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BackgroundAtrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely, AF is not associated with hemorrhagic complications or functional outcomes in patients undergoing mechanical thrombectomy (MT). This differential effect of MT and IVT in AF associated stroke raises the question of whether bridging thrombolysis increases hemorrhagic complications in AF patients undergoing MT.MethodsThis international cohort study of 22 comprehensive stroke centers analyzed patients with large vessel occlusion (LVO) undergoing MT between June 1, 2015 and December 31, 2020. Patients were divided into four groups based on comorbid AF and IVT exposure. Baseline patient characteristics, complications, and outcomes were reported and compared.Results6461 patients underwent MT for LVO. 2311 (35.8%) patients had comorbid AF. In non-AF patients, bridging therapy improved the odds of good 90 day functional outcomes (adjusted OR (aOR) 1.29, 95% CI 1.03 to 1.60, p=0.025) and did not increase hemorrhagic complications. In AF patients, bridging therapy led to significant increases in symptomatic intracranial hemorrhage and parenchymal hematoma type 2 (aOR 1.66, 1.07 to 2.57, p=0.024) without any benefit in 90 day functional outcomes. Similar findings were noted in a separate propensity score analysis.ConclusionIn this large thrombectomy registry, AF patients exposed to IVT before MT had increased hemorrhagic complications without improved functional outcomes, in contrast with non-AF patients. Prospective trials are warranted to assess whether AF patients represent a subgroup of LVO patients who may benefit from a direct to thrombectomy approach at thrombectomy capable centers.

BackgroundPreliminary clinical studies on the safety and efficacy of the pipeline embolization device (PED) for the treatment of small/medium aneurysms have demonstrated high occlusion rates with low complications.ObjectiveTo evaluate the safety and effectiveness of the PED for treatment of wide necked small and medium intracranial aneurysms.MethodsPREMIER is a prospective, multicenter, single arm trial. Patients were treated with the PED for unruptured wide necked aneurysms, measuring ≤12 mm along the internal carotid artery or vertebral artery, between July 2014 and November 2015. At 1 year post-procedure, the primary effectiveness endpoint was complete occlusion (Raymond grade 1) without major parent vessel stenosis (≤50%) or retreatment, and the primary safety endpoint was major stroke in the territory supplied by the treated artery or neurologic death.ResultsA total of 141 patients were treated with PEDs (mean age 54.6±11.3 years, 87.9% (124/141) women). Mean aneurysm size was 5.0±1.92 mm, and 84.4% (119/141) measured ConclusionsTreatment of wide necked small/medium aneurysms with the PED results in high rates of complete occlusion without significant parent vessel stenosis and low rates of permanent neurologic complications.Trial registrationNCT02186561.

Background The Pipeline Embolization Device (PED) has been increasingly used for the treatment of posterior circulation aneurysms. The purpose of the present study was to examine the clinical and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. Methods We performed a retrospective review of vertebrobasilar aneurysms treated with the PED at 4 high-volume neurovascular centers. Patient, aneurysm, and procedural data were collected, including perioperative and delayed complications. Aneurysm occlusion on follow-up imaging studies was defined as complete (100%), near-complete (>90%), or incomplete ( Results The cohort included 35 patients with 37 vertebrobasilar aneurysms who underwent 36 treatment sessions. Of the 35 patients, 10 were men (29%), and the mean patient age was 54.1 years (range, 32–75). Eight patients (23%) underwent urgent treatment because of a ruptured aneurysm (n = 6), brainstem perforator stroke (n = 1), or post-traumatic pseudoaneurysm (n = 1). Of the 37 aneurysms, 22 arose from the vertebral artery (59%) and 15 from the basilar artery (41%). Also, 19 were saccular aneurysms (51%), with a mean size of 7.7 mm (range, 1.7–38.0); 17 were fusiform aneurysms (46%), with a mean size of 11.0 mm (range, 4.3–34); and 1 was a 2.9-mm blister aneurysm. The overall procedural complication rate was 14% (5 of 36), including 3 neurologically symptomatic complications. At a mean follow-up period of 14 months (range, 3–59), 24 of 34 aneurysms (71%) were completely occluded and 29 of 34 (85%) were completely or near-completely occluded. Conclusion Our results show that Pipeline embolization of vertebrobasilar aneurysms is associated with acceptable occlusion and complication rates.

BackgroundThe pipeline embolization device (PED) is approved for the treatment of large aneurysms of the proximal internal carotid artery (ICA). Its off-label application in treating aneurysms located specifically at the ICA terminus (ICA-T) has not been studied.MethodsWe conducted a retrospective chart review of patients from 2011 to 7 treated with PEDs. Out of 365 patients, 10 patients with ICA-T aneurysms were included. Patient demographics, procedural information, follow-up imaging, and clinical assessments were recorded.ResultsMean age was 46.9 years (± 8.8), and 6 (60%) patients were women. The mean maximum diameter of the aneurysms treated was 14.7 mm (± 10.7) and the mean neck diameter was 9.3 mm (± 6.6). Reasons for presentation included six incidental findings, one acute subarachnoid hemorrhage (SAH), and three patients with prior SAH. Kamran–Byrne Occlusion Scale scores for the treated aneurysms were as follows: three class IV (complete obliteration), four class III (ConclusionThe PED has potential for treating ICA-T aneurysms not amenable to conventional treatment strategies. Further studies are warranted to confirm the long term outcomes.

* on behalf of the Stroke Thrombectomy and Aneurysm Registry (STAR) Collaborators Introduction: Intravenous thrombolysis complications are enriched in AF associated stroke, as these patients have worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications. These data suggest that AF patients may be at particularly high risk for complications of bridging therapy for large vessel occlusions treated with mechanical thrombectomy (MT). Here we determine whether clinical outcomes differ in AF associated stroke treated with MT and bridging therapy. Methods: We performed a retrospective cohort study of the Stroke and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4,169 patients who underwent MT for an anterior circulation stroke, 1,517 (36.4 %) of which had comorbid AF. Prospectively defined baseline characteristics and clinical outcomes were compared. Results: Hemorrhagic complications after MT were similar in patients with or without AF. In patients without AF, bridging therapy improved 90-day outcomes (aOR 1.32, 1.02-1.74, p Conclusions: Bridging therapy in AF patients undergoing thrombectomy independently increased the odds of intracranial hemorrhage and did not improve functional outcomes. AF patients may represent a high-risk subgroup for thrombolytic complications. Randomized trials are warranted to determine whether patients with AF associated stroke may benefit by deferring bridging therapy at thrombectomy-capable centers.

Background The Woven EndoBridge (WEB) device was granted premarket approval in the United States following results of the Woven EndoBridge Intrasaccular Therapy (WEB-IT) study. WEB-IT reported excellent adequate angiographic occlusion of treated aneurysms with a high safety profile. These results were achieved, however, in the context of a prospective study with strict inclusion criteria and rigorous training support. Objective To review early as-practiced clinical experience with the WEB device in the United States. Methods Retrospective review across 6 institutions identified 91 patients undergoing 92 treatment sessions for WEB device placement in treatment of 91 intracranial aneurysms. Details regarding demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed in a multicenter database. Angiograms from the index procedure and follow-up studies were reviewed by a blinded and independent adjudicator. Results The middle cerebral, anterior communicating, and basilar artery complexes were the commonly treated locations. Eight patients presented with ruptured aneurysms. A mean of 1.2 devices were introduced per case. Technical failure without deployment of a WEB device occurred in 2% (2/92) of sessions. Adequate aneurysm occlusion for patients with imaging follow-up was 49% (mean follow-up of 8 mo). Four aneurysms were retreated. 90% of patients had modified Rankin Scale ≤ 2 at last clinical follow-up with no mortalities. Conclusion Immediate postmarket experience with the WEB device, newly introduced at American centers, confirms safe procedural use, but long-term efficacy remains unclear. Early challenges include accurate sizing and device selection.

OBJECTIVE Cerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, the authors describe their experience with intrathecal (IT) nicardipine for this indication. METHODS Patients admitted to the Emory University Hospital neuroscience ICU between 2012 and 2017 with nontraumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Using a propensity-score model, this patient cohort was compared to patients in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository who did not receive IT nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events. RESULTS The analysis included 1351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n = 859), the treated group was significantly younger (mean age 51.1 ± 12.4 years vs 56.7 ± 14.1 years, p < 0.001), had a higher World Federation of Neurosurgical Societies score and modified Fisher grade, and were more likely to undergo clipping of the ruptured aneurysm as compared to endovascular treatment (30.3% vs 11.3%, p < 0.001). Treatment with IT nicardipine decreased the daily mean transcranial Doppler velocities in 77.3% of the treated patients. When compared to patients not receiving IT nicardipine, treatment was not associated with an increased rate of bacterial ventriculitis (3.1% vs 2.7%, p > 0.1), yet higher rates of ventriculoperitoneal shunting were noted (19.9% vs 8.8%, p < 0.01). In a propensity score comparison to the SAHIT database, the odds ratio (OR) to develop DCI with IT nicardipine treatment was 0.61 (95% confidence interval [CI] 0.44–0.84), and the OR to have a favorable functional outcome (modified Rankin Scale score ≤ 2) was 2.17 (95% CI 1.61–2.91). CONCLUSIONS IT nicardipine was associated with improved outcome and reduced DCI compared with propensity-matched controls. There was an increased need for permanent CSF diversion but no other safety issues. These data should be considered when selecting medications and treatments to study in future randomized controlled clinical trials for SAH.

Background and PurposeCerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, we describe our experience with intrathecal (IT) nicardipine for this indication.MethodsPatients admitted to Emory University Hospital Neuroscience ICU between 2012-2017 with non-traumatic SAH, either aneurysmal or idiopathic, were included in the analysis. This patient cohort was compared using a propensity-score model to patients in the SAH international trialist (SAHIT) repository who did not receive intrathecal nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events.ResultsThe analysis included 1,351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n=859) the treated group was younger (51.1±12.4 vs. 56.7±14.1, p0.1) yet higher rates of VP shunting were noted (19.9% vs. 8.8%, pConclusionsIT nicardipine was associated with improved outcome and reduced DCI compared with propensity matched controls. There was an increased need for permanent CSF diversion but no other safety issues. This data should be considered when selecting medications and treatments to study in future randomized controlled clinical trial for SAH.

BackgroundRuptured aneurysms of the intracranial vertebral artery (VA) or posterior inferior cerebellar artery (PICA) are challenging to treat as they are often dissecting aneurysms necessitating direct sacrifice of the diseased segment, which is thought to carry high morbidity due to brainstem and cerebellar stroke. However, relatively few studies evaluating outcomes following VA or proximal PICA sacrifice exist. We sought to determine the efficacy and outcomes of endovascular VA/PICA sacrifice.MethodsA retrospective series of ruptured VA/PICA aneurysms treated by endovascular sacrifice of the VA (including the PICA origin) or proximal PICA is reviewed. Collected data included demographic, radiologic, clinical, and disability information.ResultsTwenty-one patients were identified. Median age was 57 years (IQR 11); 15 were female. The Hunt and Hess grade was mostly 3 and 4 (18/21). Seven cases (33%) involved VA-V4 at the PICA take-off, and 14 cases (67%) involved the PICA exclusively. For VA pathology, V4 was sacrificed in all cases, while for PICA pathology, sacrificed segments included anterior medullary (4/14), lateral medullary (7/14), and tonsillomedullary (3/14) segments. Four patients went to hospice (19%). Twelve patients (57%) had evidence of stroke on follow-up imaging: cerebellar (8), medullary (1), and both (3). One patient required suboccipital decompression for brainstem compression. No aneurysm re-rupture occurred. Median discharge modified Rankin Scale score was 2.0 (IQR 2), which decreased to 1.0 (IQR 1) at median follow-up of 6.5 months (IQR 23).ConclusionsEndovascular sacrifice of V4 or PICA aneurysms may carry less morbidity than previously thought, and is a viable alternative for poor surgical candidates or those with good collateral perfusion.

BackgroundAtrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT).ObjectiveTo determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT.MethodsWe performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared.ResultsAF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (pConclusionsIn patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.

Background Flow diversion of posterior cerebral artery (PCA) aneurysms has not been widely reported, possibly owing to concerns regarding parent vessel size and branch vessel coverage. Objective To examine the safety and effectiveness of PCA aneurysm flow diverter treatment. Methods Retrospective review of PCA aneurysms treated with the Pipeline Embolization Device (PED; Medtronic Inc, Dublin, Ireland) at 3 neurovascular centers, including periprocedural complications and clinical and angiographic outcomes. Systematic review of the literature identified published reports of PCA aneurysms treated with flow diversion. Rates of aneurysm occlusion and complications were calculated, and outcomes of saccular and fusiform aneurysm treatments were compared. Results Ten PCA aneurysms in 9 patients were treated with the PED. There were 2 intraprocedural thromboembolic events (20%), including 1 symptomatic infarction and 1 delayed PED thrombosis. Eight of 10 patients returned to or improved from their baseline functional status. Complete aneurysm occlusion with parent vessel preservation was achieved in 75% (6/8) of cases at mean follow-up of 16.7 mo. Eleven of 12 (92%) major branch vessels covered by a PED remained patent. Including the present study, systematic review of 15 studies found a complete aneurysm occlusion rate of 88% (30/34) and complication rate of 26% (10/38), including 5 symptomatic ischemic strokes (13%; 5/38). Fusiform aneurysms more frequently completely occluded compared with saccular aneurysms (100% vs 70%; P = .03) but were associated with a higher complication rate (43% vs 9%; P = .06). Conclusion The safety and effectiveness profile of flow diverter treatment of PCA aneurysms may be acceptable in select cases.

Background Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). Objective To determine the safety and efficacy of MMA embolization. Methods Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. Results A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. Conclusion MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.

BACKGROUND Computerized tomography angiography (CTA) is commonly used to diagnose ruptured cerebral aneurysms with sensitivities reported as high as 97% to 100%. Studies validating CTA accuracy in the setting of subarachnoid hemorrhage (SAH) are scarce and limited by small sample sizes. OBJECTIVE To evaluate the diagnostic accuracy of CTA in detecting intracranial aneurysms in the setting of SAH. METHODS A single-center, retrospective cohort of 643 patients was reviewed. A total of 401 patients were identified whose diagnostic workup included both CTA and confirmatory digital subtraction angiography (DSA). Aneurysms missed by CTA but diagnosed by DSA were further stratified by size and location. RESULTS Three hundred and thirty aneurysms were detected by CTA while DSA detected a total of 431 aneurysms. False positive CTA results were seen for 24 aneurysms. DSA identified 125 aneurysms that were missed by CTA and 83.2% of those were

BACKGROUND: There are limited data on outcomes of extracranial-intracranial (EC-IC) bypass in patients with recurrent hemispheric syndromes due to atherosclerotic internal carotid artery occlusion (AICAO). OBJECTIVE: To compare clinical outcomes and efficacy of EC-IC bypass surgery in patients with and without recurrent hemispheric syndromes associated with AICAO in the Carotid Occlusion Surgery Study (COSS). METHODS: In patients enrolled in the COSS trial, we compared baseline characteristics and clinical outcomes for participants with (rHEMI+) and without recurrent hemispheric ischemia (rHEMI−) prior to randomization into surgical vs medical groups. The primary outcome was all stroke and death from randomization through 30 d and ipsilateral ischemic stroke within 2 yr. RESULTS: Of 195 randomized participants, 100 were rHEMI+ (50 in each group). Baseline characteristics between rHEMI+ and rHEMI− participants were similar except rHEMI+ were more likely to have had previous stroke prior to randomization (61% vs 20%, P

BACKGROUND Though the Pipeline Embolization Device (Medtronic) is approved for use in adults 22 yr and older, the high efficacy and long-term durability of the device is attractive for treatment of intracranial aneurysms in younger patients who often have aneurysms less amenable to traditional endovascular treatments. OBJECTIVE To report technical, angiographic, and clinical outcomes in patients aged 21 or below undergoing flow-diversion treatment for intracranial aneurysms. METHODS Retrospective review across 16 institutions identified 39 patients aged 21 or below undergoing 46 treatment sessions with Pipeline Embolization Device placement between 2012 and 2018. A total of 50 intracranial aneurysms were treated. Details regarding patient demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed in a multicenter database. RESULTS A total of 70% of patients were male. Nonsaccular morphology was seen in half of identified aneurysms. Six aneurysms were giant, and five patients were treated acutely after ruptured presentation. Eight patients were younger than 10 yr of age. Complete aneurysm occlusion was seen in 74% of treated aneurysms. Three aneurysms (6%) were retreated. A total of 83% of patients had a modified Rankin Scale scores of ≤2 at last clinical follow-up. There were 2 early mortalities (4.3%) in the immediate postprocedure period because of rerupture of a treated ruptured aneurysm. No recanalization of a previously occluded aneurysm was observed. CONCLUSION Flow-diversion treatment is a safe and effective treatment for intracranial aneurysms in patients younger than 22 yr. Rates of complete aneurysm occlusion and adverse events are comparable for rates seen in older patients.

The video highlights a challenging case of bilateral vertebral artery dissection presenting with subarachnoid hemorrhage. The patient was found to have a critical flow-limiting stenosis in his dominant right vertebral artery and a ruptured pseudoaneurysm in his left vertebral artery. A single-stage endovascular treatment with stent reconstruction of the right vertebral artery and coil embolization sacrifice of the left side was performed. The case highlights the rationale for treatment and potential alternative strategies.The video can be found here: https://youtu.be/e0U_JE2jISw.

BackgroundThe off-label use of flow diverters in the treatment of distal aneurysms continues to be debated.ObjectiveTo report our multicenter experience in the treatment of complex anterior cerebral artery aneurysms with the Pipeline embolization device (PED).MethodsThe neurointerventional databases of the four participating institutions were retrospectively reviewed for aneurysms treated with PED between October 2011 and January of 2016. All patients treated for anterior cerebral artery aneurysms were included in the analysis. Clinical presentation, location, type, vessel size, procedural complications, clinical and imaging follow-up were included in the analysis.ResultsTwenty patients (13 female) with 20 aneurysms met the inclusion criteria in our study. Fifteen aneurysms were classified as saccular and five as fusiform (mean size 7.3 mm). Thirteen aneurysms were located in the anterior communicating region (ACOM or A1/2 junction), six were A2-pericallosal, and one was located in the A1 segment. Six patients had presented previously with subarachnoid hemorrhage and had their aneurysms initially clipped or coiled. There was one minor event (a small caudate infarct) and one major event (intraparenchymal hemorrhage). Sixteen of the 20 patients had angiographic follow-up (mean 10 months). Eleven aneurysms were completely occluded, one had residual neck, and four had residual aneurysm filling.ConclusionsThe treatment of complex anterior cerebral artery aneurysms with the PED as an alternative for patients who are not good candidates for conventional methods is technically feasible and safe. Mid-term results are promising but larger series with long-term follow-up are required to assess its effectiveness.

Background Previous studies have attempted to determine the best treatment for oculomotor nerve palsy (ONP) secondary to posterior communicating artery (PCoA) aneurysms, but have been limited by small sample sizes and limited treatment. Objective To analyze the treatment of ONP secondary to PCoA with both coiling and clipping in ruptured and unruptured aneurysms. Methods Data from 2 large academic centers was retrospectively collected over 22 years, yielding a total of 93 patients with ONP secondary to PCoA aneurysms. These patients were combined with 321 patients from the literature review for large data analyses. Onset symptoms, recovery, and time to resolution were evaluated with respect to treatment and aneurysm rupture status. Results For all patients presenting with ONP (n = 414) 56.6% of those treated with microsurgical clipping made a full recovery vs 41.5% of those treated with endovascular coil embolization (P = .02). Of patients with a complete ONP (n = 229), full recovery occurred in 47.3% of those treated with clipping but in only 20% of those undergoing coiling (P = .01). For patients presenting with ruptured aneurysms (n = 130), full recovery occurred in 70.9% compared with 49.3% coiled patients (P = .01). Additionally, although patients with full ONP recovery had a median time to treatment of 4 days, those without full ONP recovery had a median time to treatment of 7 days (P = .01). Conclusion Patients with ONP secondary to PCoA aneurysms treated with clipping showed higher rates of full ONP resolution than patients treated with coil embolization. Larger prospective studies are needed to determine the true potential of recovery associated with each treatment. Abbreviations EUH, Emory University HospitalIQR, interquartile rangeJHU, Johns Hopkins UniversitymRS, modified Rankin ScaleONP, oculomotor nerve palsyPCoA, posterior communicating arterySAH, subarachnoid hemorrhage.

Background Since its introduction in the early 1990s, endovascular treatment of cerebral aneurysms has had a steady upward trend and is the primary mode of treatment for most intracranial aneurysms. Concurrently, the need for retreatment of aneurysms after previous endovascular treatment has continued to increase, some of which can only be treated with microsurgical techniques. The factors that dictate outcomes in this group of patients are incompletely understood. Objective To study factors contributing to patient outcomes after microsurgical treatment of aneurysms with previous endovascular treatment. Methods The records of the senior author (D.L.B.) since 2002 were retrospectively reviewed for aneurysms treated after previous endovascular treatment. Demographics, treatment details, and imaging were reviewed for all patients. A systematic review of the literature on microsurgical treatment of aneurysms previously treated by endovascular therapy was also conducted. Results A total of 91 patients were identified from the retrospective review. Mean age at the time of initial treatment was 49 ± 12.68 years. Most patients initially presented with subarachnoid hemorrhage before initial endovascular treatment, with only 11 patients (12%) presenting with incidentally discovered lesions. Modified Rankin Scale score at discharge after initial treatment was good (0–3) in 81.4% of cases. Functional outcomes at the last known follow-up showed a modified Rankin Scale score of 0–3 in 77 patients (84.6%). Only aneurysm neck size was found to be a significant predictor of surgical complications (Wald χ2 = 10.79; P = 0.0010) with an odds ratio of 2.32 (95% confidence interval, 1.40–3.83) for a 2-mm increase in neck size. Systematic review identified 37 studies who were used to pool data on 370 patients. Although type of surgery was identified as a predictor of poor outcomes, this was significantly confounded by Hunt and Hess grade in the systematic review. Conclusions Favorable outcomes can be obtained even for highly complex cerebral aneurysms that have failed endovascular treatment at high-volume cerebrovascular centers. Initial presentation grade and aneurysm size are important predictors of final patient outcomes.

BackgroundAneurysmal subarachnoid hemorrhage is a potentially devastating condition, and among the first priorities of treatment is aneurysm occlusion to prevent re-hemorrhage. An emerging strategy to treat patients whose aneurysms are not ideal for surgical or endovascular treatment is subtotal coiling followed by flow diversion in the recovery phase or ‘plug and pipe’. However, data regarding the safety and efficacy of this strategy are lacking.MethodsA retrospective cohort study was performed to evaluate the efficacy and safety of ‘plug and pipe’. All patients with a ruptured intracranial aneurysm intentionally, subtotally treated by coiling in the acute stage followed by flow diversion after recovery, were included. The primary outcome was re-hemorrhage. Secondary outcomes included aneurysm occlusion and functional status. Complications were reviewed.Results22 patients were included. No patient suffered a re-hemorrhage, either in the interval between coiling and flow diversion or in follow-up. The median interval between aneurysm rupture and flow diversion was 3.5 months. Roy–Raymond (R-R) class I or II occlusion was achieved in 91% of target aneurysms at the last imaging follow-up (15/22(68%) R-R 1 and 5/22(23%) R-R 2). Complications occurred in 2 (9%) patients, 1 of which was neurological.ConclusionsOverall, these data suggest that subtotal coiling of ruptured intracranial aneurysms followed by planned flow diversion is both safe and effective. Patients who may most benefit from ‘plug and pipe’ are those with aneurysms that confer high operative risk and those whose severity of medical illness increases the risk of microsurgical clip ligation.

Background: There are limited data on the baseline characteristics and clinical outcomes of patients who have recurrent hemispheric syndromes in the territory of symptomatic atherosclerotic internal carotid artery occlusion (AICAO). Methods: Baseline characteristics and clinical outcomes were compared between patients with (rHEM+) and without (rHEM-) recurrent ipsilateral hemispheric syndromes at the time of randomization into the Carotid Occlusion Surgery Study (COSS) based on local investigator clinical impression. Results: Of 195 participants who were randomized, 100 (51%) were rHEM+ (50 in each study arm) and 95 were rHEM-(48 nonsurgical, 47 surgical). Baseline characteristics between rHEM+ and rHEM- participants were similar except that rHEM+ participants were more likely to have had a previous stroke prior to entry event (59% vs 22%, p < 0.001) and to have had TIA vs stroke as the entry event (61% vs 20%, p 0.10). For the nonsurgical participants, there was no statistically significant difference in the primary endpoint for those rHEM+ vs rHEM- (26.3% vs 18.9%, p=.410) Conclusion: Patients with recurrent hemispheric stroke syndromes enrolled in the COSS trial were more likely to have had previous stroke and to have TIAs as the entry event to randomization. Given the lack of surgical treatment benefit seen in these patients, early aggressive risk factor measures should be prioritized to reduce recurrent strokes, including blood pressure control which was associated with a 70% reduction in stroke in the nonsurgical group in COSS ( Neurology 2014; 82:1027-1032).

BackgroundAdministration of ε-aminocaproic acid (εACA), as adjuvant therapy following incompletely embolized cranial dural arteriovenous (dAVFs) and direct carotid artery to cavernous sinus fistulae (CCFs), is a strategy to promote post-procedural thrombosis. However, the efficacy of εACA to treat incompletely obliterated dAVFs and CCFs has not been published. The purpose of this study was to determine if administration of εACA following incomplete embolization of cranial dAVFs or CCFs was associated with an increased likelihood of cure on follow-up imaging compared with patients not given adjuvant εACA.MethodsA retrospective cohort study was performed. All patients who underwent treatment of a dAVF or CCF at our institution between 1998 and 2016 were reviewed (n=262). Patients with residual shunting following the first attempted endovascular embolization were included in the analysis (n=52). The study groups were those treated with εACA following incomplete obliteration of the fistula and those who were not. The primary outcome was obliteration of the fistula on initial follow-up imaging. Complication rates between cohorts were compared.Results20 (38%) patients with incompletely obliterated fistulae were treated with adjuvant εACA. A trend towards an improved rate of complete obliteration on initial follow-up imaging was observed in the group treated with εACA (55% vs 34% in the group not treated with εACA, p=0.14). No difference in clinical outcomes or thromboembolic complications was observed between the groups.ConclusionsIn summary, these data suggest that administration of εACA is a safe adjuvant therapy in the management of cranial dAVFs and CCFs that are incompletely treated endovascularly.

The presented case is of a 65-yr-old gentleman referred for thoracic myelopathy. He developed bilateral, nondermatomal foot dysesthesia 14 mo prior to presentation, which progressed to numbness below the L3 level. He reported progressive gait instability, bilateral lower extremity weakness, and required a cane for ambulation. He subsequently developed urinary incontinence, while bowel function was spared. The neurological examination upon presentation revealed lower extremity strength was reduced to 4/5 in all major muscle groups bilaterally, while sensation and proprioception were reduced below the L3 level. Patellar and Achilles reflexes were not elicited and clonus was absent. Gait was unsteady and slow. The patient was not able to perform heel, toe and tandem gait. MRI revealed abnormal T2 hyper-intense signal and spinal cord expansion from T6 through the conus medullaris. Angiography revealed a dural arteriovenous fistula (dAVF) originating from the left T9 radicomedullary pedicle, which also supplied the Artery of Adamkiewicz (AoA). The patient underwent T8-10 laminectomies. Prior to disconnection of the fistula, an aneurysm clip was applied to the fistulous point and an indocyanine green video angiogram was completed to show that the fistula no longer opacified, but that the AoA remained patent, which was later confirmed with angiography. As of discharge, the patient's motor exam had improved substantially, though his sensory deficits persisted. This case demonstrates that surgical disconnection is requisite in the treatment of spinal dAVF that have a shared blood supply with the AoA, as embolization risks spinal cord infarction. The patient consented to presentation of this case in a de-identified fashion.

Background Pericallosal, or A2 bifurcation, aneurysms are an infrequently encountered cause of subarachnoid hemorrhage (SAH). While the International Subarachnoid Aneurysm Trial showed improved outcomes for patients with any ruptured anterior circulation aneurysm treated with embolization, there was also a higher recurrence rate for embolized aneurysms. Notably, there were relatively few pericallosal aneurysms. Objective Specific analysis of pericallosal aneurysms may help guide therapeutic decisions. Methods Retrospective analysis of patients who presented with proven saccular pericallosal aneurysms was performed at two institutions from 1999 to 2009. Patients were stratified according to presentation Hunt and Hess grades and modified Fisher scores, treatment modality and outcomes as well as development of vasospasm, hydrocephalus and required treatment. Results Eighty-eight patients with pericallosal aneurysms were identified. Sixty-two presented with SAH and 26 in elective fashion, 2 of whom had a prior history of SAH. Fifty-four patients underwent microsurgical repair and 32 endovascular repair. Patients presenting with SAH due to pericallosal aneurysm treated with an endovascular approach were more likely to have a good modified Rankin scale (mRS) (mRS 0–2 vs 3–6) (p=0.028), to make a complete recovery (mRS=0) (p=0.017) and were less likely to die (mRS=6) (p=0.026). Patients with electively treated pericallosal aneurysms did not have statistically significant differences in outcome between surgical and endovascular cohorts. Differences in secondary endpoints did not reach significance. Conclusion Patients with ruptured pericallosal aneurysms fare better with endovascular therapy, with better chance of complete recovery. Surgical and endovascular treatments of unruptured pericallosal aneurysms have similar results and outcome.

To identify prognostic factors for vasospasm, hydrocephalus, and clinical outcomes in patients with angiographically negative, non-traumatic, diffuse subarachnoid hemorrhage (d-SAH). Retrospective review of patients who experienced angiographically negative SAH at our institution over the past 6 years was undertaken. The patients were stratified based on grade at presentation, severity, and pattern of SAH on initial non-enhanced, computed tomography (CT) of the head into perimesencephalic and diffuse subtypes. The patients were further differentiated based on the development of vasospasm, hydrocephalus and required treatments, and clinical outcomes. Patients were excluded if a causative lesion was discovered subsequently. Ninety-four patients with angiographically negative SAH were identified. A total of 31 patients were considered to have the perimesencephalic (p-SAH) subtype, while 63 patients fit criteria for the diffuse (d-SAH) subtype. Compared to the p-SAH subtype, those patients with d-SAH subtype had significantly higher risk for complications related to SAH with an increased incidence of hydrocephalus (50.8% vs. 9.6%), requirement for external ventricular drainage (41% vs. 9.6%), and for the hydrocephalus requiring eventual permanent cerebrospinal fluid diversion (20.6% vs. 0%). Patients with d-SAH were also at an increased risk for symptomatic vasospasm (28.6% vs. 9.6%). Ultimately, only 76% of d-SAH patients achieved complete recovery and independent living, compared to 96.7% of p-SAH patients. The angiographically negative d-SAH pattern is associated with worse presentations and outcome. These patients are at increased risk for vasospasm and hydrocephalus requiring aggressive treatment and should therefore be cared for with a higher level of surveillance.

OBJECTIVE Tentorial dural arteriovenous malformations (DAVMs) are uncommon lesions associated with an aggressive natural history. Controversy exists regarding their optimal treatment. We present a single-institution series of tentorial DAVMs treated during a 12-year period, address the current controversies, and present the rationale for our current therapeutic strategy. METHODS Twenty-two patients with tentorial DAVMs were treated between 1988 and 2000. Treatment consisted of transarterial or transvenous embolization, surgical resection, disconnection of venous drainage, or a combination of these therapies. The clinical presentations, radiological features, treatment strategies, and results were studied. RESULTS Eighteen patients (82%) presented with intracranial hemorrhage or progressive neurological deficits. Retrograde leptomeningeal venous drainage was documented in 22 cases (100%), classifying the lesions as Borden Type III. Angiographic follow-up monitoring was performed for 0 to 120 months and clinical follow-up monitoring for 1 to 120 months. Posttreatment angiography demonstrated obliteration in 22 cases (100%). Two patients experienced neurological decline after endovascular treatment and died. All of the 20 surviving patients exhibited clinical improvement; there were no episodes of rehemorrhage or new neurological deficits. Outcomes were excellent in 17 cases (77%), good in 2 cases (9%), and fair in 1 case (5%), and there were 2 deaths (9%). CONCLUSION Tentorial DAVMs are aggressive lesions that require prompt total angiographic obliteration. Disconnection of the venous drainage from the fistula may be accomplished with transarterial embolization to the venous side, transvenous embolization, or surgical disconnection of the fistula. We think that extensive nidal resections carry more risk and are unnecessary. We do not think there is a role for stereotactic radiosurgery in the treatment of these lesions.

Object. Indications for intraoperative angiography during aneurysm surgery remain unclear. To define its use, the authors report the results of a prospective study in which this modality was used in all patients undergoing surgery for intracranial aneurysms. Methods. Intraoperative angiography was performed prospectively in the surgical treatment of 517 consecutive aneurysms regardless of the lesion's location, size, or complexity. In 64 (12.4%) of 517 aneurysms intraoperative angiography findings prompted a change in surgical treatment. Residual aneurysm (47%) was the most frequent finding leading to clip revision. In 44% of cases, intraoperative angiography revealed vessel compromise. Surgery for aneurysms of the proximal internal carotid artery (ICA) was the most frequently altered, with lesions located at the superior hypophyseal artery (SHA) and clinoidal region having the highest revision rates, eight (40%) of 20 and eight (44%) of 18, respectively. Aneurysm size predicted the need for revision; giant aneurysms (> 24 mm) underwent revision in nine (29%) of 31 cases, whereas large aneurysms (15–24 mm) were revised in 12 (22%) of 54 cases. In a multivariate logistic regression model, factors related to increased revision rates included the SHA and clinoidal locations, as well as giant and large size. Ninety-five patients underwent both intraoperative and postoperative angiography. Five discrepancies were noted (95% accuracy); four were flow-related and one involved a previously unrecognized residual aneurysm. Complications attributable to intraoperative angiography occurred in 0.4% of cases. Conclusions. Proximal ICA location and large aneurysm size significantly predicted revision of surgery following intraoperative angiography. Unexpected findings, even in less complex locations, are frequently identified on intraoperative angiography. Low complication rates, high accuracy, and the unexpected need for clip readjustments favor a more widespread use of intraoperative angiography.

PurposeThe pipeline embolization device (PED) necessitates dual antiplatelet therapy (APT) to decrease thrombotic complications while possibly increasing bleeding risks. The role of APT dose, duration, and response in patients with hemorrhagic and thromboembolic events warrants further analysis.MethodsA PubMed and Google Scholar search from 2009 to 2014 was performed using the following search terms individually or in combination: pipeline embolization device, aneurysm(s), and flow diversion, excluding other flow diverters. Review of the bibliographies of the retrieved articles yielded 19 single and multicenter studies. A statistical meta-analysis between aspirin (ASA) dose (low dose ≤160 mg, high dose ≥300 mg), loading doses of APT agents, post-PED APT regimens, and platelet function testing (PFT) with hemorrhagic or thrombotic complications was performed.ResultsASA therapy for ≤6 months post-PED was associated with increased hemorrhagic events. High dose ASA ≤6 months post-PED was associated with fewer thrombotic events compared with low dose ASA. Post-PED clopidogrel for ≤6 months demonstrated an increased incidence of symptomatic thrombotic events. Loading doses of ASA plus clopidogrel demonstrated a decreased incidence of permanent symptomatic hemorrhagic events. PFT did not show a statistically significant relationship with symptomatic hemorrhagic or thrombotic complications.ConclusionsHigh dose ASA >6 months is associated with fewer permanent thrombotic and hemorrhagic events. Clopidogrel therapy ≤6 months is associated with higher rates of thrombotic events. Loading doses of ASA and clopidogrel were associated with a decreased incidence of hemorrhagic events. PFT did not have any significant association with symptomatic events.

Dural arteriovenous fistulas are abnormal connections of dural arteries to dural veins or venous sinuses originating from within the dural leaflets. They are usually located near or within the wall of a dural venous sinus that is frequently obstructed or stenosed. The dural fistula sac is contained within the dural leaflets, and drainage can be via a dural sinus or retrograde through cortical veins (leptomeningeal drainage). Dural arteriovenous fistulas can occur at any dural sinus but are found most frequently at the cavernous or transverse sinus. Leptomeningeal venous drainage can lead to venous hypertension and intracranial hemorrhage. The various treatment options include transarterial and transvenous embolization, stereotactic radiosurgery, and open surgery. Although many of the advances in dural arteriovenous fistula treatment have occurred in the endovascular arena, open microsurgical advances in the past decade have primarily been in the tools available to the surgeon. Improvements in microsurgical and skull base approaches have allowed surgeons to approach and obliterate fistulas with little or no retraction of the brain. Image-guided systems have also allowed better localization and more efficient approaches. A better understanding of the need to simply obliterate the venous drainage at the site of the fistula has eliminated the riskier resections of the past. Finally, the use of intraoperative angiography or indocyanine green videoangiography confirms the complete disconnection of fistula while the patient is still on the operating room table, preventing reoperation for residual fistulas.

Object. A canine craniotomy model was used to evaluate the dural sealing efficacy and biocompatibility of a novel, synthetic, bioresorbable hydrogel. Methods. Bilateral craniotomies were performed in 24 dogs assigned to six survival periods. In each animal a parasagittal durotomy was created and then repaired. At the treatment sites the hydrogel sealant was applied over the dural repair and photopolymerized. The repair was tested for leaks to 20 cm H2O by using a Valsalva maneuver. At the control sites the incisions were sutured and tested for leaks only. After uneventful survival periods, the leak test was repeated in three of the four animals in each group. Bone—dura adhesion was evaluated, after which the dura and underlying brain were removed, fixed, and examined histologically. En bloc histological investigation was performed on a specimen obtained from the fourth animal in each group. Over a 56-day period, 18 treated sites were tested for leaks. A leak was detected at a site remote from that of the repair in one animal; this was excluded from analysis. Thus 17 of 17 treated sites remained free of leaks. On the control side of one animal, there was a leak from a new dural tear at the cranial end of the durotomy, which occurred when the bone flap was removed. This site was also excluded from analysis. Eleven of 17 leak-tested control sites remained free of leaks over the study period. Bone—dura adhesions occurred in 15 of 19 control sites and had a mean adhesion score of 1.37 (range 0–4), whereas adhesions occurred in 10 of 19 treated sites with a mean adhesion score of 0.84 (range 0–3). No cortical reaction was noted. Conclusions. This novel hydrogel sealant is efficacious in sealing dural repair sites measuring up to 2 mm. Healing of the underlying dura is not compromised and exposed cortical tissue is not altered histologically.

Background:ε-Aminocaproic acid (EACA) has been used to reduce the rate of cerebral aneurysm rerupture before definitive treatment. In centers administering EACA to patients with a subarachnoid hemorrhage (SAH), patients eventually diagnosed with angiographically negative subarachnoid hemorrhage (ANSAH) may also initially receive EACA, perhaps placing them at increased risk for ischemic complications.Objective:To evaluate the effect of short-term EACA on outcomes and secondary measures in patients with ANSAH.Methods:We conducted a retrospective study of 454 consecutive SAH patients over a 2-year period under a current protocol for EACA use. Patients were excluded if a source for the SAH was discovered, yielding a total of 83 ANSAH patients. The patients were assigned to groups that did or did not receive EACA. The primary end points of the study were ischemic complications, pulmonary emboli, vasospasm, ventriculoperitoneal shunting rates, and outcomes.Results:Statistical analysis yielded no significant difference between the 2 arms with respect to any of the end points: vasospasm (P = .65), deep vein thrombosis (P = .51), pulmonary embolism (P = 1.0), stroke (P = 1.0), myocardial infarction (P = 1.0), and ventriculoperitoneal shunt (P = .57). There was no statistically significant outcome difference using the modified Rankin Scale (P = .30).Conclusion:Short-term (

Background: There are limited data on the effect of an early aggressive risk factor modification program to achieve risk factor targets and its impact on clinical outcomes among patients with symptomatic intracranial stenosis. Methods: We prospectively identified patients with symptomatic intracranial stenosis of 50% to 99% (using computed tomographic angiography or cerebral angiography) who failed to qualify for or declined to participate in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis trial but elected to receive aggressive medical management. Aggressive medical management was defined as aspirin plus clopidogrel therapy for a minimum of 3 months, blood pressure control, statin use with a low-density lipoprotein (LDL) goal of ,70 mg/dL, smoking cessation, and body mass index ,25 kg/m 2 . Results: Of 22 patients, the mean age was 65.6 6 7.7 years, 82% were male, 59% were white, and mean percent stenosis was 71.5 6 9.5% (55% with 70% to 99% stenosis). Median time from symptomatic event to first evaluation was 3 days. All patients completed 3 months of dual antiplatelet therapy, and at last follow-up, 86% had met their blood pressure goal, all were on statin therapy although only 73% had met their LDL goal, 96% reported no active tobacco use, and 36% had lost weight, but only 23% had achieved the BMI target. Over a mean follow-up of 1.2 years, there was no ischemic stroke, brain hemorrhage, or death from other vascular causes. Conclusions: An early aggressive risk factor modification program achieved high levels of blood pressure and cholesterol targetsforpatients withsymptomatic intracranial stenosis and when combinedwith dual antiplatelet therapy was effective for the prevention of recurrent vascular

BACKGROUND: Antithrombotic states are encountered frequently, either because of medical therapy or by preexistent pathological states, and may affect the severity of hemorrhagic strokes such as angiographically negative subarachnoid hemorrhages. OBJECTIVE: To determine the effects of antithrombotic states on the outcomes of patients with angiographically negative subarachnoid hemorrhage by examining data pooled from 2 institutions. METHODS: This is a retrospective review of patients who experienced angiographically negative subarachnoid hemorrhage at 2 institutions over the past 5 years. The patients were grouped into those with and those without an antithrombotic state at time of hemorrhage and were stratified according to presentation, clinical grades, outcomes, need for cerebrospinal fluid diversion, and development of vasospasm. Computed tomography of the head was assessed for bleed pattern and modified Fisher grade. Patients were excluded if a causative lesion was subsequently discovered. RESULTS: There is a statistically significant association between antithrombotic states and poorer presentation, higher Hunt and Hess score, increased amount of subarachnoid hemorrhage, higher modified Fisher grade, increased incidence of vasospasm, hydrocephalus, and poor outcomes as assessed by modified Rankin scale (P < .001). Patients with an antithrombotic state experience worse outcomes even with adjustment for the amount of hemorrhage as assessed by modified Fisher grade (P < .001). CONCLUSION: Patients in an antithrombotic state presenting with angiographically negative subarachnoid hemorrhage present with inferior clinical scores, diffuse hemorrhage patterns, and worse modified Fisher grades and have worse outcomes.

The advent of endovascular therapy for intracranial aneurysms and the rapid advances in that field have supplanted microsurgical treatment for many intracranial aneurysms. Applying current outcome data and other parameters, nuances of selecting the modality of treatment for intracranial aneurysms are reviewed. Patient factors, such a age, co-morbidities, vasospasm and other medical conditions, are addressed. A custom-tailored multimodality treatment paradigm for the management of ruptured and unruptured aneurysms will maximize the favorable results seen in this difficult patient population.

Background Mechanical thrombectomy devices rely on the ability of an operator to directly access a thrombus with the device. The authors demonstrate the first reported posterior-to-anterior circulation approach using the Penumbra Stroke System (Penumbra, Inc, Alameda, CA) for thrombectomy in acute stroke. Case Description A 53-year–old man presented 5 hours and 15 minutes after onset of left homonymous hemianopia, left facial droop, left upper extremity plegia, and left lower extremity paresis (NIHSS = 15). Computed tomography of the head revealed hyperdense material in the right M1 to M2 segments without loss of gray-white differentiation in the right cerebral hemisphere. Cerebral angiography at 6 hours and 50 minutes revealed occlusion of the right ICA at its origin. Injection of the left vertebral artery demonstrated clot in the right M1 segment with no anterograde flow. An Excelsior 1018 (Boston Scientific, Natick, MA) microcatheter was used to access the right PCOM and subsequently the right ICA and right MCA. A joint decision was made with the stroke neurology service to bury the microcatheter within the right MCA clot and administer 13 mg of tPA. A triaxial system using the Penumbra 041 catheter, Excelsior SL-10 microcatheter, and Synchro2 (Boston Scientific) guidewire was used to traverse the left vertebral and basilar arteries, the right PCOM, and the right ICA to the thrombosed right M1 segment. Aspiration using the Penumbra 41 catheter and 41 Separator was performed, resulting in a TIMI-2 result with minimal residual superior right M2 thrombus. Conclusion In patients with proximal vascular occlusion, mechanical thrombectomy with relatively stiff thrombectomy systems can be achieved through collateral pathways in the circle of Willis. Although the diameter mismatch between the Penumbra 41 catheter and a microguidewire may make sharp turns challenging, the use of an SL-10 microcatheter as a functional obturator may afford access.

OBJECTIVE AND IMPORTANCE An intracranial aneurysm that hemorrhages into the subintimal layer of the blood vessel is a rare clinical entity. Such a hemorrhage is distinct from dissecting aneurysms or pseudoaneurysms of the cerebral circulation and may represent an aneurysm in the process of rupturing. The authors report their experience in the management of a patient who presented with a subintimal hemorrhage of a superior cerebellar aneurysm. CLINICAL PRESENTATION A 54-year-old man presented with a progressively worsening headache over the course of 3 days. A noncontrast computed tomographic scan did not demonstrate subarachnoid hemorrhage but was suggestive of a posterior circulation aneurysm. INTERVENTION In the absence of subarachnoid hemorrhage on the computed tomographic scan, negative findings for xanthochromia in the cerebrospinal fluid, and no evidence of subarachnoid blood on magnetic resonance imaging, a conventional four-vessel cerebral angiogram was performed, which revealed a right superior cerebellar artery aneurysm. Further evaluation on magnetic resonance imaging demonstrated abnormal signal conforming to the aneurysm wall, suggesting the presence of a contained subintimal hemorrhage. The patient underwent a right frontotemporal craniotomy (half-and-half approach) for clip ligation of the superior cerebellar artery aneurysm. CONCLUSION Subintimal hemorrhage of an aneurysm in the absence of subarachnoid hemorrhage may be conceptually considered an aneurysm in the process of rupturing. Thus, aneurysms found in the acute setting may benefit from further workup, such as magnetic resonance imaging or highly selective angiographic evaluation of the aneurysm itself. Timely surgical intervention may prevent otherwise imminent rupture into the subarachnoid space.

Object The introduction of the Neuroform microstent has facilitated the embolization of complex cerebral aneurysms, which were previously not amenable to endovascular therapy. Typically, the use of this stent necessitates the administration of dual antiplatelet therapy to minimize thromboembolic complications. Such therapy may increase the risk of hemorrhage in patients who require concurrent external ventricular drainage and/or subsequent permanent cerebrospinal fluid diversion. Methods The authors' neurosurgical database was queried for all patients who underwent stent-assisted coil embolization for cerebral aneurysms and who required an external ventricular drain (EVD) or ventriculoperitoneal (VP) shunt placement for management of hydrocephalus. Results Thirty-seven patients underwent stent-assisted coil embolization for intracranial aneurysms at the authors' institution over a recent 2-year period. Seven of these patients required placement of an EVD and/or a VP shunt. Three of the 7 patients suffered an immediate intraventricular hemorrhage (IVH) associated with placement or manipulation of an EVD; 1 experienced a delayed intraparenchymal hemorrhage and an IVH; 1 suffered an aneurysmal rehemorrhage; and the last patient had a subdural hematoma (SDH) that resulted from placement of a VP shunt. This patient required drainage of the SDH and exchange of the valve. Conclusions The necessity of dual antiplatelet therapy in the use of stent-assisted coil embolization increases the risk of intracranial hemorrhage and possibly rebleeding from a ruptured aneurysm. This heightened risk must be recognized when contemplating the appropriate therapy for a cerebral aneurysm and when considering the placement or manipulation of a ventricular catheter in a patient receiving dual antiplatelet therapy. Further study of intracranial procedures in patients receiving dual antiplatelet therapy is indicated.

Background and Purpose— To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease. Summary of Review— A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors. Conclusions— There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.

Objective With the increased use of endovascular therapy, an increasing number of patients with incompletely treated intracranial aneurysms are presenting for further surgical management. This study reviews our experiences with such patients. Methods During a 7-year period, 38 patients with 40 intracranial aneurysms who were initially treated with endovascular therapy underwent surgical obliteration of refractory or recurrent lesions. All patients were recorded in a prospective registry, and their clinical data and imaging studies were analyzed retrospectively. Results Twenty-six anterior and 14 posterior circulation aneurysms were treated. Four aneurysms were on the cavernous internal carotid artery, 13 were on the distal internal carotid artery, 6 were on the anterior communicating artery complex, 2 were on the middle cerebral artery, 3 were on the posteroinferior cerebellar artery, 1 was at the vertebrobasilar junction, 3 were on the superior cerebellar artery, 4 were at the basilar apex, 2 were on the posterior cerebral artery, and 1 was on the distal vertebral artery. Two pseudoaneurysms-one on the petrocavernous segment of the internal carotid artery and one on the distal VA-also were treated. The median time until recurrence was 6 months. Thirty-one aneurysms were clip-ligated, and six were treated with trapping. Three extracranial-intracranial bypasses were performed. One aneurysm was treated with muslin wrapping. Two aneurysms required the use of surgical approaches that involved hypothermic circulatory arrest. Nine aneurysms required coil mass extraction and/or complex vascular reconstruction to complete lesion obliteration. All aneurysms except the single wrapped aneurysm were successfully excluded from the intracranial circulation. Two deaths occurred as a result of the operative procedures, and another patient died as a result of subarachnoid hemorrhage-induced massive myocardial infarction. Ultimately, 86.8% of patients achieved an excellent or good recovery. Conclusion With endovascular therapy assuming an increasing role in the treatment of patients with intracranial aneurysms, more lesions that are refractory to initial treatment will require surgical management. Our experience indicates that good results are attainable, although technical challenges are frequently encountered.