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Stagnant blood flow and organizing thrombus are intralesional components of patients with cerebral cavernous malformations (CCM). Stasis and inflammation are mechanisms of growth, lesional instability and acute hemorrhages with or w/o symptoms. We evaluate the association of pre-diagnostic aspirin and/or statin use with acute hemorrhages at diagnosis. Patients with a CCM diagnosis were identified and categorized according to their medications on admission into four groups (no therapy, statin, aspirin, combined). The primary outcome was an acute hemorrhage (with or w/o symptoms) at diagnosis reported in a standardized manner from the T2 weighted magnetic resonance image. A multivariate generalized linear mixed models (GLMM) was utilized to conduct per-lesion analysis. We identified 446 patients with 635 lesions. An acute hemorrhage at diagnosis was observed in 31% of the patients. There were 328 patients without statin or aspirin therapy, 34% of whom presented with acute hemorrhage. Of patients on aspirin therapy at diagnosis, 25% presented with hemorrhage. Of patients on statin therapy, 26% had a hemorrhage at diagnosis. Combined therapy in 44 patients demonstrated a lower proportion of patients with acute hemorrhages (7 patients, 16% incidence). A GLMM showed that patients in the combined therapy group to have significantly lower odds of having an acute hemorrhage at diagnosis compared to the reference group of no therapy (OR 0.24; 95% CI 0.09–0.59; P = 0.002). Patients with a CCM receiving therapy with both aspirin and statins were less likely to present at diagnosis with acute hemorrhage.

OBJECTIVEThe Pipeline embolization device (PED) is a routine choice for the endovascular treatment of select intracranial aneurysms. Its success is based on the high rates of aneurysm occlusion, followed by near-zero recanalization probability once occlusion has occurred. Therefore, identification of patient factors predictive of incomplete occlusion on the last angiographic follow-up is critical to its success.METHODSA multicenter retrospective cohort analysis was conducted on consecutive patients treated with a PED for unruptured aneurysms in 3 academic institutions in the US. Patients with angiographic follow-up were selected to identify the factors associated with incomplete occlusion.RESULTSAmong all 3 participating institutions a total of 523 PED placement procedures were identified. There were 284 procedures for 316 aneurysms, which had radiographic follow-up and were included in this analysis (median age 58 years; female-to-male ratio 4.2:1). Complete occlusion (100% occlusion) was noted in 76.6% of aneurysms, whereas incomplete occlusion (≤ 99% occlusion) at last follow-up was identified in 23.4%. After accounting for factor collinearity and confounding, multivariable analysis identified older age (> 70 years; OR 4.46, 95% CI 2.30–8.65, p < 0.001); higher maximal diameter (≥ 15 mm; OR 3.29, 95% CI 1.43–7.55, p = 0.005); and fusiform morphology (OR 2.89, 95% CI 1.06–7.85, p = 0.038) to be independently associated with higher rates of incomplete occlusion at last follow-up. Thromboembolic complications were noted in 1.4% and hemorrhagic complications were found in 0.7% of procedures.CONCLUSIONSIncomplete aneurysm occlusion following placement of a PED was independently associated with age > 70 years, aneurysm diameter ≥ 15 mm, and fusiform morphology. Such predictive factors can be used to guide individualized treatment selection and counseling in patients undergoing cerebrovascular neurosurgery.

Background Pipeline embolization device (PED; Medtronic) and stent-assisted coiling (SAC) are established modalities for treatment of intracranial aneurysms. Objective To comparatively assess the efficacy of these techniques. Methods We conducted a retrospective analysis of patients with aneurysms treated at our institution with either PED from 2013 to 2017 or SAC from 2009 to 2015. All large (>10 mm), ruptured, fusiform, anterior communicating artery, posterior circulation aneurysms, and patients with no available follow-up imaging were eliminated before running the propensity score matching (PSM). Patients were matched using nearest neighbor controlling for: age, gender, smoking, exact location, maximal diameter, and presence of multiple aneurysms. Total hospital costs for equipment and implants were calculated from procedure product and hospital billing records, and compared between the propensity-matched pairs. Results Out of 165 patients harboring 202 aneurysms; 170 (84.2%) were treated with the PED, and 32 (15.8%) were treated using SAC. PSM resulted in 23 matched pairs; with significantly longer follow up in the SAC group (mean 29.8 vs 14.1 mo; P = .0002). Complete occlusion rates were not different (82.6 vs 87%; P = .68), with no difference between the groups for modified Rankin Scale on last clinical follow-up, procedural complications or retreatment rates. Average total costs calculated from the hospital records, including equipment and implants, were not different between propensity-score matched pairs (P = .48). Conclusion PED placement and SAC offer equally efficacious occlusion rates, functional outcomes, procedural complication rates, and cost profiles for small unruptured anterior circulation saccular aneurysms which do not involve the anterior communicating artery.

Background Hydrocephalus after nontraumatic subarachnoid hemorrhage (SAH) is a common sequela that may require the placement of ventriculoperitoneal shunts (VPS). Adjustable-pressure valves (APVs) are being widely used in this situation though more expensive than differential-pressure valves (DPVs). Objective To compare outcomes between APV and DPV in SAH-induced hydrocephalus. Methods We performed a retrospective chart review of patients with nontraumatic SAH who underwent VPS placement for the treatment of hydrocephalus after SAH, between July 2007 and December 2016. Patients were classified according to the type of valve (APV vs DPV). We evaluated factors that could predict the type of valve used, outcomes in VPS revision/replacement rate, and complications. Results A total of 66 patients underwent VPS placement who were equally distributed into the 2 groups of valves. VPS failure with the need for revision/replacement occurred in 13 (19.7%) cases. Ten (30.3%) patients with DPV had a VPS failure, while 3 (9.1%) patients with an APV had a similar failure with the need for revision/replacement (P = .03). VPS placement before discharge during the initial hospitalization (P = .02) was statistically significant associated with the use of a DPV, while the reason of external ventricular drain (EVD) failure (P = .03) was associated with the use of an APV. Conclusion APVs had a lower rate of surgical revisions compared to DPVs. Early placement of VPS was associated with the use of a DPV. The need for EVD replacement due to EVD infection or malfunction was associated with higher rates of APV use.

Background Posterior communicating artery segment aneurysms are one of the most frequent intracranial aneurysms. Currently, limited data have described the use of the pipeline embolization device (PED) in these aneurysms. Methods We conducted a multicenter retrospective review of 3 prospectively collected databases of patients treated with the PED from January 2013 to December 2017. The primary objective was to assess the efficacy and safety of the PED in the treatment of saccular posterior communicating artery (PComA) aneurysms. We also assessed the effect of anatomical variations on the angiographic and clinical outcomes, including the presence of fetal PComA, vessel origin relationship to the aneurysm, and patency after PED placement. Results We identified 57 patients with 60 saccular aneurysms; Their mean age was 60.5 years, and 49 were female (86.0%). A total of 55 aneurysms (91.7%) were unruptured. The median imaging follow-up duration was 8.5 months. Complete occlusion at the last imaging follow-up study was 84.0%. At the last follow-up examination, 94.5% of patients had a modified Rankin scale score of ≤2. The presence of fetal PComA, origin type, and patency during follow-up did have a significant effect on aneurysm occlusion (P = 0.61, P = 0.40, and P = 0.14, respectively). Conclusions PED use for treatment of PComA aneurysms resulted in acceptable occlusion rates. The present study did not find that fetal PComA, its origin, or its patency during follow-up had an effect on aneurysm occlusion.

OBJECTIVECurrently, there is no established standard regarding the ideal number of external ventricular drain (EVD) clamp trials performed before ventriculoperitoneal (VP) shunt insertion following nontraumatic subarachnoid hemorrhage (SAH). In this study, the authors aimed to evaluate this relationship.METHODSA retrospective review of all patients presenting with SAH between July 2007 and December 2016 was performed. Patients with SAH who had received an EVD within the first 24 hours of hospital admission and had undergone at least 1 clamp trial prior to EVD removal were eligible for inclusion in the study. Patient demographics, clinical presentations, SAH etiologies and grades, clamp trial data, hospital lengths of stay, and functional outcomes were recorded.RESULTSOne hundred fourteen patients with nontraumatic SAH complicated by posthemorrhagic hydrocephalus were included in the study. The median patient age was 57 years (range 28–90 years), with a male/female ratio of 1:1.7. A ruptured aneurysm was the underlying etiology of SAH in 79.8% of patients. A majority of patients (69.4%) had a Hunt and Hess grade III–V on admission. The median number of clamp trials performed was 2 (range 1–6). A VP shunt was required in 40.4% of patients. In those who underwent 2 and 3 clamp trials, 60% and 38.9%, respectively, did not require subsequent VP shunt placement.CONCLUSIONSSurgical placement of a VP shunt is associated with complications. Clamp trials are routinely performed before making the decision to insert a shunt. In the present study, the authors found that a significant percentage of patients passed their second and third clamp trials without requiring subsequent shunt insertion. These data support performing multiple clamp trials prior to shunt placement.

Background Sutures are conventionally used for external ventricular drain (EVD) catheter fixation, but staples are an appealing alternative as they are quicker and easier to learn. We report our institutional experience with EVD fixation techniques and the patterns of catheter fixation. Methods We conducted a retrospective review of all aneurysmal subarachnoid hemorrhage (aSAH) patients treated in a single US center between 2007 and 2017. Results Out of 307 patients, 217 patients (62.2% female, mean age 59.5 years) met inclusion criteria harboring 268 EVDs. Two main configurations were used for EVD catheter fixation; spiral-shaped EVDs in 139 (51.9%) cases and arciform (C-shaped) EVDs in 129 (48.1%) of the cases. 220 (82.1%) were secured with staples and 48 (17.9%) with sutures. The most common complication was obstruction (n = 43, 16.2%), followed by infections (n = 18, 6.8%). Catheter dislodgements occurred in 16 (5.9%) catheters and 61 (22.8%) required repositioning/replacement. EVD dislodgement rates did not differ between the staples and sutures group, or between the spiral and C-shaped EVDs (p = 0.5 and 0.93, respectively). No cases of catheter perforation by the staples were encountered in our cohort. Conclusion Staples and sutures are equally valid and acceptable methods for EVD fixation with similar dislodgement rates. Scarce data exist in the literature regarding dislodgements, and further studies are needed to address its incidence and the best preventive strategies.

Background The ISAT (International Subarachnoid Aneurysm Trial) has generated a paradigm shift towards endovascular treatment for intracranial aneurysms but remains unclear if this has led to a true reduction in the risk for aneurysmal subarachnoid hemorrhage (aSAH). We sought to study the association between the treatment burden of unruptured and ruptured aneurysms in the post‐ISAT era. Methods and Results Admissions data from the National Inpatient Sample (2004–2014) were extracted, including patients with a primary diagnosis of aSAH or unruptured intracranial aneurysms treated by clipping or coiling. Within each year, this combined group was randomly matched to non‐aneurysmal control group, based on age, sex, and Elixhauser comorbidity index. Multinomial regression was performed to calculate the relative risk ratio of undergoing treatment for either ruptured or unruptured aneurysms in comparison with the reference control group, adjusted for time. After adjusting for National Inpatient Sample sampling effects, 243 754 patients with aneurysm were identified, 174 580 (71.6%) were women; mean age, 55.4±13.2 years. A total of 121 882 (50.01%) patients were treated for unruptured aneurysms, 79 627 (65.3%) endovascularly and 42 256 (34.7%) surgically. A total of 121 872 (49.99%) patients underwent procedures for aSAH, 68 921 (56.6%) endovascular, and 52 951 (43.5%) surgically. Multinomial regression revealed a significant year‐to‐year decrease in aSAH procedures compared with the control group of non‐aneurysmal hospitalizations (relative risk ratio, 0.963 per year; P P =0.35). Conclusions With each passing year, there is a significant decrease in relative risk ratio of undergoing treatment for aSAH, concomitant with a stable annual risk of undergoing treatment for unruptured intracranial aneurysms.

The role of an early CTA approach in neurologically stable patients with nontraumatic SAH has not been assessed. This study explored the use of CTA in clinically stable SAH patients to pre-emptively identify cerebral vasospasm, to evaluate whether this approach is associated with improved clinical outcomes.We conducted a retrospective chart review of SAH patients presenting between July 2007 and December 2016 in a single academic center. Patients were divided into two groups: (1) Early CTA (stable patients who underwent a CTA between days 5-8 post-SAH), and (2) Standard Protocol. The co-primary outcomes were a composite of the mRS at discharge and last clinical follow-up (good = 0-2; poor = 3-6). A multivariable binary logistic regression was conducted to compare both groups against outcomes, controlling for potential confounders.A total of 415 patients were included, 103 (24.8%) with early CTA, and 312 (75.2%) undergoing the standard protocol; the mean age was 57 years and 248 (59.8%) patients were female. Patients in the early CTA group had a higher modified Fisher grade (3-4) (87.4% vs 63.1%; p 0.02). The multivariable analysis showed that early CTA was independently associated with lower poor outcomes at discharge (OR = 0.21, 95% CI 0.07-0.61, p = 0.004). Plus, vasospasm detection was associated with an increased risk of poor outcomes (OR = 4.77, 95% CI 1.41 - 16.10, p = 0.01). Early CTA was not associated with outcomes at clinical follow-up.The early CTA surveillance approach was associated with better functional outcomes at discharge when compared to the current imaging standard practice.

Background The International Subarachnoid Aneurysm Trial has generated a paradigm shift towards endovascular procedures for treating intracranial aneurysms, but it remains unclear if this has led to a true reduction in the risk for aneurysmal subarachnoid hemorrhage (aSAH). Our study aims to simultaneously quantify the annual intervention rates for ruptured and unruptured cerebral aneurysms, in order to evaluate any association between the treatment burden of unruptured and ruptured aneurysms after the endovascular treatment era. Methods Admissions data from the National Inpatient Sample (NIS; 2004–2014) were extracted. Patients with a primary diagnosis of subarachnoid hemorrhage or unruptured aneurysms treated by either clipping or coiling were included. Within each year, this combined group was randomly matched to a non-aneurysmal control group, based on age, sex and Elixhauser comorbidity index. Multinomial logistic regression was performed to calculate the relative risk ratio (RRR) of undergoing treatment for either ruptured or unruptured aneurysms in comparison to the reference control group, adjusted for time. Results After adjusting for the NIS sampling effects, 243,7754 aneurysm patients were identified, 174,580 (71.6%) of whom were female. The mean (SD) age was 55.4±13.2 years. A total of 121,882 (50.01%) patients were treated for unruptured aneurysms, 79,627 (65.3%) endovascularly and 42,256 (34.7%) surgically. A total of 121,872 (49.99%) patients underwent procedures for aSAH, 68,921 (56.6%) endovascular and 52,951 (43.5%) surgical. Multinomial logistic regression revealed a significant year-to-year decrease in aSAH procedures compared to the control group of non-aneurysmal hospitalizations (RRR 0.963 per year, 95% CI 0.944–0.982, P Conclusion With each passing year, there is a significant decrease in RRR of undergoing treatment for aSAH, concomitant with a stable annual risk of undergoing treatment for UIA. Disclosures M. Salem: None. G. Maragkos: None. S. Gomez-Paz: None. L. Ascanio: None. L. Ngo: None. C. Ogilvy: None. A. Thomas: None. J. Moore: None.

BACKGROUND The association of blood pressure variation with poor outcomes in aneurysmal subarachnoid hemorrhage (aSAH) is unknown. OBJECTIVE To evaluate the association of systolic blood pressure (SBP) variation and clinical outcomes in aSAH. METHODS We conducted a retrospective chart review of all aSAH patients treated at an academic institution between 2007 and 2016. Patient demographics, aSAH characteristics, and blood pressure observations for the first 24 h of admission in 4-h intervals were obtained. SBP variability metrics assessed were mean, standard deviation, maximum, minimum, peak, trough, coefficient of variation, and successive variation. The primary outcome was a composite of the modified Rankin scale as good (0-2) or poor (3-6) at last follow-up. Comparisons between outcome groups were performed. Logistic regression models for each significant SBP metric controlling for potential confounders were constructed. RESULTS The study population was 202 patients. The mean age was 57 yr; 66% were female. The median follow-up time was 18 mo; 57 (29%) patients had a poor outcome. Patients with poor outcomes had higher standard deviation (17.1 vs 14.7 mmHg, P = .01), peak (23.5 vs 20.0 mmHg, P = .02), trough (22.6 vs 19.2 mmHg, P

Objective Headache is the presenting symptom of unruptured intracranial aneurysm (UIA) in more than one-third of cases. Some patients may expect their headache to remit after aneurysm treatment. This study aims to identify factors influencing headache outcomes following endovascular treatment of UIA. Methods This prospective observational study was conducted in patients with UIAs treated with flow diversion. Subjects reported their headache intensity with a visual analog scale (VAS) and completed 3 surveys before treatment: Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT-6), and Patient Health Questionnaire-2 (PHQ-2). Follow-up was at 1 month, 3 months, and 6 months after treatment. Analysis was performed using generalized mixed-effects models. Results We identified 38 patients, 29 of whom reported headaches at baseline (76.3%). Mean patient age was 55.3 ± 12.4 years, and 79% of the cohort was female. Mean aneurysm diameter was 6.8 ± 5.3 mm, and treatment modality was Pipeline embolization in all cases. At the last follow-up, 5 aneurysms (15.1%) were incompletely occluded. The mean VAS scores for patients with headache at baseline were 4.36 ± 0.59 at baseline, 4.08 ± 0.60 at 1 month, 3.04 ± 0.62 at 3 months, and 2.76 ± 0.57 at 6 months. Controlling for occlusion status, medication, and depression, significant improvement was seen at the 3- and 6-month follow-ups. Similar patterns were observed with MIDAS and HIT-6. Conclusions In the present study, endovascular UIA treatment led to significantly decreased headache intensity in patients with headache at baseline, after a short delay. Our data shed light on postintervention headache patterns and can help inform patient discussions and treatment expectations.

BACKGROUND Patients with bilateral chronic subdural hematoma (bCSDH) undergo unilateral evacuation for the large or symptomatic side because the contralateral hematoma is either small or asymptomatic. However, the contralateral hematoma may subsequently grow and require evacuation. OBJECTIVE To characterize factors that predict contralateral hematoma growth and need for evacuation. METHODS A retrospective study on 128 surgically treated bCSDHs. RESULTS Fifty-one and 77 were bilaterally and unilaterally evacuated, respectively. Glasgow Coma Scale was lower and midline shift was higher in those evacuated unilaterally compared to those evacuated bilaterally. Hematoma size was a significant determinant of decision for unilateral vs bilateral evacuation. The contralateral side needed evacuation at a later stage in 7 cases (9.1%). There was no significant difference in terms of reoperation rate between those evacuated unilaterally and bilaterally. Greater contralateral hematoma thickness on the first postoperative day computed tomography (CT) and more postoperative midline shift reversal had higher rates of operation in the opposite side. There was no difference between the daily pace of hematoma decrease in the operated and nonoperated sides (0.7% decrease per day vs 0.9% for the operated and nonoperated sides, respectively). CONCLUSION Results of this study show that most bCSDHs evacuated unilaterally do not experience growth in the nonoperated side and unilateral evacuation results in hematoma resolution for both sides in most cases. Hematoma thickness on the opposite side on the first postoperative day CT and amount of midline shift reversal after surgery are the most important factors predicting the need for surgery on the opposite side.

In the current dynamic health environment, increasing number of procedures are being completed by advanced practitioners (nurse practitioners and physician assistants). This is the first study to assess the clinical outcomes and safety of external ventricular drain (EVD) placements by specially trained advanced practitioners. Compare the safety and outcomes of EVD placement by advanced practitioners in patients with subarachnoid hemorrhage (SAH). A cohort comparison study was performed from an aneurysmal SAH database selecting patients treated with EVD from a single major academic institution in the USA between June 2007 and June 2017. Safety, accuracy, and complications of EVD placement were compared between advanced practitioners and neurosurgical physicians (attending neurosurgeon and subspecialty clinical fellow). Statistical analysis was performed using the Mann–Whitney test for continuous variables and χ2 test for categorical variables, with p values set at

Stroke in pregnant women has a mortality rate of 1.4 deaths per 100,000 deliveries. Vascular malformations are the most common cause of hemorrhagic stroke in this population; preeclampsia and other risk factors have been identified. However, nearly a quarter of strokes have an undeterminable cause. Spontaneous intracranial hemorrhage (ICH) is less frequent but results in significant morbidity. The main objective of this study is to review the literature on pregnant patients who had a spontaneous ICH. A systematic review of the literature was conducted on PubMed and the Cochrane library from January 1992 to September 2016 following the PRISMA guidelines. Studies reporting pregnant patients with spontaneous intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and subdural hemorrhage (SDH) were selected and included if patients had non-structural ICH during pregnancy or up to 6 weeks postpartum confirmed by imaging. Twenty studies were included, and 43 patients identified. Twenty-two patients (51.3%) presented with IPH, 15 patients (34.8%) with SAH, and five patients (11.6%) with SDH. The most common neurosurgical management was clinical in 76.7% of patients, and cesarean section was the most common obstetrical management in 28% of patients. The most common maternal outcome was death (48.8%), and fetal outcomes were evenly distributed among term delivery, preterm delivery, and fetal or neonatal death. Spontaneous ICH carries a high maternal mortality with IPH being the most common type, most frequently presenting in the third trimester. Diagnosis and management do not differ for the parturient compared to the non-pregnant woman.

Hydrocephalus is a frequently encountered complication in the context of aneurysmal subarachnoid hemorrhage (aSAH). Here, we performed an external validation of the recently proposed postsubarachnoid shunt scoring (PS3) system, which aims to stratify patients presenting with aSAH based on their relative risk of requiring ventriculoperitoneal (VP) shunt insertion.A retrospective review of all patients presenting with aSAH to our institution between July 2007 and December 2016, who underwent computed tomography imaging at the time of hospital admission, was performed.A total of 242 patients (66.1% women) with aSAH were included in the analysis with a mean age of 55.6 years. Sixty-four (26.4%) patients had a Hunt and Hess grade of 4 or 5 on admission. An external ventricular drain (EVD) was placed in 130 (53.7%) patients during the hospital admission. EVD placement was found to correlate with an increased rate of VP shunt placement (P0.001), and a trend toward an association between a high Hunt and Hess grade and VP shunt placement was observed (P = 0.05). The area under the receiver operating characteristic curve for the PS3 system was found to be 0.845. The system reliably predicted shunt-dependent chronic hydrocephalus in our patient cohort (odds ratio, 3.36; 95% confidence interval, 2.31-4.89; P0.001).Data from this study validated the previously proposed PS3 system, which was found to more accurately predict shunt-dependent chronic hydrocephalus in patients with aSAH compared with other such systems in the neurosurgical literature, such as the chronic hydrocephalus ensuing from SAH score, Barrow Neurological Institute, and shunt dependency in aSAH systems.

Patients with a cerebral cavernous malformation (CCM) can have intracranial hemorrhages ranging from insignificant and chronic microbleeds to life-threatening hemorrhage. Management decisions and patient counseling are based on a heterogeneous body of evidence. We sought to improve the literature by providing our results based on the standardized definitions and aimed to delineate differences in the symptomatic burden for CCMs, based on their anatomic location and presence of developmental venous anomalies. This evidence will aid in clinical decision making and patient counseling.A retrospective cohort analysis between 1990 and 2018 was performed, including patients with a diagnosis of a CCM. The primary outcome was acute symptomatic hemorrhages.We identified 438 patients harboring 632 CCMs. Mean age at diagnosis was 50 years (standard deviation ±17 years). Median follow-up was 26 months (interquartile range, 7-72 hours). Multiple lesions were encountered in 64 patients (15%). An initial symptomatic presentation was observed in 64% of the patients. There were 438 supratentorial lesions (69%) and 194 infratentorial lesions (31%). A symptomatic hemorrhage was observed in 25% of the supratentorial lesions and 29% of the infratentorial lesions (P0.001). A linear mixed-effects regression model showed a significant difference in developing a symptomatic hemorrhage at diagnosis or follow-up between CCMs with an infratentorial location and those with a supratentorial location (odds ratio, 1.81; 95% confidence interval, 1.17-2.81; P = 0.008).Infratentorial cavernous malformations are more likely to present with symptomatic hemorrhages at diagnosis or during follow-up when accounting for size differences between lesions.

BackgroundAneurysms arising from the communicating segment (C7) of the internal carotid artery (ICA) are one of the most frequent locations of intracranial aneurysms. Stent-assisted coiling (SAC) and flow diversion therapies are both endovascular strategies used for the treatment of ICA aneurysms occurring at the C7 segment.ObjectiveThe aim of this study is to compare both methods' angiographic and functional outcomes, and procedural complications. To our knowledge, this is the first study to compare both modalities for aneurysms at this location.MethodsA retrospective review was performed of our prospectively collected database from 2008 until 2017 for patients treated with SAC and from 2013 until 2017 for patients treated with pipeline embolization devices (PEDs).ResultsWe identified 35 patients for this cohort with 38 aneurysms; 17 treated with SAC and 21 with PED. Mean age was 59 years, and 30 patients were female (86%). Complete occlusion at last follow-up occurred in 70.6% of patients in the SAC group and in 81% in the PED group ( p = 0.45). Posterior communicating artery patency at last follow-up did not differ significantly between the two groups (94.1% vs 85.7%; p = 0.40). Good functional outcome at last follow-up (mRS 0–2) was achieved in 100% and 88.2% of patients, respectively. Additionally, there was no significant difference between the two groups for retreatment rates, procedural hemorrhagic, or thromboembolic complications.ConclusionSAC and PED are two equally efficacious modalities for endovascular treatment of ICA aneurysms arising at the communicating segment of the ICA.

Intracerebral hemorrhage (ICH) is the most deadly form of stroke with a 40% mortality rate and bleak functional outcomes. 1 There is currently no effective treatment of the condition, but preliminary trials focusing on endoscopic minimally invasive evacuation have suggested a potential benefit. 2 , 3 , 4 The “SCUBA” technique (Stereotactic Intracerebral Hemorrhage Underwater Blood Aspiration) builds on prior strategies by permitting effective clot removal with visualization and cauterization of active arterial bleeding. 5 , 6 , 7 The patient was a male in his ’50s who presented with left-sided numbness after loss of consciousness and was found to have a right basal ganglia 5 mL ICH with a spot sign on computed tomography angiography CTA ( Video 1 ). The hematoma then expanded to 28 mL and his examination worsened significantly for a National Institutes of Health Stroke Scale score of 15, a Glasgow Coma Scale score of 14, and an ICH score of 1. Approximately 8 hours after the patient was last known to be well, he was taken to the angiography suite for a diagnostic cerebral angiogram and right frontal minimally invasive endoscopic ICH evacuation with the Artemis system. The hematoma was evacuated using the stereotactic ICH underwater blood aspiration technique. After significant debulking of the clot, suction strength was decreased to 25% and irrigation was maintained on high. Sites of active bleeding were cauterized with the endoscopic bipolar cautery. The patient improved neurologically and was discharged from the hospital neurologically intact on postbleed day 4 with a National Institutes of Health Stroke Scale score of 0.

Background Determining the risks of treatment of unruptured intracranial aneurysms is critical in the decision-making process of management. Most studies have reported the results for endovascular or surgical management. Our objective was to better delineate the risk estimates for unruptured intracranial aneurysms treated with surgical or endovascular techniques in a comprehensive fashion, according to the patients' risk profiles. Methods Data were gathered from 553 patients with 658 unruptured intracranial aneurysms treated at a single institution from 2014 to 2017. The decision to treat was determined by a projected morbidity that was lower than the natural history rupture risk. Data on aneurysm size, location, patient age, and outcome at the last clinical visit (modified Rankin scale scores) were collected and analyzed retrospectively. Results The mean patient age was 59 years, and the mean lesion size was 7.3 mm. Microsurgical clipping was used in 251 lesions (38.2%), endovascular coiling in 70 (10.6%), stent-assisted coiling in 89 (13.5%), and a pipeline embolization device in 248 (37.7%). Complications from the procedures or during hospital admission occurred 66 lesions (10% of the total). Of these 66 complications, 28 (4.32% of the total) were non-neurological, treated, and resolved without permanent morbidity. Neurologic complications occurred in 38 procedures (5.7% of the total). Of these, 7 (1%) resulted in a permanent poor outcome (modified Rankin scale score, 3–6). Conclusion Aneurysmal obliteration using endovascular and surgical approaches in a comprehensive fashion has low treatment risks for unruptured aneurysms. The nomograms generated are useful in the discussion with patients and families regarding the risks of total institutional treatment of unruptured aneurysms.

This operative video demonstrates the important considerations and details to perform a suction decompression technique to assist in clipping of a large middle cerebral artery (MCA) aneurysm (Video 1). We present the case of a 58-year-old man with a 5-day history of dizziness. A computed tomography angiography revealed a 15-mm-diameter aneurysm in the left middle cerebral artery and a 6-mm-diameter aneurysm in the anterior communicating artery. Characterization of both lesions was obtained with a cerebral angiogram. Given the wide nature of the base of the MCA lesion, a surgical obliteration was considered best. A left frontotemporal craniotomy with the patient under total intravenous anesthesia and continuous neurophysiological monitoring was performed to approach both intracranial aneurysms. Access through the Sylvian fissure corridor was obtained, and the dome of the MCA lesion was quickly identified. The large aneurysm neck challenged visualization of the takeoff vessels of the MCA divisions, and after careful dissection, visualization remained poor; therefore, a suction decompression technique was considered appropriate to gain anatomical control.1,2 For doing so, we used a 21-gauge needle wired to a 3-mm retractor on the Greenberg System, connected distally to suction. After cornering the lesion with temporary aneurysm clips, needle insertion was performed, enabling aneurysmal collapse and perfect visualization of the take-off vessels, which allowed proper clip deployment across the lesion. Next, we approached the anterior communicating artery aneurysm through the subfrontal region with successful clip deployment. Careful suction decompression could help the surgeon in obtaining better visualization. Patient approval and consent was obtained for submission of this video to this journal. Key words: Aneurysm, Microsurgery, Middle cerebral artery, Operative surgical procedure, Suction decompression

Background Isolated cervical pseudoaneurysms of the internal carotid artery (ICA) in patients with Marfan syndrome are extremely rare. Case Description A 73-year-old female with Marfan syndrome and history of multiple aortic aneurysms presented to an outside hospital with dysphagia, a mass in her neck, dizziness, nausea, and vomiting. A computed tomography angiogram showed bilateral cervical ICA pseudoaneurysms, more significant on the right side. A laryngoscopy demonstrated edematous vocal cords and a significant mass effect on the right side. She suffered from significant respiratory distress and aspiration, for which she had to be intubated and transferred to our institution for definitive care. The patient was taken for angiography for carotid artery test occlusion and endovascular trapping with coils and onyx embolization of the carotid pseudoaneurysm. The hospital course was complicated with femoral closure device failure, leading to groin hematoma, pneumonia, and respiratory failure requiring tracheostomy and percutaneous endoscopic gastrostomy. The patient was discharged to rehabilitation 34 days after admission. Stable exclusion of the large right pseudoaneurysm was observed at 3 months' follow-up with computed tomography angiography, as well as significant improvement in the last clinical follow-up obtained 6 months after the procedure. Conclusion Pseudoaneurysms of the cervical ICA associated with Marfan syndrome are rare. Carotid test occlusion and endovascular permanent embolization are possible in a patient with life-threatening symptoms. Cautious use of vascular closure devices, especially collagen plug-based ones, are required in such patients, given their abnormal extracellular matrix structure.

Background Several outcome prediction systems have been developed to evaluate aneurysmal subarachnoid hemorrhage (aSAH). However, they can be difficult to use and can contain subjective elements. We sought to identify the predictors of aSAH outcomes at discharge to provide an accurate and reliable scoring system. Methods A retrospective cohort study of patients with aSAH at an academic institution from 2007 to 2016 was conducted. The primary outcome measure was the modified Rankin scale (mRS) score at discharge, with mRS scores of 0–2 considered favorable and mRS scores of 3–6 considered unfavorable. Factors significant on multivariate regression were used to develop a scale, which was compared with other established grading systems using receiver operating characteristic curves. Results We identified 279 patients with aSAH, 37.3% of whom had unfavorable outcomes. The proposed scale assigns 2 points for postresuscitation Glasgow coma scale score of ≤8, 1 point for age ≥70 years, 1 for antiplatelet therapy on admission, and 1 for SAH thickness of ≥10 mm, with a total score of 0–5. The proposed, Subarachnoid Hemorrhage International Trialists, and Hunt and Hess scales had similar areas under the curve (85.2%, 84.8%, and 80.6%, respectively; P > 0.05) but were significantly better than the World Federation of Neurological Surgeons (78.5%; P = 0.001) and modified Fisher (60.8%; P Conclusion We propose a grading scale to predict discharge mortality and functional outcomes in patients with aSAH. The proposed scale outperformed most other outcome prediction scales. The proposed scale contains objective elements, is easy to apply by memory, and can be a useful and effective measure to predict aSAH outcomes.

Cavernous malformations (CMs) are intracranial vascular anomalies of the brain blood vessels which are usually asymptomatic but sometimes may cause headache, seizures, or focal neurologic symptoms.1 The latter may be attributed to either hemorrhage of the lesion or due to associated mass effect.2 Here, we describe the case of a 27-yr-old woman who had an acute onset of headache and occasional left sided peripheral visual disturbances. A brain computed tomography scan revealed intraparenchymal hemorrhage near the right hypothalamus and a brain magnetic resonance imaging (MRI) was consistent with an anterior perforated substance CM. Medical management was pursued but severe headache persisted for several weeks to the point of interfering with normal daily function. Given the evidence of past hemorrhage and the persistence of symptoms, a microsurgical resection was indicated. She was scheduled for an elective resection through a right frontotemporal craniotomy. The lesion was found in the right anterior perforated substance, just above the optic tract and was resected without complications. The patient was neurologically stable at discharge. At 4-mo follow-up, the patient had a significantly decreased intensity of headache and an adequate resection cavity on MRI. Otherwise, she was neurologically intact. Cavernous malformations of deep brain structures, such as the anterior perforated substance can be surgically treated but carry a challenging procedure with a risk of visual deficits. In the following video illustration, we narrate this operative case and highlight the nuances of this approach. Patient consent was obtained for the submission of the video to this journal.

Moyamoya disease (MMD) management during pregnancy poses a challenge to health care providers, and recommendations are outdated, vague, and controversial. We conducted a systematic review to investigate and present the available evidence. We searched five online databases and bibliographies of relevant published original studies to identify case reports, case series, cohort studies, and reviews reporting on patients diagnosed with MMD before, during, or shortly after pregnancy. We report and analyze the respective data. Fifty-four relevant articles were identified. In the group of patients with MMD diagnosed prior to pregnancy, 68.7% had previously undergone bypass surgery, 64.5% delivered via cesarean section, 95.2% of mothers had good outcomes, and no bad fetal outcomes were reported. In patients first diagnosed with MMD due to a cerebrovascular accident during pregnancy, the mean gestational age on symptom onset was 28.7 weeks and 69.5% presented with cerebral hemorrhage. In this group, 57.2% received neurosurgical operative management, and 80% underwent cesarean section with 13.6% maternal mortality and 23.5% fetal demise. In patients diagnosed with MMD immediately postpartum, 46.6% suffered a cerebrovascular event within 3 days of delivery, 78.3% of which were ischemic. Only 15.3% underwent surgical hematoma evacuation and one patient (9%) expired. MMD may coincide with pregnancy, but there is paucity of high-quality data. It appears that MMD is not a contraindication to pregnancy, if blood pressure and ventilation are properly managed. There is no clear evidence that bypass surgery before pregnancy or cesarean mode of delivery improve outcomes.

Interhospital transfers for endovascular thrombectomy (EVT) evaluation have increased since the publication of landmark neuroendovascular stroke trials in 2015. The lack of guidelines to select potential EVT candidates prior to transfer can lead to instances where, despite considerable costs and transport risks, transferred patients do not ultimately undergo EVT. Our aim was to characterize the patterns and identify predictors for EVT on transfer.In this observational cohort study, we retrospectively analyzed patients with acute ischemic stroke (AIS) transferred to our institution for EVT evaluation from January 2015 to March 2016. Clinical and radiographic predictors for EVT on transfer were determined with multivariable logistic regression analysis.A total of 103 transfer patients with AIS were included in the study, and 52% were women. A higher collateral score (P0.01), a higher National Institutes of Health Stroke Scale (NIHSS) score (P0.01), computed tomography angiography (CTA) at referring hospital (P0.01), and large vessel occlusion on arrival CTA (P0.01) were significant in patients who underwent EVT on univariable analysis. More than half (61.1%) of transfers were futile and primarily related to absence of large vessel occlusion on arrival. A higher collateral score (P = 0.02), a higher NIHSS score (P = 0.006), and having undergone a CTA at the referring center (P = 0.002) remained the independent predictors of EVT. The C statistic for the model was 0.94.A higher collateral score, the acquisition of CTA imaging at the referring centers, and a higher NIHSS score independently predicted EVT on transfer.

Background The effect of statins and diabetes on angiographic and clinical outcomes in aneurysms treated with pipelines has not been adequately reported. Our aim is to assess the effect of concurrent statin medications and diabetes mellitus (DM) on aneurysm occlusion status and outcomes in patients treated with the pipeline embolization device. Methods A retrospective review of our institution's database of aneurysms treated with the pipeline embolization device between 2013 and 2017 was conducted. We collected data about statin therapy status and intensity, and identified patients with a documented history of DM. Our primary outcome was aneurysm obliteration seen on digital subtracted angiography or magnetic resonance angiography at last follow-up. Results We identified 151 patients with 182 aneurysms for this cohort, with a median radiographic follow-up time of 7.2 months (6.1–14.5). Thirty-nine patients were taking statins, and 112 patients did not receive statins. Log-rank tests revealed no statistically significant difference in occlusion rates between patients with and without statin therapy (P = 0.30). A history of DM was documented in 11 patients, with 14 aneurysms in total; 140 patients with 168 aneurysms had no history of DM. Similarly, there were no differences in occlusion rates between the diabetic and nondiabetic groups in multivariate analysis (P = 0.24). Only 2 patients showed significant in-stent stenosis on angiographic follow up, and both were diabetic. Conclusions Our analysis did not identify a statistically significant association between statin therapy or DM and higher occlusion rates or better outcomes after pipeline embolization. Diabetic patients may have a theoretic risk of significant in-stent stenosis.

OBJECTIVEThere is currently no standardized follow-up imaging strategy for intracranial aneurysms treated with the Pipeline embolization device (PED). Here, the authors use follow-up imaging data for aneurysms treated with the PED to propose a standardizable follow-up imaging strategy.METHODSA retrospective review of all patients who underwent treatment for ruptured or unruptured intracranial aneurysms with the PED between March 2013 and March 2017 at 2 major academic institutions in the US was performed.RESULTSA total of 218 patients underwent treatment for 259 aneurysms with the PED and had undergone at least 1 follow-up imaging session to assess aneurysm occlusion status. There were 235 (90.7%) anterior and 24 posterior (9.3%) circulation aneurysms. On Kaplan-Meier analysis, the cumulative incidences of aneurysm occlusion at 6, 12, 18, and 24 months were 38.2%, 77.8%, 84.2%, and 85.1%, respectively. No differences in the cumulative incidence of aneurysm occlusion according to aneurysm location (p = 0.39) or aneurysm size (p = 0.81) were observed. A trend toward a decreased cumulative incidence of aneurysm occlusion in patients 70 years or older was observed (p = 0.088). No instances of aneurysm rupture after PED treatment or aneurysm recurrence after occlusion were noted. Sixteen (6.2%) aneurysms were re-treated with the PED; 11 of these had imaging follow-up data available, demonstrating occlusion in 3 (27.3%).CONCLUSIONSThe authors propose a follow-up imaging strategy that incorporates 12-month digital subtraction angiography and 24-month MRA for patients younger than 70 years and single-session digital subtraction angiography at 12 months in patients 70 years or older. For recurrent or persistent aneurysms, re-treatment with the PED or use of an alternative treatment modality may be considered.

Background Vascular compression of the medullary pyramid resulting in neurologic compromise is rare; therefore diagnosis is difficult and ultimately delayed. Most patients present with a combination of cranial nerve, autonomic, and/or motor and sensory dysfunction. Presentation with a single sign such as hemiparesis is rare. The low number of cases reported has made it impossible to define a standard treatment for this unusual disorder. Case Description Here, we present a patient with progressive left hemiparesis due to compression of the upper medulla by the vertebral artery, which was treated with repositioning of the artery using a sling. Clinical and radiologic features including upper medullary compression by the left vertebral artery with effacement of the left medullary pyramid and T2/fluid-attenuated inversion recovery signal changes in the right medulla are illustrated. The patient underwent a standard left retrosigmoid craniectomy for mobilization of the left vertebral artery with a Hemashield (Maquet Cardiovascular, San Jose, California, USA) sling (see video). Postoperatively, the patient had significant improvement of the left hemiparesis and follow-up imaging showed decompression of the medulla with edema reduction. Conclusions Vascular decompression using a sling has proven to be a valuable option for treatment of symptomatic vascular brainstem compression.