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Objective: Transradial access (TRA) is commonly utilized in neurointerventional procedures. This study compared the technical and clinical outcomes of the use of TRA versus those of transfemoral access (TFA) for intracranial aneurysm embolization with the Woven EndoBridge (WEB) device., Methods: This is a secondary analysis of the Worldwide WEB Consortium, which comprises multicenter data related to adult patients with intracranial aneurysms who were managed with the WEB device. These aneurysms were categorized into two groups: those who were treated with TRA or TFA. Patient and aneurysm characteristics and technical and clinical outcomes were compared between groups. Propensity score matching (PSM) was used to match groups according to the following baseline characteristics: age, sex, subarachnoid hemorrhage, aneurysm location, bifurcation aneurysm, aneurysm with incorporated branch, neck width, aspect ratio, dome width, and elapsed time since the last follow-up imaging evaluation., Results: This study included 682 intracranial aneurysms (median [interquartile range] age 61.3 [53.0-68.0] years), of which 561 were treated with TFA and 121 with TRA. PSM resulted in 65 matched pairs. After PSM, both groups had similar characteristics, angiographic and functional outcomes, and rates of retreatment, thromboembolic and hemorrhagic complications, and death. TFA was associated with longer procedure length (median 96.5 minutes vs 72.0 minutes, p = 0.006) and fluoroscopy time (28.2 minutes vs 24.8 minutes, p = 0.037) as compared with TRA. On the other hand, deployment issues were more common in those treated with TRA, but none resulted in permanent complications., Conclusions: TRA has comparable outcomes, with shorter procedure and fluoroscopy time, to TFA for aneurysm embolization with the WEB device.

Objective: Wide-neck bifurcation cerebral aneurysms have historically required either clip ligation or stent- or balloon-assisted coil embolization. This predicament led to the development of the Woven EndoBridge (WEB) aneurysm embolization system, a self-expanding mesh device that achieves intrasaccular flow disruption and does not require antithrombotic medications. The authors report their operative experience and 6-month follow-up occlusion outcomes with the first 115 aneurysms they treated via WEB embolization., Methods: The authors reviewed the first 115 cerebral aneurysms they treated by WEB embolization after FDA approval of the WEB embolization device (from February 2019 to January 2021). Data were collected on patient demographics and clinical presentation, aneurysm characteristics, procedural details, postembolization angiographic contrast stasis, and functional outcomes., Results: A total of 110 patients and 115 aneurysms were included in our study (34 ruptured and 81 unruptured aneurysms). WEB embolization was successful in 106 (92.2%) aneurysms, with a complication occurring in 6 (5.5%) patients. Contrast clearance was seen in the arterial phase in 14 (12.2%) aneurysms, in the capillary phase in 16 (13.9%), in the venous phase in 63 (54.8%), and no contrast was seen in 13 (11.3%) of the aneurysms studied. Follow-up angiography was performed on 60 (52.6%) of the aneurysms, with complete occlusion in 38 (63.3%), neck remnant in 14 (23.3%), and aneurysmal remnant in 8 (13.3%). Six (5.5%) patients required re-treatment for persistent aneurysmal residual on follow-up angiography., Conclusions: The WEB device has been successfully used for the treatment of both unruptured and ruptured wide-neck bifurcation aneurysms by achieving intrasaccular flow diversion. Here, the authors have shared their experience with its unique technical considerations and device size selection, as well as critically reviewed complications and aneurysm occlusion rates.

Background: Tandem occlusion (TO) describes not only occlusion of the middle cerebral artery but a contemporaneous occlusion of the cervical internal carotid artery. There is a paucity of data over whether mechanical thrombectomy (MT) alone, MT with angioplasty, or MT with carotid artery stent placement is superior. We aim to address a gap in the literature comparing carotid stenting with mechanical thrombectomy (CSMT) and carotid angioplasty with mechanical thrombectomy (CAMT) in patients presenting with acute anterior circulation TOs., Methods: This is a multicenter, retrospective study from 2012 to 2020 comparing CSMT and CAMT presenting with acute anterior circulation TOs. Primary outcomes of interest were functional status, perioperative stroke, mortality, and symptomatic intracranial hemorrhage (sICH). A total of 92 patients (66 vs. 26 in CSMT and CAMT, respectively) met inclusion criteria for analysis., Results: There was no statistically significant difference in functional outcomes at 90-day follow-up (adjusted odds ratio [aOR] 0.82; 95% confidence interval [CI] 0.20-3.5; P = 0.46). In addition, there was no statistically significant difference in 90-day mortality (aOR 0.361; 95% CI 0.016-2.92; P = 0.532) and perioperative stroke rate (aOR 1.76; 95% CI 0.160-15.6; P = 0.613). However, sICH risk was significantly greater in the stent-treated cohort (aOR 3.94; 95% CI 0.529-37.4; P = 0.003)., Conclusions: Functional outcomes, mortality, and perioperative stroke rates do not significantly differ in CSMT and CAMT procedures in the acute setting. However, CSMT-treated patients do appear to have an increased risk of sICH, potentially due to the use of additional antiplatelet agents following stent placement., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Data in neurointerventional literature is extremely limited regarding the safety and efficacy of flow diversion using transradial access (TRA). We aim to demonstrate the safety and efficacy of intracranial aneurysm treatment with the Pipeline Embolization Device (PED) using TRA compared to transfemoral access (TFA)., Methods: We conducted a retrospective analysis of a prospectively maintained database and identified 79 consecutive patients who underwent neuroendovascular embolization for cerebral aneurysms using the PED from April 2018 through October 2019. Patients were divided into 2 groups: TRA (32 patients) and TFA (47 patients). A comparative analysis was performed between the two groups., Results: There was no significant difference in postoperative intracranial hemorrhage (p>.99), symptomatic ischemic stroke (p=.512), access site complications (p=.268), or other complications (p=.512). However, there was a significant increase in overall complications (14.9% vs. 0.0%, p=.038) and procedure duration (71.4 min ± 31.2 vs. 58.5 ± 20.3, p=.018) in the TFA group. There was no significant difference in complete occlusion at latest follow-up (19/25, 76.0% vs. 35/40, 87.5%; p=.311), 6-month follow-up (17/23, 73.9% vs. 33/38, 86.8%; p=.303), or 12-month follow-up (8/8, 100.0% vs. 5/6, 83.3%; p=.429). There was also no significant difference in rate of retreatment (p>.99), morbidity (p=.512), mortality (p>.99), latest follow-up (p=.985), or loss of follow-up (p=.298)., Conclusions: The feasibility and efficacy of flow diversion with the PED via TRA for the treatment of intracranial aneurysms is comparable to TFA. Widespread adoption of this approach may be facilitated by improvements in device navigation and manipulation via radial-specific engineering., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Background: CSF shunting is among the most widely utilized interventions in patients with idiopathic intracranial hypertension (IIH). Ventriculoperitoneal shunting (VPS) and lumboperitoneal shunting (LPS) are 2 possible treatment modalities., Objective: To evaluate and compare complications, malfunction, infection, and revision rates associated with VPS compared to LPS., Methods: Electronic medical records were reviewed to identify baseline and treatment characteristics for patients diagnosed with IIH treated with VPS or LPS., Results: A total of 163 patients treated with either VPS (74.2%) or LPS (25.8%) were identified. The mean follow-up was 35 mo. Shunt revision was required in 40.9% of patients. There was a nonsignificant higher rate of revision with LPS (52.4%) than VPS (36.4%, P = .07). In multivariate analysis, increasing patient age was associated with higher odds of shunt revision (P = .04). LPS had higher odds of shunt revision, yet this association was not significant (P = .06). Shunt malfunction was the main indication for revision occurring in 32.7%, with a significantly higher rate with LPS than VPS (P = .03). In total, 15 patients had shunt infection (9.4% VPS vs 12.2% LPS P = .50). The only significant predictor of procedural infection was the increasing number of revisions (P = .02)., Conclusion: The incidence of shunt revision was 40.9%, with increasing patient age as the sole predictor of shunt revision. The incidence of shunt malfunction was significantly higher in patients undergoing LPS, while there was no significant difference in the incidence of shunt infection between the 2 modalities., (© Congress of Neurological Surgeons 2021.)

Background: Transradial access (TRA) for neuroendovascular procedures has several clear benefits compared to transfemoral access. In this study, we report our initial experience with neuroendovascular procedures performed via transradial access using the novel Ballast 088 long sheath., Methods: We conducted a retrospective analysis and identified 91 consecutive patients who underwent neuroendovascular procedures via TRA using the Ballast 088 long sheath. Data collection was performed on indication for procedure, number of vessels selectively catheterized, fluoroscopy time, procedure duration, radiation exposure, failure of radial access and conversion to transfemoral access, periprocedural complications, and procedural outcomes., Results: Amongst 91 patients, the average age was 65.5 years ± 14.2 with 45 (49.5 %) female patients. 25 (27.5 %) patients underwent aneurysm treatment, 2 (2.2 %) AVM/AVF embolization, 28 (30.8 %) intracranial or extracranial stenting, 31 (34.1 %) stroke treatment, and 5 (5.5 %) underwent diagnostic angiogram. The mean number of target vessels catheterized was 1.07 ± 0.25, the mean procedure duration (minutes) was 96.5 ± 57.2, mean fluoroscopy time (minutes) was 21.9 ± 14.2, mean contrast dose (ml) was 112.7 ± 66.7, and mean radiation exposure (Gycm2) was 54.82 ± 41.37. The success rate of target vessel catheterization was 100 %. There were no complications resulting in long term sequelae. Access complications occurred in 1 (1.1 %) patients. Transfemoral conversion was required in 3 (3.3 %) patients., Conclusions: The Ballast 088 long sheath is safe and effective for TRA in neuroendovascular procedures with a low rate of complications and conversion., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Aneurysms associated with fenestrations of intracranial arteries are exceptionally rare findings. Management strategies for these aneurysms are not well-defined, especially regarding endovascular treatment. We sought to investigate the strategies and feasibility of endovascular treatment approaches for various fenestration-associated intracranial aneurysms., Methods: We performed a retrospective chart review of 2000 aneurysms treated endovascularly, identifying 8 aneurysms located at arterial fenestrations. The technical details and procedural outcomes were reviewed to identify common management approaches, technical nuances, and treatment outcomes., Results: There were 3 (37.5%) aneurysms associated with fenestrations of the basilar artery or vertebrobasilar junction. All 3 were successfully treated with a previously undescribed coil-assisted flow-diversion technique, resulting in complete obliteration. Three (37.5%) aneurysms were associated with fenestrations of the anterior communicating artery. Of those, 2 were successfully treated with stent-assisted coil embolization and 1 with coil embolization alone. One (12.5%) aneurysm was associated with a fenestration of the paraclinoid internal carotid artery and 1 (12.5%) aneurysm found was at the takeoff of the posterior inferior cerebellar artery at a fenestration of the vertebral artery. Both were successfully treated with coil-assisted flow diversion. There were no permanent procedural complications. Major considerations for endovascular management of these aneurysms were the dominance of fenestration trunks, aneurysms arising from the fenestration apex or a fenestration limb, amenability to flow diversion, and anticipation of vascular remodeling., Conclusions: Fenestration-associated aneurysms are very rare. We have identified common factors to help guide decision-making for endovascular approaches and demonstrate successful aneurysm treatment using these methods., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Neuroangiography has seen a recent shift from transfemoral to transradial access. In transradial neuroangiography, the right dominant hand is the main access used. However, the left side may be used specifically for left posterior circulation pathologies and when right access cannot be used. This study describes our initial experience with left radial access for diagnostic neuroangiography and assesses the feasibility and safety of this technique. We performed a retrospective review of a prospective database of consecutive patients between April 2018 and January 2020, and identified 20 patients whom a left radial access was used for neurovascular procedures. Left transradial neuroangiography was successful in all 20 patients and provided the sought diagnostic information; no patient required conversion to right radial or femoral access. Pathology consisted of anterior circulation aneurysms in 17 patients (85%), brain tumor in 1 patient (5%), and intracranial atherosclerosis disease involving the middle cerebral artery in 2 patients (10%). The left radial artery was accessed at the anatomic snuffbox in 18 patients (90%) and the wrist in 2 patients (10%). A single vessel was accessed in 7 (35%), two vessels in 8 (40%), three vessels in 4 (20%), and four vessels in 1 (5%). Catheterization was successful in 71% of the cases for the right internal carotid artery and in only 7.7% for the left internal carotid artery. There were no instances of radial artery spasm, radial artery occlusion, or procedural complications. Our initial experience found the left transradial access to be a potentially feasible approach for diagnostic neuroangiography even beyond the left vertebral artery. The approach is strongly favored by patients but has significant limitations compared with the right-sided approach.

Objective: In this study, the authors aimed to investigate procedural and clinical outcomes between radial and femoral artery access in patients undergoing thrombectomy for acute stroke., Methods: The authors conducted a single-institution retrospective analysis of 104 patients who underwent mechanical thrombectomy, 52 via transradial access and 52 via traditional transfemoral access. They analyzed various procedural and clinical metrics between the two patient cohorts., Results: There was no difference between patient demographics or presenting symptoms of stroke severity between patients treated via transradial or transfemoral access. The mean procedural time was similar between the two treatment cohorts: 60.35 ± 36.81 minutes for the transradial group versus 65.50 ± 29.92 minutes for the transfemoral group (p = 0.451). The mean total fluoroscopy time for the procedure was similar between the two patient cohorts (20.31 ± 11.68 for radial vs 18.49 ± 11.78 minutes for femoral, p = 0.898). The majority of patients underwent thrombolysis in cerebral infarction score 2b/3 revascularization, regardless of access site (92.3% for radial vs 94.2% for femoral, p = 0.696). There was no significant difference in the incidence of access site or periprocedural complications between the transradial and transfemoral cohorts., Conclusions: Acute stroke intervention performed via transradial access is feasible and effective, with no significant difference in procedural and clinical outcomes compared with traditional transfemoral access. Larger studies are required to further validate the efficacy and limitations of transradial access for neurointerventional procedures.

Background: Posterior circulation tandem occlusions are poorly characterized in current literature. Data regarding endovascular approaches and outcomes in this patient subgroup is extremely limited., Methods: We conducted a retrospective analysis of a prospectively maintained database and identified 17 patients with posterior circulation tandem occlusions who underwent mechanical thrombectomy between 2014 and 2019., Results: Of 17 patients with posterior circulation tandem occlusion, the mean age was 55.76 ± 11.8 with 35.3% female. The mean NIHSS score on presentation was 17.2 ± 9.2. Tissue plasminogen activator was administered in 7 (41.2%) patients, stent-retrievers alone were used in 2 (11.8%), aspiration catheters alone were used in 2 (11.8%), a combination was used 12 (70.6%), and a self-expandable stent in 5 (29.4%). The mean number of device passes was 2.24 ± 2.02, recanalization failure occurred in 4 (23.5%) patients, the mean time from stroke onset to puncture was 6.9 ± 2.4 h, and the mean time from puncture to recanalization was 59.3 ± 26.6 min. Postprocedural symptomatic ICH occurred in 1 (5.9 %) patient, periprocedural ICH/SAH occurred in 2 (11.8%), periprocedural distal emboli occurred in 0 (0%), periprocedural vessel dissection occurred in 1 (5.9%), and periprocedural vessel perforation occurred in 1 (5.9%) patient. TICI score>2b was achieved in 13 (76.5%) patients. An improvement in NIHSS>3 at discharge occurred in 10 (58.8%) patients, and good outcomes (mRS score < 2) occurred in 7 (41.2%). The mean length of stay was 11.6 ± 12.2 days, and the mortality rate was 41.2%., Conclusion: Endovascular intervention with mechanical thrombectomy is safe and feasible in patients with posterior circulation tandem occlusions., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) has become the mainstay in treatment for these pathologies. Traditional techniques required the formation of a proximal plug of Onyx around the microcatheter prior to embolization to avoid reflux. Recently, dual-lumen balloon catheters have been introduced as a potential solution to this issue. We sought to compare our institutional experience with dual-lumen balloons to traditional microcatheters in the endovascular embolization of AVMs and DAVFs. A retrospective analysis of consecutive patients treated with Scepter between 2016 and 2020 was obtained. A control cohort treated with Marathon between 2012 and 2020 was also obtained. Variables collected included patient demographics, procedure times, pedicles treated, operative complications, obliteration rate, and retreatment rate. A total of 44 trial (30 DAVFs and 14 AVMs) and 25 control (15 DAVFs and 10 AVMs) subjects were identified. Average Scepter procedure times were 66.0 and 68.0 min for DAVFs and AVMs, respectively. Average Scepter volume of Onyx injected was 2.2 and 1.4 mL for DAVFs and AVMs, respectively. Complete angiographic occlusion Scepter rate was 86.7% and 50.0% for DAVFs and AVMs, respectively. The Scepter retreatment rate was 13.3% and 50.0% for DAVFs and AVMs, respectively. Predictors of angiographic occlusion included the number of pedicles (OR 0.54, 95%CI 0.30-0.97, p = 0.04). Predictors of retreatment included DAVF (OR 0.16, 95%CI 0.04-0.66, p = 0.01) and Marathon (OR 3.34, 95%CI 1.00-11.56, p = 0.05). Our study shows that dual-lumen balloon catheters are a viable option in the embolization of DAVFs and AVMs., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Mobile stroke units (MSUs), specialized ambulances with a built-in computed tomography (CT) scanner and telemedicine connected stroke team, have been on the rise in recent years largely due to the 'time is brain' concept. We aim to report our initial experience since establishing our MSU, the first unit in the Tri-state area, and assess its impact on the stroke standards of care timeline., Methods: We conducted a retrospective analysis of a prospectively maintained database of all MSU dispatched cases from August 2019 to March 2020., Results: Of 195 MSU responses, 101 were treated and transported by the MSU. The mean time (hr:mm) of dispatch to scene arrival was 0:07+0:03, scene arrival to CT start was 0:10+0:03, CT start to teleneuro start was 0:05+0:03, teleneuro start to scene departure was 0:06+0:05, scene departure to hospital arrival was 0:12+0:06, and hospital arrival to arterial puncture was 2:59+1:01. The mean time of dispatch to arterial puncture was 3:34+1:02. The mean teleneuro consult duration was 0:04+0:02. The mean time of last know well (LKW) to tPA administration was 1:28+0:48 with 4 (57.1 %) patients receiving tPA within 60 min of LKW and 5 (71.4 %) patients receiving tPA within 90 min. The mean time of dispatch to tPA was 0:37+0:09 and scene arrival to tPA administration was 0:28+0:07., Conclusion: MSUs may expedite each step along the stroke standards of care. In theory, this should drastically improve functional outcomes. However, the impact on functional outcomes or reductions in stroke-related morbidity is still unknown., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Visual dysfunction and headache are major symptoms in patients with idiopathic intracranial hypertension (IIH). We aimed to evaluate the improvement of these symptoms in patients who underwent ventriculoperitoneal (VPS) and lumboperitoneal (LPS) shunting., Methods: Electronic medical records were reviewed to identify baseline and treatment characteristics for patients diagnosed with IIH over 10 years. Visual outcomes and headache were evaluated at the latest follow-up post shunting., Results: We included 163 patients with a mean age of 32.6 years. Most patients (74.2%) underwent VPS versus 25.8% of patients who received LPS. After a mean follow-up duration of 35 months, there was a 58.3% decrease in patients reporting headache (P = 0.006), an 87.7% decrease in papilledema (P = 0.1), a 100% resolution of diplopia with VPS or LPS, and an 88.5% decrease in transient visual obscurations (P = 1). In the worse eye, improved visual acuity (VA) occurred in 53.7% of eyes (P = 1), was stable in 16.4%, and worsened in 29.8%. The mean LogMAR VA was improved by 0.06 LogMAR (20/68) in the worse eye (P = 0.97) and 0.08 LogMAR (20/31) in the better eye (P = 0.7). The visual function that impairs daily activity was decreased by 55.4% (P = 0.08). Patients shunted within 1 month of presentation had a significantly higher rate of headache (P = 0.04) and VA improvement (P < 0.001)., Conclusions: VPS and LPS are effective in improving visual symptoms and headache in patients with IIH., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Carotid blowout syndrome (CBS) is a potential complication of head and neck cancer, and its therapy is associated with high morbidity and mortality. Recent advances in endovascular techniques have improved patient outcomes. In this study, we report outcomes of emergent endovascular intervention for CBS., Methods: We conducted a retrospective analysis of a prospectively maintained neurovascular database and identified 38 consecutive endovascular procedures for CBS from 2008-2019 at our institution. Data collection was performed on patient demographics, type of cancer, previous cancer treatments, type of CBS, location of bleed, diagnostic workup, endovascular treatment, and procedural outcomes and complications., Results: A total of 38 consecutive endovascular procedures for CBS were performed from 2008-2019 at our single academic institution. Technical success was achieved in 100% of endovascular procedures. Procedural stroke occurred in 1 (2.6%) procedure, procedural mortality occurred in 1 (2.6%) procedure, recurrent CBS occurred in 4 (10.5%) procedures, and fatal rehemorrhage occurred in 1 (2.6%) procedure. Regarding secondary outcomes, delayed stroke/transient ischemic attack occurred in 1 (2.6%) procedure, whereas there were no cases of delayed infectious complications., Conclusions: The endovascular treatment of CBS is safe and effective with relatively low rates of morbidity and mortality compared with other currently available treatment modalities. However, the overall rate of complications demands attention and sheds light on the need for further improvement in management., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Double stent-assisted coiling of wide-neck bifurcation aneurysms (WNBAs) can be technically challenging with high thromboembolic rates. Single stent-assisted coiling (SSAC) decreases procedural complexity and thromboembolic risk but increases risk of coil prolapse and recanalization. In this study, we present our institution's experience with SSAC of WNBA performed via a "shouldering" and "framing" with a single Atlas stent and a spherical 3-dimensional (3D) Stryker coil., Methods: A retrospective review of 35 patients who underwent SSAC of WNBA performed via a shouldering and framing with a single Atlas stent and a spherical 3D Stryker coil from 2018 to 2019. Data collection were performed on baseline demographics, clinical presentation, aneurysm characteristics, angiographic and functional outcomes, and perioperative and postoperative complications., Results: Of 35 patients, the mean age was 59.9 ± 11.6 years and 25/35 (71.4%) were women. The mean aneurysm diameter was 6.3 ± 3.4 mm, the mean neck size was 3.9 ± 1.3 mm, and the mean dome-to-neck ratio was 1.5 ± 0.6. Initial complete/near-complete occlusion was demonstrated in 30/35 (85.7%) patients. On angiographic follow-up at a mean of 6 months, 9/24 (37.5%) patients showed progressive thrombosis, 13/24 (54.2%) showed stable occlusion, and 2/24 (8.5) showed recanalization. Thromboembolic events occurred in 2/35 (5.7%) patients, intraoperative technical complications occurred in 2/35 (5.7%) patients, and access-site complications occurred in 2/35 (5.7%) patients. The were no cases of retreatment, rehemorrhage, or procedural-related permanent morbidity or mortality., Conclusions: Coil embolization performed via shouldering with a single Atlas stent and framing with a spherical 3D Stryker coil is a feasible, safe, and effective neuroendovascular treatment for WNBAs., (Published by Elsevier Inc.)

Objectives: Intra-arterial chemotherapy (IAC) has become one of the most important pillars in retinoblastoma (Rb) management. It allows for targeted delivery of chemotherapy by superselective catheterization of the ophthalmic artery, thus, reducing systemic toxicity. As in most neurovascular procedures, IAC has traditionally been performed through a transfemoral access. However, recent publications have spurred the use of the transradial route for neuroendovascular procedures due to its lower complication rates and higher patient satisfaction. Here, we present the first case series in the literature on the technique, safety, and feasibility of IAC via the transradial route in the pediatric population., Patients and Methods: We retrospectively analyzed our prospectively maintained database and present our technique and initial experience from 5 consecutive pediatric patients aged between 3 and 15 years who underwent 10 transradial IAC treatments., Results: All IACs were performed successfully. Two patients had repeat IACs through the same wrist. There were no thromboembolic events or access site complications, such as hand ischemia or hematoma. All patients were discharged home the same day of the procedure., Conclusion: Our case series demonstrates the safety and feasibility of transradial IAC in pediatric patients with Rb. As more experience is gained with the transradial route for neurovascular procedures in adults, it may become the preferred route in some pediatric patients as well., Competing Interests: Conflict of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI)., Methods: The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018., Results: A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1-47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44-50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0-1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6-87.1; p = 0.003)., Conclusions: The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.

Background: The transradial approach has slowly been gaining momentum in neuroendovascular procedures. We sought to assess its feasibility and safety and present a case series of transradial intraoperative angiography (IOA) during microsurgical clip ligation of intracranial aneurysms., Methods: The setup and technique for transradial intraoperative angiography are described. Data on 10 consecutive patients undergoing IOA through the radial artery are presented., Results: All target vessels were successfully catheterized transradially, and conversion to the transfemoral access was not required in any of the cases. There was no access-site complication, such as hand ischemia, hematoma, or radial artery spasm. There were also no thromboembolic events causing a stroke. The average time for the IOA was 9.3 minutes., Conclusions: Our initial experience shows the transradial approach for IOA in clip ligation of aneurysms to be feasible and safe, with potential advantages over transfemoral IOA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Several independent randomized controlled trials have shown superior efficacy of mechanical thrombectomy (MT) for management of acute ischemic stroke (AIS). However, elderly patients have been underrepresented or excluded in these trials. The aim of this study was to investigate the feasibility and safety of MT in patients with AIS ≥90 years old., Methods: A retrospective review was performed of patients ≥90 years old presenting with AIS who underwent MT between 2010 and 2018., Results: Of 453 patients with AIS, 5.74% (n = 26) were ≥90 years old, and 69.32% (n = 314) were 60-89 years old. Of baseline characteristics between both groups, there was a significant difference in age, sex, body mass index, smoking, hyperlipidemia, atrial fibrillation, and diabetes mellitus. Mean National Institutes of Health Stroke Scale score on admission was higher in the nonagenarians (17 vs. 15). Similar proportions of both groups received tissue plasminogen activator, 57.69% (n = 15) versus 42.68% (n = 134), P = 0.14). There was no difference in periprocedural and postprocedural complications, good Thrombolysis In Cerebral Infarction scores (88.46% [n = 23] vs. 87.58% [n = 275], P = 1.00), good modified Rankin Scale scores (34.62% [n = 4] vs. 49.36% [n = 155], P = 0.40), or mortality (11.54% [n = 3] vs. 13.06% [n = 41], P = 0.82)., Conclusions: Age is a factor that affects functional outcome following MT. Advancements in catheter techniques, technical experience, and great outcomes with MT allow for pushing the boundaries to consider age as one factor, rather than an exclusion criterion. Our results show that MT is safe and feasible in nonagenarians., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Flow-diverting stents had gained prominence among neurointerventionalists. Aneurysms originating from distal vessels, particularly dissecting or fusiform, pose more technical challenges. The aim of the following single center large series was to report the safety, efficacy, and functional outcome of flow diversion for aneurysms originating from small caliber vessel and compare to proximal vessels group., Methods: A retrospective chart review of a prospectively maintained database for subjects treated with flow diversion from 2010-2019., Results: A total of 598 aneurysms were treated during a period extending from 2010-2019 (87.8% large caliber group versus 12.20% small caliber group); 84.28% (N.=504) were females and the average age was 55.5 years. Ischemic stroke occurred at a rate of 2.99% with a non-significant difference between both groups. Delayed aneurysmal rupture and distal intraparenchymal bleed occurred at a rate of 3.70% with a non-significant difference between both groups. Complete aneurysms occlusion was seen at a rate of 75.3% with a non-significant difference between both groups. Morbidity rate occurred at a rate of 5.8% with non-significant difference between both groups. Multivariate logistic regression showed that small vessel was an independent predictor of aneurysm obliteration with a 2.6-fold-higher likelihood., Conclusions: Flow-diverting stents are being used to treat diverse types of aneurysms and in various locations, in distal small caliber vessels where other treatment options pose a considerable risk. Small caliber group had similar complication and occlusion rates compared to proximal vessel group.

Objective: MRI and MRA studies are routinely obtained to identify the etiology of intracerebral hemorrhage (ICH). The diagnostic yield of MRI/MRA in the setting of an acute ICH, however, remains unclear. The authors' goal was to determine the utility of early MRI/MRA in detecting underlying structural lesions in ICH and to identify patients in whom additional imaging during hospitalization could safely be foregone., Methods: The authors reviewed data obtained in 400 patients with spontaneous ICH diagnosed on noncontrast head CT scans who underwent MRI/MRA between 2015 and 2017 at their institution. MRI/MRA studies were reviewed to identify underlying lesions, such as arteriovenous malformations, aneurysms, cavernous malformations, arteriovenous fistulas, tumors, sinus thrombosis, moyamoya disease, and abscesses., Results: The median patient age was 65 ± 15.8 years. Hypertension was the most common (72%) comorbidity. Structural abnormalities were detected on MRI/MRA in 12.5% of patients. Structural lesions were seen in 5.7% of patients with basal ganglia/thalamic ICH, 14.1% of those with lobar ICH, 20.4% of those with cerebellar ICH, and 27.8% of those with brainstem ICH. Notably, the diagnostic yield of MRI/MRA was 0% in patients > 65 years with a basal ganglia/thalamic hemorrhage and 0% in those > 85 years with any ICH location, whereas it was 37% in patients < 50 years and 23% in those < 65 years. Multivariate analysis showed that decreasing age, absence of hypertension, and non-basal ganglia/thalamic location were predictors of finding an underlying lesion., Conclusions: The yield of MRI/MRA in ICH is highly variable, depending on patient age and hemorrhage location. The findings of this study do not support obtaining early MRI/MRA studies in patients ≥ 65 years with basal ganglia/thalamic ICH or in any ICH patients ≥ 85 years. In all other situations, early MRI/MRA remains valuable in ruling out underlying lesions.

Objective: The authors sought to determine the predictors of late neurological and hospital-acquired medical complications (HACs) in patients with low-grade aneurysmal subarachnoid hemorrhage (aSAH)., Methods: The authors conducted a retrospective study of 424 patients with low-grade aSAH admitted to their institution from 2008 to 2015. Data collected included patient comorbidities, Hunt and Hess (HH) grade, ICU length of stay (LOS), and complications. A logistic regression analysis was performed to determine the predictors for neurological and hospital-associated complications., Results: Out of 424 patients, 50 (11.8%) developed neurological complications after the first week, with a mean ICU stay of 16.3 ± 6.5 days. Of the remaining 374 patients without late neurological complications, 83 (22.2%) developed late HACs with a mean LOS of 15.1 ± 7.6 days, while those without medical complications stayed 11.8 ± 6.2 days (p = 0.001). Of the 83 patients, 55 (66.3%) did not have any HACs in the first week. Smoking (p = 0.062), history of cardiac disease (p = 0.043), HH grade III (p = 0.012), intraventricular hemorrhage (IVH) (p = 0.012), external ventricular drain (EVD) placement (p = 0.002), and early pneumonia/urinary tract infection (UTI)/deep vein thrombosis (DVT) (p = 0.001) were independently associated with late HACs. Logistic regression showed early pneumonia/UTI/DVT (p = 0.026) and increased HH grade (p = 0.057) to be significant risk factors for late medical complications., Conclusions: While an extended ICU admission allows closer monitoring, low-grade aSAH patients develop HACs despite being at low risk for neurological complications. The characteristics of low-grade aSAH patients who would benefit from early discharge are reported in detail.