), respectively. mRS at pre-hemorrhage baseline, 3-month follow-up, and 6-month follow-up was 0.7 ± 1.2 (n=35), 4.3 ± 1.5 (n=30), and 3.9 ± 1.9 (n=26), respectively. Conclusions: Evacuation of ICH using BrainPath is associated with acceptable rates of surgical morbidity. The 30-day mortality rate was better than expected based on admission ICH scores. Patients showed improvement in GCS between admission and discharge, and they showed improvement in NIHSS and mRS at three and six months postoperatively. A comparative study is needed to investigate whether surgical evacuation using this technique results in improved clinical outcomes compared to medical management.

Introduction: Flow diverter embolization is a novel method to treat intracranial aneurysms. The device has been shown to reduce procedure time and radiation exposure along with excellent long-term occlusion rates for single lesions. However, the effect of flow diversion on multiple adjacent aneurysms has not been well studied. We present our single center experience with flow diverter treatment of tandem aneurysms. Methods: We retrospectively collected clinical, imaging, procedural and follow up data on patients in whom flow diverters were used to treat intracranial anterior circulation aneurysms between 2011 and 2016. We included patients who had 2 or more tandem aneurysms of the internal carotid artery segment and where flow diverter was intended to treat all the aneurysms either as primary or secondary method. Results: We identified 21 patients with 52 aneurysms that met inclusion criteria. All were females with median age of 57 (Interquartile range [IQR] 51 - 69). Seventeen patients had 2 adjacent aneurysms, while 4 patients had 3 contiguous aneurysms. Of these, only one patient was treated acutely for ruptured aneurysm. The median largest aneurysm diameter was 3.1mm (IQR 2.5 - 4.8) with most common locations being cavernous and ophthalmic aneurysms. In 19 patients (90.5%) only a single flow diverter stent was used; only one patient required concurrent coiling. One patient (4.8%) suffered a post procedural mild stroke but improved rapidly. There were no other procedural complications. Follow up data in 13 patients (61.9%) with a median follow up of 8 months (IQR 6 - 13) demonstrated that 20 out of 28 aneurysms showed complete occlusion (71.4%). None of the patients at follow up required re-treatment, and there were no delayed/late aneurysm ruptures. Conclusion: Flow diverter is a feasible, efficacious and safe treatment option in patients with multiple tandem aneurysms, in a single session with good early outcomes. Long term follow up data and large cohort studies are required.

Background— The implantation of left atrial appendage closure device (WATCHMAN, Boston Scientific, Natick, MA) is an alternative option to oral anticoagulation (OAC) for stroke prevention in atrial fibrillation. Patients require short-term OAC after implantation to avoid device thrombosis. The 2 clinical trials that assessed this device excluded patients thought not to be candidates for OAC. As such, little is known about the safety of this strategy in patients with previous major bleeding events. Methods and Results— All 20 consecutive patients with history of spontaneous major bleeding while on OAC who had subsequently undergone WATCHMAN device implantation at our institution were included. A newly conceived multidisciplinary Atrial Fibrillation Stroke Prevention Center evaluated patients for candidacy for device implantation and subsequent antithrombotic therapy. The primary outcome was spontaneous major bleeding while receiving short-term postprocedural OAC. Median CHA 2 DS 2 -VASc and HAS-BLED scores were 5 (quartiles 5–6) and 5 (quartiles 4–5), respectively. Previous major bleeding events were major gastrointestinal bleeding, intracranial bleeding, spontaneous hemopericardium with cardiac tamponade, and hemarthrosis in 11, 7, 1, and 1 patients, respectively. None of the patients had spontaneous major bleeding during the course of OAC after device implantation. In 1 patient, OAC was discontinued after 40 days because of mechanical fall with head trauma resulting in subdural hematoma with no associated neurological deficits; this was managed conservatively. Conclusions— With careful multidisciplinary evaluation, a short course of OAC after WATCHMAN device implantation in patients with previous spontaneous major bleeding events is associated with low risk of recurrent spontaneous major bleeding.