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Several collateral venous pathways exist to assist in cranial venous drainage in addition to the internal jugular veins. The important extrajugular networks (EJN) are often readily identified on diagnostic cerebral angiography. However, the angiographic pattern of venous drainage through collateral EJN has not been previously compared among patients with and without idiopathic intracranial hypertension (IIH).To quantify EJN on cerebral angiography among patients both with and without IIH and to determine whether there is a different EJN venous drainage pattern in patients with IIH.Retrospective imaging review of 100 cerebral angiograms (50 IIH and 50 non-IIH patients) and medical records from a single academic medical center was performed by 2 independent experienced neuroendovascular surgeons. Points were assigned to EJN flow from 0 to 6 using an increasing scale (with each patient's dominant internal jugular vein standardized to 5 points to serve as the internal reference). Angiography of each patient included 11 separately graded extrajugular networks for internal carotid and vertebral artery injections.Patients in the IIH group had statistically significant greater flow in several of the extrajugular networks. Therefore, they preferentially drained through EJN compared with the non-IIH group. Right transverse-sigmoid system was most often dominant in both groups, yet there was a significantly greater prevalence of codominant sinus pattern on posterior circulation angiograms.Patients with IIH have greater utilization of EJN compared with patients without IIH. Whether this is merely an epiphenomenon or possesses actual cause-effect relationships needs to be determined with further studies.

Introduction Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA. Methods A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0–2). Secondary endpoints included complications and radiographic occlusion at follow-up. Results A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access. Conclusion Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.

Acute occlusion of the posterior sagittal sinus may lead to dramatic increase in intracranial pressure (ICP), refractory to standard treatment. Hybrid vascular bypass of cranial venous outflow into the internal jugular vein (IJV) has seldom been described for this in recent neurosurgical literature. To describe creation of a novel vascular bypass shunt from the superior sagittal sinus (SSS) to internal jugular vein (IJV) utilizing a covered stent-Dacron graft construct for control of refractory ICP. We illustrate a patient with refractory ICP increases after acute sinus ligation that was performed to halt torrential bleeding from intraoperative injury. A temporary shunt was created that successfully controlled ICP. From the promising results of the temporary shunt, we utilized a prosthetic hybrid bypass graft to function as a shunt from the sagittal sinus to IJV. Yet the associated anticoagulation led to complications and a poor outcome. Rapid and sustained ICP reduction can be expected after sagittal sinus-to-jugular bypass shunt placement in acute sinus occlusion. Details of the surgical technique are described. Heparin anticoagulation, while imperative, is also associated with worrisome complications. Acute occlusion of posterior third of sagittal sinus carries a very malignant clinical course. Intractable intracranial hypertension from acute sinus occlusion may be effectively treated with a SSS-IJV bypass shunt. A covered stent construct provides an effective vascular bypass conduit. However, the anticoagulation risk can lead to fatal outcomes. The neurosurgeon must always strive for primary repair of an injured sinus.

BackgroundRadial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates.MethodsAn international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature.ResultsOne hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%).ConclusionsUETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.

Background Endovascular therapy is a viable alternative to surgical clipping for the treatment of intracranial aneurysms; however, aneurysms arising at bifurcations remain a challenge. The purpose of this technical report is to share the nuances of treating aneurysms with the PulseRider (PR), including device selection and positioning strategy, from authors who are highly experienced in its use. Methods We offer a comprehensive guide for neuroendovascular surgeons less experienced with PR applications to include design, general coil embolization technique, principles of deployment and detachment, positioning options, and geometric challenges and their solutions. Results In our experience, the PR is well suited for addressing the challenges of treating bifurcation aneurysms. Conclusions PR use is intuitive and straightforward for use in bifurcation aneurysms with ideal favorable. PR can also be safely and effectively used to address a much broader and more challenging range of geometries.

BackgroundThe transradial approach (TRA) has gained increasing popularity for neuroendovascular procedures. However, the experience with TRA in neuroangiography is still in early stages in most centers, and the safety and feasibility of this approach have not been well established. The purpose of this study is to report the safety and feasibility of TRA for neuroendovascular procedures.MethodsWe reviewed charts from six institutions in the USA to include consecutive patients who underwent diagnostic or interventional neuroendovascular procedures through TRA from July 2018 to July 2019. Collected data included baseline characteristics, procedural variables, complications, and whether there was a crossover to transfemoral access.ResultsA total of 2203 patients were included in the study (age 56.1±15.2, 60.8% women). Of these, 1697 (77%) patients underwent diagnostic procedures and 506 (23%) underwent interventional procedures. Successfully completed procedures included aneurysm coiling (n=97), flow diversion (n=89), stent-assisted coiling (n=57), balloon-assisted coiling (n=19), and stroke thrombectomy (n=76). Crossover to femoral access was required in 114 (5.2%). There were no major complications related to the radial access site. Minor complications related to access site were seen in 14 (0.6%) patients.ConclusionIn this early stage of transforming to the ‘radial-first’ approach for neuroendovascular procedures, TRA was safe with low complication rates for both diagnostic and interventional procedures. A wide range of procedures were completed successfully using TRA.

Background The middle meningeal artery (MMA) is an important conduit for the endovascular treatment of skull base and intracranial pathologies including, recently, subdural hematomas. A key aspect of such procedures is to perform a thorough diagnostic angiogram to detect anomalous arterial origins and “dangerous” anastomoses with branches of the internal carotid arteries. Although the most common anomaly related to the MMA is an abnormal origin from the ophthalmic artery, anomalous origin from the posterior circulation is rare. Moreover, its recognition requires a concerted effort at performing a vertebral artery angiogram irrespective of the location of the pathology (e.g., in subdural hematoma). Case Description We describe a case of anomalous origin of MMA from the basilar artery as a lateral pontine artery branch that was detected in a patient with recurrent subdural hematoma who presented for endovascular MMA embolization. Conclusions The embryologic origin of the entity is briefly discussed, along with suggestions for managing such an anomaly during endovascular embolization.

The large size of guide catheters in the traditional triaxial configuration can prove limiting during transradial vertebrobasilar thrombectomy. This is especially important for the direct aspiration technique because of the large aspiration catheters that can reach an inner diameter of 0.072 in. A strategy that strikes a balance between stable proximal vessel support and distal navigation for aspiration is conceptually attractive.To describe a series of transradial posterior circulation thrombectomy procedures in which the aspiration catheter served a dual role of guide support and clot aspiration in a coaxial configuration, thus obviating a larger guide catheter.Patients selected in the series underwent radial artery access and direct over-the-wire navigation of the aspiration catheter into the vertebral artery. With coaxial microcatheter navigation, the aspiration catheter reached distal enough to ingest the clot successfully. Along with clinical and angiographic data, imaging features such as angle of vertebral artery origin were calculated.Five patients underwent a stand-alone aspiration catheter technique for basilar artery occlusion through transradial access. All procedures resulted in thrombolysis in cerebral infarction 3 recanalization. The mean time to basilar artery recanalization was 10 minutes. No access site complications or vertebral artery dissection were noted. The mean subclavian artery-vertebral origin angle was 84.06° (range 78.2-90.2°).For patients selected properly based on vascular anatomy and a careful technique, a large bore aspiration catheter can fulfil a stand-alone dual-role, thus obviating the need for a guide catheter. This can potentially improve the technical feasibility and success of transradial vertebrobasilar thrombectomy.

Background The adoption of endovascular techniques for treatment of pericallosal artery aneurysms (PAAs) has been comparatively gradual due to anatomic and technological factors. We conducted a retrospective cohort study to evaluate the outcomes of PAA treatment with coiling and flow diversion at our institution. Methods This was a retrospective study of patients treated endovascularly for PAAs from December 2007 to January 2019. Results In total, 33 patients with 34 aneurysms were included (25 aneurysms ruptured, 9 unruptured or recurrent). Of the ruptured group, 22 were coiled (88%) and rest treated with flow diversion. Initial angiographic follow up rate was 72%, at median of 159 days. Overall recurrence rate was 40% (10/25) at median of 376 days, all among coiled aneurysms. 6 recurrent aneurysms were retreated with further coiling (2) and flow diversion (4). Of the unruptured/recurrent group, 5 were coiled (55%) and remainder treated with flow diversion. Angiographic follow-up rate was 100% at median of 267 days. Recurrence rate was 22% (2/9), both in coiled aneurysms. Overall, 27 aneurysms were coiled, 9 treated with flow diversion and 3 with “partial” flow diversion. All aneurysms treated with pipeline flow diversion achieved 100% occlusion. No re-rupture or new rupture was observed. Good clinical outcome (modified Rankin Scale 0–2) was seen in 79% of patients. Conclusions Our study demonstrates that endovascular coiling for PAAs is associated with a definite rate of recurrence, which has to be monitored with timely angiography. We also demonstrate the excellent effectiveness of flow diversion for PAAs with either presentation.

International audience; Abstract BACKGROUND Randomized controlled trials evaluating mechanical thrombectomy (MT) for acute ischemic stroke predominantly studied anterior circulation patients. Both procedural and clinical predictors of outcome in posterior circulation patients have not been evaluated in large cohort studies. OBJECTIVE To investigate technical and clinical predictors of functional independence after posterior circulation MT while comparing different frontline thrombectomy techniques. METHODS In a retrospective multicenter international study of 3045 patients undergoing MT for stroke between 06/2014 and 12/2018, 345 patients had posterior circulation strokes. MT was performed using aspiration, stent retriever, or combined approach. Functional outcomes were assessed using the 90-d modified Rankin score dichotomized into good (0-2) and poor outcomes (3-6). RESULTS We included 2700 patients with anterior circulation and 345 patients with posterior circulation strokes. Posterior patients (age: 60 ± 14, 46% females) presented with mainly basilar occlusion (80%) and were treated using contact aspiration or ADAPT (39%), stent retriever (31%) or combined approach (19%). Compared to anterior strokes, posterior strokes had delayed treatment (500 vs 340 min, P

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

Basilar artery occlusions (BAOs) are devastating ischemic strokes that account for 1% of all strokes with high morbidity and mortality; however, neuroendovascular techniques such as ADAPT have recently revolutionized the clinical outcomes of these patients.1-3 Common underlying pathology in patients with BAO include intracranial atherosclerotic disease (ICAD) as well as thromboembolic origin.4 Basilar artery ICAD in a setting of acute stroke portends a poor prognosis and post-thrombectomy residual critical flow limiting stenosis treatment options, including balloon angioplasty with or without stent placement.5-7 We present a video illustration of neuroendovascular technique and challenges encountered when managing this pathology. Image at 5:42 reprinted with permission from Alawieh et al, Lessons learned over more than 500 stroke thrombectomies using ADAPT with increasing aspiration catheter size, Neurosurgery, 86(1), 2020, pp. 61-70, with permission from the Congress of Neurological Surgeons.1.

Background Traditionally, neuroangiography for diagnosis and therapy has been achieved via the transfemoral route. Femoral access, however, has been associated with catastrophic complications. Although transradial access (TRA) has been adopted late by the field of neuroendovascular surgery, several groups have recently demonstrated a dramatically safe and rapid learning curve with a radial-first approach. However, there is a need for a detailed illustrative approach on the transradial technique. Objective To provide a detailed description of the operative technique with step-by-step illustrations derived from our single center series of 506 cases, as an early adopter. Methods A step-by-step illustrated approach to our technique of transradial angiography is provided, based on our clinical experience of an early radial-first approach. Prospective review of patients undergoing transradial angiography and interventions from April 1 to November 30, 2019, at our institution was performed. We included all cases that received radial-first arterial access for diagnostic and interventional neuroangiography. Efficacy, complications, catheter use, and radiation metrics of TRA for the entire cohort were noted. The radial approach was described in 4 stages beginning from the wrist (Stage I) and ending with distal access to target vessel of interest (Stage IV). Results A total of 506 patients underwent TRA over the 7-mo period. Procedural success was achieved in 92.3% of patients (93.7% for diagnostic and 88.5% for interventional). Crossover to the femoral route occurred in 33 (6.5%) cases (25 diagnostic and 8 interventional). The majority occurred in Stage I. No major complications were noted. Conclusion Our preferred technique for the transradial approach provides excellent safety and efficacy in performing diagnostic and interventional neuroangiography. The illustrated technical steps are expected to provide guidance for early adopters of TRA.

BACKGROUND. Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage. METHODS. MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0–3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number . FINDINGS. Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0–3 at 365 days (adjusted risk difference 4% [95% CI –4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012). INTERPRETATION. For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons.

Background and importance Aneurysms of the ophthalmic artery (OA) within the orbit and optic canal are extremely rare. Given the peripheral location of these aneurysms and the fact that most are fusiform, parent artery occlusion is preferred for symptomatic aneurysms. However, the impact of OA occlusion on vision is not always innocuous. Balloon occlusion testing (BOT) of the OA has the potential to gauge the possibility of visual compromise, in addition to assessing collaterals. While BOT has been assessed for carotid artery occlusion, its role in OA occlusion has not been well defined. Clinical presentation We describe a patient with a 6-mm intracanalicular OA aneurysm who was treated with endovascular coil embolization of the aneurysm and occlusion of the parent artery. We performed a 30-min balloon occlusion test, in which we verified intact visual and neurological function. Collateral vascularity was confirmed. Complete occlusion was achieved and the patient recovered with intact visual and neurological function. We provide a review of literature pertaining to parent artery occlusion of OA aneurysms that occur within optic canal and orbit. A brief note on anatomy of OA and collaterals is provided. Conclusion Endovascular parent artery occlusion is an effective treatment for OA aneurysms that occur in optic canal and orbit. Assessment of effect of occlusion on vision is important. BOT can assess this and provide valuable information. Recovery or preservation of visual function is highly dependent on preoperative visual status.

Wide-necked bifurcation aneurysms pose technical and anatomical challenges to endovascular treatment, which make the simpler assisted (balloon or single stent) coiling techniques less effective.1 Consequently, unique endovascular solutions to treat such aneurysms have been devised.2,3 One such device is PulseRider (Cerenovus, New Brunswick, New Jersey), which is designed to provide neck support for a coil mass while protecting the bifurcation.3 The device comprises a body or stem that is deployed in the parent artery and a saddle component that sits at the aneurysm neck to keep the coil mass away from the bifurcation. There are several technical nuances involved in successful use of the device during positioning, deployment, and detachment.3 We present a surgical video detailing the steps of PulseRider-assisted coiling of unruptured basilar bifurcation (or basilar apex) aneurysms. The first case highlights index treatment at diagnosis and the second showcases treatment of a recurrent basilar apex aneurysm. Both patients provided informed consent to the procedure. We also briefly discuss the rationale for treating basilar apex aneurysms.4,5.

Malignant large artery stroke is associated with high mortality of 70% to 80% with best medical management. Decompressive craniectomy (DC) is a highly effective tool in reducing mortality. Convincing evidence has accumulated from several randomized trials, in addition to multiple retrospective studies, that demonstrate not only survival benefit but also improved functional outcome with DC in appropriately selected patients. This article explores in detail the evidence for DC, nuances regarding patient selection, and applicability of DC for supratentorial intracerebral hemorrhage and posterior fossa ischemic and hemorrhagic stroke.

Background Neuroendovascular intervention has become a key treatment option for acute ischemic stroke. The Sofia (6F) PLUS catheter was designed for neurovascular access for diagnostic or therapeutic interventions. Objective To report the first series describing use of the Sofia PLUS intermediate/distal access reperfusion catheter in the treatment of acute ischemic stroke. Methods In this retrospective study, 41 stroke cases were identified in which the catheter was utilized for thrombolysis/thrombectomy. Mean preprocedure National Institutes of Health Stroke Scale score was 16.5 ± 5.2 (range 4-29). Occluded vessels included the M1 segment, M2 segment, internal carotid artery terminus, cervical internal carotid artery, and basilar artery. Results Successful positioning of the Sofia PLUS catheter near the occlusion site was achieved in 38 (92.7%) of 41 cases in which thrombectomy or thrombolysis was attempted using intraarterial tissue plasminogen activator, a direct aspiration first-pass technique, and/or stent retrieval. A postprocedure thrombolysis in cerebral infarction (TICI) score of 2b/3 was achieved in 37 of 41 cases. Of 15 cases where the Sofia PLUS was used for a direct aspiration first-pass technique, TICI 2b/3 was achieved in 11 (73.3%). In one case where intra-arterial tissue plasminogen activator was used as the only treatment modality, TICI 2a was achieved. No device-related or catheter-related complications were observed. The mean 7-d-postprocedure National Institutes of Health Stroke Scale score among the 39 survivors was 8.5 ± 7.3 (range 0-23). Conclusion Initial results with use of the Sofia (6F) PLUS for endovascular treatment of acute ischemic stroke have been encouraging. Experience with a larger series is warranted to further evaluate the safety and efficacy of this device and compare it with other reperfusion catheters.

BackgroundThe transradial approach as a frontline approach is a novel technique in neuroendovascular procedures. In this study we aim to present our early experience with full transition to transradial access as the first-line approach for neuroendovascular procedures.MethodsWe prospectively collected data on the first 100 consecutive patients who underwent a diagnostic or interventional neuroendovascular procedure using the transradial approach at our institution between March 22 and April 30, 2019. Baseline characteristics were collected in addition to the type of procedure, access site, catheters and wires used, complications, and whether there was crossover to transfemoral access.ResultsTransradial access was attempted in 121 cases and 91 cases were completed successfully (72 diagnostic procedures and 19 interventional procedures). Mean (SD) age was 56.8 (14.7) years, 54.9% (50/91) underwent the procedure in the outpatient setting, and 60.4% (55/91) were women. Seven patients had minor immediate complications related to the radial access. Interventional procedures successfully performed included aneurysm embolization (ruptured (n=3) and unruptured (n=8)), tumor embolization (n=2), cervical internal carotid artery stenting (n=2), balloon occlusion test (n=1), vertebral artery sacrifice (n=1), and arteriovenous malformation embolization (n=2).ConclusionIn this early experience, full transition to the transradial approach as the frontline approach is feasible with a low complication rate for both diagnostic and interventional neuroendovascular procedures.

BACKGROUND AND PURPOSE: Selection of the correct flow-diverter size is critical for cerebral aneurysm treatment success, but it remains challenging due to the interplay of device size, anatomy, and deployment. Current convention does not address these challenges well. The goals of this pilot study were to determine whether computational modeling improves flow-diverter sizing over current convention and to validate simulated deployments. MATERIALS AND METHODS: Seven experienced neurosurgeons and interventional neuroradiologists used computational modeling to prospectively plan 19 clinical interventions. In each patient case, physicians simulated 2–4 flow-diverter sizes that were under consideration based on preprocedural imaging. In addition, physicians identified a preferred device size using the current convention. A questionnaire on the impact of computational modeling on the procedure was completed immediately after treatment. Rotational angiography image data were acquired after treatment and compared with flow-diverter simulations to validate the output of the software platform. RESULTS: According to questionnaire responses, physicians found the simulations useful for treatment planning, and they increased their confidence in device selection in 94.7% of cases. After viewing the simulations results, physicians selected a device size that was different from the original conventionally planned device size in 63.2% of cases. The average absolute difference between clinical and simulated flow-diverter lengths was 2.1 mm. In 57% of cases, average simulated flow-diverter diameters were within the measurement uncertainty of clinical flow-diverter diameters. CONCLUSIONS: Physicians found computational modeling to be an impactful and useful tool for flow-diverter treatment planning. Validation results showed good agreement between simulated and clinical flow-diverter diameters and lengths.

BACKGROUND: MRI-based modeling of tumor cell density (TCD) can significantly improve targeted treatment of Glioblastoma (GBM). Unfortunately, interpatient variability limits the predictive ability of many modeling approaches. We present a Transfer Learning (TL) method that generates individualized patient models, grounded in the wealth of population data, while also detecting and adjusting for interpatient variabilities based on each patient’s own histologic data. METHODS: We recruited primary GBM patients undergoing image-guided biopsies and preoperative imaging including contrast-enhanced MRI (CE-MRI), Dynamic-Susceptibility-Contrast (DSC)-MRI, and Diffusion Tensor Imaging (DTI). We calculated relative cerebral blood volume (rCBV) from DSC-MRI and mean diffusivity (MD) and fractional anisotropy (FA) from DTI. Following image coregistration, we assessed TCD for each biopsy and identified corresponding localized MRI measurements. We then explored a range of univariate and multivariate predictive models of TCD based on MRI measurements in a generalized one-model-fits-all (OMFA) approach. We then implemented both univariate and multivariate individualized TL predictive models, which harness the available population level data but allow for individual variability in their predictions. Finally, we compared Pearson correlation coefficients and mean absolute error between the individualized TL versus generalized OMFA models. RESULTS: TCD significantly correlated with rCBV (r=0.33,p

Background Of the minimally invasive “keyhole” alternatives to the pterional region, the supraorbital eyebrow approach is the most widely adopted. Yet it can prove disadvantageous when a more direct lateral microsurgical trajectory of attack to the Sylvian fissure and anterior middle fossa are needed. Objective The extended lateral orbital (XLO) approach was designed to be direct and minimally invasive, with the sphenoid ridge at the center of exposure. Methods Five injected cadaver heads were used for anatomic study of the XLO approach. The anatomic course of the frontalis branch of facial nerve was studied in relation to the XLO incision. Following XLO incision, the bone exposure was measured. The intracranial microsurgical exposure was assessed subjectively. Application of the technique in representative clinical operative cases is provided. Results The frontalis nerve was protected in the subgaleal fat pad, with an average minimum distance of 2.3 cm from the XLO incision. The mean calvarial area exposure was 4.95 cm2 and consistently centered on the sphenoid ridge. Excellent access to ipsilateral Sylvian's fissure, perisylvian regions, and supra-/parasellar structures was possible. The main limitations related to exposure of the posterior Sylvian fissure and the expected limitations of microsurgical instrument manipulation from a smaller craniotomy. Conclusions The XLO approach is a minimally invasive keyhole approach to the pterional region that affords a unique lateral trajectory via a craniotomy centered on the sphenoid ridge. Excellent exposure to properly selected lesions is possible. The incision is at a safe distance from the frontalis branch and shows excellent cosmetic healing.

Aneurysm recanalization constitutes a limitation in the endovascular treatment of intracranial aneurysms using conventional bare platinum coils. The development of platinum coils coupled with hydrogel polymers aimed at decreasing the rates of recurrence by way of enhanced coil packing density and biological healing within the aneurysm. While enhanced occlusion and durability has been shown for the first generation hydrogel coils, their use was limited by technical challenges. Less data is available regarding the second-generation hydrogel coils which have been designed to perform like bare platinum coils. The new generation Hydrogel Endovascular Aneurysm Treatment Trial (HEAT) is a multicenter, randomized controlled trial that compares the health outcomes of the second-generation HydroCoil Embolic System with bare platinum coils in the endovascular intracranial aneurysms. The primary endpoint is aneurysm recurrence, defined as any progression on the Raymond aneurysm scale, over a 24-month follow-up period. Secondary endpoints include packing density, functional independence, procedural adverse events, mortality rate, initial complete occlusion, aneurysm retreatment, hemorrhage from treated aneurysm, and any aneurysm recurrence. Patient recruitment initiated in June 2011 and ended in January 2016 in 46 centers. Six hundred eligible patients diagnosed with an intracranial aneurysm, ruptured or unruptured were randomly assigned to one of the two treatment arms. The HEAT trial compares the durability, imaging, and clinical outcomes of the second-generation hydrogel versus bare platinum coils in the endovascular treatment of ruptured or unruptured intracranial aneurysms. The results of this trial may further inform current endovascular treatment guidelines based on observed long-term outcomes.

OBJECTIVE: To assess the impact of a simulation-based educational curriculum of 4 modules on neurosurgical trainees at the Neurological Societies of India annual meeting,whichwasheldinMumbai,India,inDecember2013. -METHODS: We developed a microanastomosis, anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), and durotomy repair and their corresponding objective assessment scales. Each module was divided into 3 components: 1) a before didactic cognitive knowledge and technical skills testing, 2) a didactic lecture, and 3) an after didactic cognitive knowledgeand technicalskills testing. We compared the trainees’ cognitive and technical scores from the before and after testing phases. Wilcoxon sum rank test was used to test statistical significance. The incorporation of a simulation-based educational program into neurosurgical education curriculum has faced a number of barriers. It is essential to develop and assess the success and feasibility of simulation-based modules on neurosurgical residents. -RESULTS: The knowledge test median scores increased from 60%, 69% to 72%, and 60% to 80%, 85%, 90%, and 75% on the microanastomosis, ACDF, PCF, and durotomy modules, respectively (P < 0.05). The practical hands-on scores increased from 45%, 45% to 60%, and 65% to 62%, 68%, 81%, and 70% on the microanastomosis, ACDF, PCF, and durotomy modules, respectively (P < 0.05).

Traumatic brain injury (TBI) is a leading cause of permanent disability in people younger than 40 years of age. An increase in intracranial pressure (ICP) during hospitalization for a TBI has been associated with poor long-term neurologic outcomes. On the basis of encouraging research, hypothermia has been embraced by some centers as an innovative way to treat high ICP. More recent trials, however, have hinted that therapeutic hypothermia might contribute to poor neurologic outcomes. In an attempt to define the role of hypothermia in TBI, the Eurotherm 3235 Trial collaborators conducted a randomized controlled trial, which was published October 7, 2015 in the New England Journal of Medicine. The inclusion criteria included patients with closed head injury who sustained an ICP >20 mm Hg for >5 minutes. For the purpose of creating a framework for study analysis, treatments for TBI were divided into stage 1, 2, and 3 therapies (Table 1). Eligible patients were randomized to an experimental arm, hypothermia (32 C 35 C) in addition to best management practice, and a control arm that consisted of best management practices alone. Statistical analysis was performed using ordinal logistic regression to compare the Extended Glasgow Outcome Scale scores between the hypothermia and control groups at 6 months. Only 25.7% of patients from the hypothermia group (49/191) had favorable outcomes at

he formation of intracranial aneurysms (IAs) has been intensively investigated due to its potential for devasT tating consequences. Numerous studies have documented the strong association between aneurysm pathophysiology and “traditional” atherosclerotic risk factors such as smoking, hypertension, and vessel wall inflammation. The presence of multiple aneurysms and familial occurrence, however, raises the valid question of the extent to which genetically determined factors contribute to the phenotype of an innate arteriopathy. Such an association between IAs and several monogenic or polygenic syndromes is well known.

Objective Although a significant amount of experience has accumulated for awake procedures for brain tumor, epilepsy, and carotid surgery, its utility for intracranial neurovascular indications remains largely undefined. Awake surgery for select neurovascular cases offers the advantage of precise brain mapping and robust neurologic monitoring during surgery for lesions in eloquent areas, avoidance of potential hemodynamic instability, and possible faster recovery. It also opens the window for perilesional epileptogenic tissue resection with potentially less risk for iatrogenic injury. Methods Institutional review board approval was obtained for a retrospective review of awake surgeries for intracranial neurovascular indications over the past 36 months from a prospectively maintained quality database. We reviewed patients' clinical indications, clinical and imaging parameters, and postoperative outcomes. Results Eight consecutive patients underwent 9 intracranial neurovascular awake procedures conducted by the senior author. A standardized “sedated–awake–sedated” protocol was used in all 8 patients. For the 2 patients with arteriovenous malformations and the 3 patients with cavernoma, awake brain surface and white matter mapping was performed before and during microsurgical resection. A neurological examination was obtained periodically throughout all 5 procedures. There were no intraoperative or perioperative complications. Hypotension was avoided during the 2 Moyamoya revascularization procedures in the patient with a history of labile blood pressure. Postoperative imaging confirmed complete arteriovenous malformation and cavernoma resections. No new neurologic deficits or new-onset seizures were noted on 3-month follow-up. Conclusions Awake surgery appears to be safe for select patients with intracranial neurovascular pathologies. Potential advantages include greater safety, shorter length of stay, and reduced cost.

Cognard type V dural fistulas represent a rare and unique entity, and present clinically with myelopathy. They are frequently located around the foramen magnum and are most commonly fed by dural branches of the vertebral and external carotid artery. Detection requires meticulous angiography to define the angioarchitecture of the fistula, which in turn defines the treatment modality. We present the case of a 63 yr old woman, after informed consent was obtained, with prolonged, severe and progressive lower extremity myelopathy for 6 yr, with T2-weighted signal changes in the thoracic spinal cord on magnetic resonance imaging (MRI). Cervical MRI was unremarkable. Following computed tomography (CT), angiography of the spinal canal that revealed tortuous and dilated veins on the thoracic spinal cord surface, catheter angiography was performed. This demonstrated a fistula in relation to a dural branch of left vertebral artery with a characteristic single draining vein coursing caudally to the thoracic level, with delayed outflow suggestive of venous hypertension. Given the fact that the dural feeder was tortuous and relatively small, thus, precluding distal microcatheter access, and with presence of a single accessible draining vein, microsurgical treatment was preferred. Following a midline suboccipital craniotomy in prone position, a limited vertical dural opening was performed. Careful microsurgical arachnoid dissection revealed the arterialized draining vein with the aid of Indocyanine Green angiography. The draining vein was clipped, coagulated, and disconnected. Postoperative recovery was uneventful and the patient is undergoing rehabilitation therapy. Follow-up angiography showed complete elimination of the fistula. Salient teaching points are narrated at conclusion.

Background The potential for simulation-based learning in neurosurgical training has led the Congress of Neurosurgical Surgeons to develop a series of simulation modules. The Northwestern Objective Microanastomosis Assessment Tool (NOMAT) was created as the corresponding assessment tool for the Congress of Neurosurgical Surgeons Microanastomosis Module. The face and construct validity of the NOMAT have been previously established. Objective To further validate the NOMAT by determining its interrater reliability (IRR) between raters of varying levels of microsurgical expertise. Methods The NOMAT was used to assess residents' performance in a microanastomosis simulation module in 2 settings: Northwestern University and the Society of Neurological Surgeons 2014 Boot Camp at the University of Indiana. At Northwestern University, participants were scored by 2 experienced microsurgeons. At the University of Indiana, participants were scored by 2 postdoctoral fellows and an experienced microsurgeon. The IRR of NOMAT was estimated by computing the intraclass correlation coefficient using SPSS v22.0 (IBM, Armonk, New York). Results A total of 75 residents were assessed. At Northwestern University, 21 residents each performed microanastomosis on 2 model vessels of different sizes, one 3 mm and one 1 mm. At the University of Indiana, 54 residents performed a single microanastomosis procedure on 3-mm vessels. The intraclass correlation coefficient of the total NOMAT scores was 0.88 at Northwestern University and 0.78 at the University of Indiana. Conclusion This study indicates high IRR for the NOMAT. These results suggest that the use of raters with varying levels of expertise does not compromise the precision or validity of the scale. This allows for a wider adoption of the scale and, hence, a greater potential educational impact.

We present the case of a 56-yr-old right-handed male, after informed consent was obtained, who presented with acute confusion and agitation, on the background of a remote history of an uncomplicated resection of a left parietal grade 2 glioma. Imaging revealed a large, acute right temporal intracerebral hemorrhage (ICH). Standard vascular workup for the cause of the ICH included catheter angiography. No direct cause of the hemorrhage was revealed; however, a high grade parasagittal dural arteriovenous fistula (DAVF) with cortical venous reflux was noted close to the prior craniotomy site. The venous reflux was towards the left hemisphere, but it was hypothesized that similar reflux on the right side may have been present and was not presently evident due to thrombosis. The DAVF was embolized by endovascular means, followed by evacuation of the hematoma. Follow-up angiogram 7 mo later revealed a high-flow, right superior temporal cortical arteriovenous malformation (AVM). The DAVF unfortunately had also progressed. Endovascular occlusion of both lesions was attempted but was not successful. Subsequently, microsurgical resection for both the vascular malformations was performed with careful pre- and intraoperative planning to obtain a successful clinical and angiographic result. In this video, we summarize diagnostic and therapeutic nuances that have broad implications for the workup of ICH and the strategic management of a unique scenario involving a brain AVM and high-grade cranial dural fistula in the same patient. Prior to each procedure, informed consent was obtained from the patient, which includes consent for publication.

Posterior fossa tumors are associated frequently with hydrocephalus. Remote supratentorial hematoma after posterior fossa surgery is a rare but dreaded complication. These hematomas can be intraparenchymal or extradural. The possible causes include sudden decompression of ventricular pressure in the supratentorial compartment, rupture of cortical veins in the sitting position, coagulopathy, hemodynamic fluctuations during surgery, and position-related ischemia. We report a large bifrontal extradural hematoma following posterior fossa surgery for a vermian medulloblastoma.

Symptomatic intracerebral hemorrhage (sICH) is the most dreaded complication in ischemic stroke patients treated with recombinant tissue plasminogen activator (rtPA). Symptomatic intracerebral hemorrhage is associated with significant morbidity and a mortality rate of approximately 50%. Yet management of this cohort has been based mostly on anecdotal experience. Since its approval by the U.S. Food and Drug Administration in 1996, rtPA has become the standard of care for select patients with acute ischemic stroke. In the October JAMA Neurology issue, Yaghi et al. reported on a retrospective study examining current treatment paradigms for sICH after rtPA administration at 10 U.S. stroke centers. Patients included in the study had to meet the criteria for the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST). Symptomatic intracerebral hemorrhage was defined as the presence of a parenchymal hematoma accounting for more than one third of the infarct volume (parenchymal hematoma type 2) identified on head computed tomography (CT) with at least a 4point increase from the baseline National Institute of Health Stroke Scale (NIHSS). The primary outcome was in-hospital mortality, and the secondary outcome was hematoma expansion identified on follow-up CT. Other variables were included in the study to examine if there was any association between in-hospital mortality and hematoma expansion. First data on pretreatment factors were reported. These factors included patient demographics, stroke risk factors, antiplatelet or anticoagulant use before thrombolysis, admission NIHSS, and code status change to comfort care measures. Second were laboratory measures, comprising pretreatment blood glucose level, coagulation laboratory values, and fibrinogen level. Third were imaging features including hematoma volume and the time from initiation of rtPA therapy to sICH diagnosis. Fourth was the treatment modality, ranging from fresh frozen plasma, cryoprecipitate, vitamin K, platelet transfusion, recombinant factor VIIa, aminocaproic acid, and surgical decompressive craniotomy or hematoma evacuation.