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Background and Purpose: Isolated basal ganglia strokes are thought to have worse clinical outcomes as compared to mixed and cortical infarcts. Methods: Review of a prospectively collected database of endovascular patients with anterior circulation Large vessel occlusion strokes from January 2014-June 2018. Only patients with an ASPECT score of 6 to 9 were included. Patients were dichotomized into 2 groups according to ASPECT region involvement: (i) isolated basal ganglia and (iBG) (ii) other stroke patterns. Baseline characteristics and Clinical outcomes were compared. Results: 465 patients qualified for the study of which 324 (70%) were iBG strokes. Baseline characteristics were comparable between the 2 groups except for higher rates of hypertension (73.8%vs63.8%,p=0.03) and larger CTP core infarct (3.6 cc[0-13] vs 3[0-10.85], p Conclusions: iBG strokes carry similar procedural and clinical outcomes as other stroke patterns with a trend towards lower mortality.

Introduction: The optimal approach for distal intracranial occlusions in thrombectomy for acute ischemic stroke is unclear. We aim to compare our experience with 3mmx20 Trevo Retriever against the Penumbra 3max in small vessels. Methods: Retrospective review of a prospective thrombectomy databank for consecutive cases of use of 3mmx20 Trevo Retriever or Penumbra 3max for middle cerebral artery (MCA) mid or distal M2, M3, anterior cerebral artery (ACA A1, A2, A3) or posterior cerebral artery (PCA P1, P2) from Jan 2014-July 2018. Results: Of 1071 patients treated within the study period, 136 patients/144 different arteries underwent treatment with small devices (3mmTrevo n=92 vs 3Max n=52). There was no difference in the distal occlusion presentation: isolated distal occlusion, emboli to new or same distal territory, or multiple occlusions (p=0.11). The distribution of occlusions site was comparable (p=0.37). Demographics were comparable including age, gender, hypertension, atrial fibrillation, systolic blood pressure, last-normal to puncture. The use of intravenous alteplase was similar (p=0.47) as well as the use of balloon guide catheter (p=1.00). The approached vessel pre-clot diameter was comparable between the 3mmTrevo and 3Max groups (1.6±0.2mm vs 1.4±0.3;p=0.66), respectively. The frequency of superior vs inferior vs middle MCA division was similar (p=0.42) amongst arms. A trend for higher first-pass mTICI2b-3 reperfusion was noted in the 3mmTrevo (62% vs 44%;p=0.05) vs 3Max group. Rates of first-pass full reperfusion was comparable (42% vs 34%;p=0.38). Adjuvant therapy was used less frequently in the 3mm Trevo group (15% vs 31%;p=0.03) for comparable final mTICI3 rates (p=0.22). The number of passes (1.3±0.5 vs 1.3±0.6; p=0.9) and the frequency of arterial spasm (any spasm; p=1.00) were comparable between groups. 90-day rates of good outcomes (35/76 vs 21/43; p=0.84) were comparable amongst arms. Subarachnoid hemorrhage (p=0.37) and parenchymal hematomas (p=0.21) in the territory of approached vessel was similar. Conclusions: The 3mm Trevo may lead to enhanced rates of successful reperfusion as compared to 3Max thromboaspiration. Further studies are warranted.

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.

Purpose: Carotid web (CaW) is an underrecognized cause of cryptogenic stroke in young patients. The optimal imaging for CaW is unknown. We aim to evaluate the diagnostic accuracy of diverse imaging modalities for the diagnosis of CaW.Methods: Retrospective analysis of institutional neurovascular database was performed to identify patients with multimodal (CT angiogram–CTA, digital subtraction angiogram–DSA, and/or ultrasound–US) imaging diagnosis of CaW or atherosclerosis. Baseline clinical demographics were recorded. Blinded image analysis was performed for each imaging modality by separate readers. Discrepancies were settled by consensus. Two-sided Cohen's Kappa (κ) coefficient was used to evaluate the inter-rater agreement for the etiological diagnosis between imaging modalities.Results: Thirty patients/60 carotids were evaluated by CTA and 55 carotids were included. Patients with symptomatic CaW (n = 20), compared to individuals with atherosclerosis (n = 10), were younger (49 ± 9 vs. 60 ± 8 years; p < 0.01), more commonly female (75% vs. 30%; p = 0.01), and less frequently presented vascular risk factors: Hypertension (40% vs. 100%; p < 0.01), hyperlipidemia (0% vs. 50%; p < 0.01), diabetes (10% vs. 40%; p = 0.05), and smoking (5% vs. 70%; p < 0.01). High inter-rater correlation strength existed for CTA (n = 55; κ = 0.88; p < 0.0001) and DSA (n = 28; κ = 0.86, p < 0.0001) readers for lesion diagnosis while US inter-rater agreement was lower (κ = 0.553; p = 0.001). Across modalities CTA and DSA shared very high strength of agreement (κ = 0.92; p < 0.0001), compared to a less pronounced agreement between US and CTA (κ = 0.553; p = 0.001). The strength of correlation between DSA-CTA was significantly more robust as compared to US-CTA (Z = 3.58; p = 0.0003).Conclusion: CTA and DSA demonstrated comparable and superior performance as compared to US in the diagnosis of CaW.

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.

Background: A carotid web (CaW) is a shelf-like lesion in the posterior aspect of the internal carotid bulb and represents an intimal variant of fibromuscular dysplasia. CaW has been associated with recurrent strokes and conventionally treated with surgical excision. We report a multicenter experience of stenting in patients with symptomatic CaWs. Methods: Retrospective review of consecutive patients admitted to 5 comprehensive stroke centers who were identified to have a symptomatic CaW and treated with carotid stenting. A symptomatic CaW was defined by the presence of a shelf-like/linear, smooth filling defect in the posterior aspect of the carotid bulb diagnosed by neck CT angiography (CTA) and confirmed with conventional angiography in patients with negative stroke workup. Results: Twenty-four patients with stented symptomatic CaW were identified (stroke in 83% and transient ischemic attack in 17%). Their median age was 47 years (IQR 41–61), 14 (58%) were female, and were 17 (71%) black. The degree of stenosis by NASCET was 0% (range 0–11). All patients were placed on dual antiplatelets and stented at a median of 9 days (IQR 4–35) after the last event. Closed-cell stents were used in 18 (75%) of the cases. No periprocedural events occurred with the exception of 2 cases of asymptomatic hypotension/bradycardia. Clinical follow-up after stent placement occurred for a median of 12 months (IQR 3–19) with no new cerebrovascular events noted. Functional independence at 90 days was achieved in 22 (91%) patients. Follow-up vascular imaging (ultrasound n = 18/CTA n = 5) was performed at a median of 10 months (IQR 3–18) and revealed no stenosis. Conclusions: Stenting for symptomatic CaW appears to be a safe and effective alternative to surgical resection. Further studies are warranted.

INTRODUCTION: Increasing reports suggest that patients have been reluctant to present for care due to fear of contracting severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), even in the setting of ischemic stroke or myocardial infarction The impact of the ongoing pandemic on patients with aneurysmal subarachnoid hemorrhage (aSAH) remains unknown METHODS: We performed a retrospective cohort study of all patients presenting to a single referral center in Atlanta, Georgia, USA with aSAH between 2012 and 2020 SARSCoV- 2 was first reported in Georgia on March 2, 2020 All patients presenting from March through June of a given calendar year were compared from the pre-SARS-CoV-2 era (2012-2019) to the SARS-CoV-2 era (2020) Patient characteristics, latency from ictus to presentation, and clinical outcomes were compared RESULTS: A total of 472 patients presented with aSAH during the study period, with comparable distribution in the age, sex, and Hunt and Hess grade on presentation The mean latency in days from ictus to presentation was significantly longer in 2020 when compared to the pre- SARS-CoV-2 era (2 3, + 3 0 vs 0 9 + 2 2, respectively, p< 05) Absolute rates of discharge home or in-hospital mortality were not significantly different In binary regression analysis, patients were more likely to present post-bleed day 2 or after (OR 3 9, 1 9-8 1, p< 05) This effect was driven by delays to presentation in low grade aSAH (OR 3 2, 1 1-9 25, p< 05) with no difference to time in presentation in highgrade aSAH (2 3, 0 25 - 21 6) The delay to presentation was persistent on multiple binary regression analysis after controlling for age and grade (aOR 3 7, 1 7-8 0, p< 05) There was a non-significant trend towards increased mortality in the SARS-CoV-2 era on multiple regression analysis (2 78, 0 95-8 16) CONCLUSIONS: Similar to patients with myocardial and cerebral infarctions, patients are presenting for care later after an aSAH This effect is driven by low grade aSAH, as high grade aSAH patients with a more fulminant presentation are still largely presenting within the first day, similar to the pre- SARS-CoV-2 era These data highlight the ongoing collateral damage of the SARS-CoV-2 pandemic and need for vigilant public health efforts to encourage rapid presentation for care

IntroductionThe minimal stroke severity justifying endovascular intervention remains elusive; however, a significant proportion of patients presenting with large vessel occlusion (LVO) and mild symptoms subsequently decline and face poor outcomes.ObjectiveTo evaluate our experience with these patients by comparing best medical therapy with thrombectomy in an intention-to-treat analysis.MethodsAnalysis of prospectively collected data of all consecutive patients with National Institutes of Health Stroke Scale (NIHSS) score ≤5, LVO on CT angiography, and baseline modified Rankin Scale (mRS) score 0–2 from November 2014 to May 2016. After careful discussion with patients/family, a decision to pursue medical or interventional therapy was made. Deterioration (development of aphasia, neglect, and/or significant weakness) triggered reconsideration of thrombectomy. The primary outcome measure was NIHSS shift (discharge NIHSS score minus admission NIHSS score).ResultsOf the 32 patients qualifying for the study, 22 (69%) were primarily treated with medical therapy and 10 (31%) intervention. Baseline characteristics were comparable. Nine (41%) medically treated patients had subsequent deterioration requiring thrombectomy. Median time from arrival to deterioration was 5.2 hours (2.0–25.0). Successful reperfusion (modified Treatment in Cerebral Infarction 2b−3) was achieved in all 19 thrombectomy patients. The NIHSS shift significantly favored thrombectomy (−2.5 vs 0; pConclusionsThrombectomy led to a shift towards a lower NIHSS in patients with LVO presenting with minimal stroke symptoms. Despite the overall perception that this condition is benign, nearly a quarter of patients primarily treated with medical therapy did not achieve independence at 90 days.

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 and Purpose— Intravenous tissue-type plasminogen activator (tPA) treatment in acute stroke has many exclusion criteria. We aimed to assess the safety and efficacy of endovascular therapy (ET) in intravenous (IV) tPA-ineligible patients. Methods— Retrospective analysis of a prospectively collected database of consecutive patients treated with ET within 6 hours of stroke onset between September 2010 and April 2015. Patients treated with IV-tPA followed by ET were compared with those treated with ET alone because of IV-tPA ineligibility. Efficacy and safety end points included the rates of good outcome (90-day modified Rankin scale score ≤2), successful reperfusion (modified Treatment in Cerebral Ischemia 2b-3), parenchymal hematoma (PH-1 and PH-2), and 90-day mortality. Univariate and logistic regression were performed to identify the predictors of outcomes. Results— A total of 422 patients were included. Two hundred and fifty-three (59%) patients received IV-tPA+ET, and 169 (41%), ET alone. Combined IV-tPA+ET patients were slightly younger (64.9±15.2 versus 67.9±14.9 years; P =0.05), more often males (56% versus 44%; P =0.01), and had less hypertension (70% versus 81%; P =0.02) and vertebrobasilar occlusions (3% versus 8%; P =0.02). The remaining baseline characteristics, including National Institutes of Health Stroke Scale score (20 [15–23] versus 19 [15–24]; P =0.85), Alberta Stroke Program Early CT Score (ASPECTS; 8 [7–9] versus 8 [7–9]; P =0.24), and stroke onset to puncture times (235±70 versus 240±81 minutes; P =0.27), were similar across both groups. There were no significant differences in the rates of modified Treatment in Cerebral Ischemia 2b-3 (83% versus 80%; P =0.52), 90-day modified Rankin scale score ≤2 (45% versus 38%; P =0.21), or any PH (3% versus 5%; P =0.21). Unadjusted 90-day mortality was higher with ET alone (21% versus 34%; P Conclusions— IV-tPA-eligible and -ineligible patients seem to have similar outcomes after early ET.

Background: Ischemic strokes due to tandem occlusions (TOs) have poor outcomes if they have been treated with only medical interventions. Recent trials demonstrated the effectiveness of endovascular treatment of acute ischemic stroke due to intracranial occlusions; however, most studies excluded patients with TOs. Methods: Retrospective review of prospectively collected thrombectomy databases from 3 stroke centers between 2011 and 2015. Consecutive patients with tandem extracranial steno-occlusive carotid disease and intracranial occlusions who underwent emergent thrombectomy were selected. Angiographic and clinical outcomes were analyzed; baseline and procedural variables were included in univariate and multivariate analyses to define the independent predictors of good outcomes (90-day modified Rankin Scale ≤2). Results: A total of 100 patients met the study inclusion criteria. The mean age was 64.4 ± 12.5, baseline National Institutes of Health Stroke Scale (NIHSS) 17.6 ± 5.0, time from last known well to puncture 7.3 ± 5.8 h, and Alberta Stroke Program Early CT Score (ASPECTS) 7.5 ± 1.6. Forty percent received intravenous tissue plasminogen activator. Intracranial occlusion sites included: internal carotid artery thrombus, 31%; middle cerebral artery (MCA)-M1, 53%; MCA-M2, 10%; and anterior cerebral artery, 6%. Good outcome was achieved in 42% and successful reperfusion modified thrombolysis in cerebral infarction (mTICI ≥2B) in 88% of the cases, including complete (mTICI 3) reperfusion in 40%. Severe parenchymal hematoma (PH)-2 occurred in 6% of the patients and 90-day mortality was 20%. In the multivariate analysis, younger age (OR 0.93; 95% CI 0.88-0.98; p = 0.004), lower baseline NIHSS (OR 0.84; 95% CI 0.74-0.94; p = 0.003), higher ASPECTS (OR 1.50; 95% CI 1.02-2.19; p = 0.038), and mTICI 3 reperfusion (OR 3.56; 95% CI 1.18-10.76; p = 0.024) were independent predictors of good outcome at 90 days. Conclusions: Acute endovascular treatment of tandem anterior circulation occlusions yields good outcomes and has similar outcome predictors to isolated intracranial occlusions. Given their comparable clinical behavior, these patients should be included in future trials.

Background and Purpose: Acute ischemic stroke (AIS) in the elderly encompasses approximately one-third of all AIS cases. Outcome data have been for the most part discouraging in this population. We aim to evaluate the outcomes in a large contemporary series of elderly patients treated with thrombectomy. Methods: Retrospective analysis of a single-center endovascular database for consecutive elderly (≥80 years) patients treated for anterior circulation large vessel occlusion AIS between September 2010 and April 2015. Univariate- and multivariate analyses were performed to identify the predictors of good clinical outcome (90-day modified Ranking Scale [mRS] ≤2). Receiver operating characteristic curves were used to calculate the optimal final infarct volume (FIV) threshold to predict good outcomes. Results: A total of 111 patients met our inclusion criteria (mean age 84.8 ± 4.2 years; National Institutes of Health Stroke Scale [NIHSS] score 19.1 ± 5.6; time from last-known normal to puncture, 349.6 ± 246.6 min; 33% male; 68% Alberta Stroke Program Early CT Score [ASPECTS] ≥8). The rates of successful reperfusion (modified treatment in cerebral ischemia ≥2b), symptomatic intracranial hemorrhage and 90-day mortality were 80%, 7% and 41%, respectively. The overall rate of good outcome was 29% (n = 32/111) but was 52% (n = 13/25) in patients with baseline mRS score of 0-2 who were selected based on CT perfusion and treated with stent retrievers. On multivariate analysis, only ASPECTS (OR 2.17; 95% CI 1.28-3.67.7; p = 0.004) and baseline NIHSS score (OR 0.87; 95% CI 0.77-0.97; p = 0.013) were independently associated with good outcome. A FIV ≤16 ml demonstrated the greatest accuracy for identifying good outcomes (sensitivity 75.0%, specificity 82.6%). Conclusions: Our results are encouraging demonstrating nearly one-third of elderly patients achieving full independence at 90 days. Contemporary treatment paradigms employing optimized patient selection and modern thrombectomy technology may result in even better outcomes.

OBJECT Programmable shunts have a valuable role in the treatment of patients with hydrocephalus, but because a magnet is used to change valve settings, interactions with external magnets may reprogram these shunts. Previous studies have demonstrated the ability of magnetic toys and iPads to erroneously reprogram shunts. Headphones are even more ubiquitous, and they contain an electromagnet for sound projection that sits on the head very close to the shunt valve. This study is the first to look at the magnetic field emissions of headphones and their effect on reprogrammable shunt valves to ascertain whether headphones are safe for patients with these shunts to wear. METHODS In this in vitro study of the magnetic properties of headphones and their interactions with 3 different programmable shunts, the authors evaluated Apple earbuds, Beats by Dr. Dre, and Bose QuietComfort Acoustic Noise Cancelling headphones. Each headphone was tested for electromagnetic field emissions using a direct current gaussmeter. The following valves were evaluated: Codman Hakim programmable valve, Medtronic Strata II valve, and Aesculap proGAV. Each valve was tested at distances of 0 to 50 mm (in 5-mm increments) from each headphone. The exposure time at each distance was 1 minute, and 3 trials were performed to confirm results at each valve setting and distance. RESULTS All 3 headphones generated magnetic fields greater than the respective shunt manufacturer's recommended strength of exposure, but these fields did not persist beyond 5 mm. By 2 cm, the fields levels were below 20 G, well below the Medtronic recommendation of 90 G and the Codman recommendation of 80 G. Because the mechanism for the proGAV is different, there is no recommended gauss level. There was no change in gauss-level emissions by the headphones with changes in frequency and amplitude. Both the Strata and Codman-Hakim valves were reprogrammed by direct contact (distance 0 mm) with the Bose headphones. When a rotation component was added, all 3 headphones reprogrammed the Strata and Codman-Hakim valves at 0 mm. At all distances above 0 mm, the headphones did not affect the shunts. The proGAV valve was not affected by headphones at any distance. CONCLUSIONS Although all the headphones studied generated significant gauss fields at distances less than 5 mm, the programmable valve settings only changed at a distance of 0 mm (i.e., with direct contact). Given the subcutaneous location of the valve, the authors conclude that is highly unlikely that commercially available or customary headphones can contribute to the reprogramming of shunts.

Following craniectomy, hygromas are relatively common. While many cases resolve spontaneously, some patients develop neurologic deficits. Management of symptomatic hygromas often involves shunting or drainage. We present two patients who three weeks after decompressive hemicraniectomy developed declining neurologic status secondary to enlarging hygroma. Failing conservative management, both were treated with urgent cranioplasty and returned to neurologic baseline. Early cranioplasty may be safe and effective for symptomatic collections.

Digital subtraction angiography (DSA) has long been the imaging gold standard in the evaluation, treatment, and follow-up of cerebro- and spinovascular disorders. However, DSA has the disadvantages of invasiveness, contrast allergy or nephropathy, the impracticality of procedural preparation and recovery, and expense. Contrast-enhanced (CE), time-resolved (TR) magnetic resonance angiography (CE TR-MRA) is a sophisticated, relatively novel imaging modality that provides multiphasic contrast-enhanced visualization of the neurovasculature. Given the crucial role of angiography in all aspects of care for patients with complex neurovascular disorders, it is incumbent on those who care for these patients to understand the usefulness and pitfalls of novel imaging in this arena to ensure best practices, and to deliver cutting edge care to these patients in a way that minimizes cost, but does not compromise quality. CE TR-MRA has the potential to play an expanded role in the workup and follow-up across the spectrum of neurovascular disease, and this review is aimed to help neurosurgeons better understand how CE TR-MRA can be used to better manage patients in this cohort.

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.

Background Obesity has been associated with increased morbidity and mortality in the general population. However, several reports have described lower mortality rates in overweight or obese patients as compared to normal weight ones. Investigations into this phenomenon, commonly described as the obesity paradox, have yielded mixed results thus far. We sought to determine whether clinical outcomes differ between patients with acute ischemic stroke after endovascular therapy according to their body mass index (BMI). Methods We reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients that underwent endovascular therapy for acute large vessel occlusion acute ischemic stroke were categorized according to their BMI into four groups (1) underweight (BMI 30). Baseline characteristics, procedural radiological as well as outcome parameters were compared. Results 926 patients qualified for the study, of which 20 (2.2%) were underweight, 253 (27.3%) had a normal weight, 315 (34%) were overweight and 338 (36.5%) obese. When compared with normal weight (reference) overweight patients had higher rates of dyslipidemia, as well as diabetes, higher baseline glycemic and HbA1c levels. Conversely, obese patients were younger, less often smokers, and had higher rates of hypertension, as well as diabetes and higher baseline glycemic and HbA1c levels. Procedural characteristics including baseline NIHSS and ASPECT scores were comparable between groups. In terms of outcomes, rates of successful reperfusion (mTICI 2b-3), parenchymal hematomas, 90 Day good clinical outcomes (modified Rankin scale, mRS 0–2) and 90 day mortality were comparable between BMI groups. On multivariate analysis, BMI was not associated with good outcomes nor mortality whether as a continuous variables or a categorical variable. Conclusions In stroke patients treated with mechanical thrombectomy, BMI does not significantly impact outcomes. However, patients who are overweight or obese have more co-morbidities which should be individually addressed. Disclosures J. Grossberg: 1; C; Georgia Research Alliance. 4; C; NTI. M. Bouslama: None. D. Haussen: None. M. Frankel: None. R. Nogueira: None.

Introduction The Pipeline Embolization Device (PED) has greatly expanded the range of aneurysms amenable to endovascular treatment, including those with wide necks that incorporate branch vessels. Published occlusion rates of anterior circulation aneurysms treated with the PED typically exceed 85%1–7 with morbidity rates of less than 7%.7 8 Prompted by this success, the PED is being increasingly utilized for the off-label treatment of posterior circulation aneurysms with widely varying results.9 10 The purpose of this study was to examine the procedural, clinical, and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. Methods Retrospective review of the neurointerventional databases of three high-volume neurovascular centers was approved by respective institutional review boards to identify patients with vertebrobasilar aneurysms treated with the PED between 2012 and December 2016. Demographic, clinical, and angiographic data were collected from electronic medical records. Procedural details, including devices used and peri-procedural complications, were collected from operative reports. Preoperative digital subtraction angiography was reviewed to determine the morphological characteristics of treated aneurysms, including largest diameter in any dimension, location, shape, and incorporated branch vessels. Follow-up angiographic images were also reviewed for intra-PED stenosis and patency of branch vessels covered by the PED. Results During the study period, 27 patients with 29 vertebrobasilar aneurysms underwent 28 treatments with the PED. The patients were 37% (10/27) men and 63% (17/27) women with a mean age of 53.3 years (range, 32–75 years), 44% (12/27) of whom were previous or current smokers. 74% (20/27) of patients were asymptomatic at presentation. Six of the remaining patients presented with subarachnoid hemorrhage (SAH; 22%, 6/27) and one patient presented with stroke related to thrombosis of brainstem perforators incorporated into the aneurysm (3.7%, 1/27). Aneurysm locations included the basilar trunk (41%, 12/29), basilar tip (7%, 2/29), vertebral artery (VA) proximal to the posterior inferior cerebellar artery (PICA; 10%, 3/29), VA at the PICA origin (10%, 3/29), and post-PICA VA (17%, 5/29). There were 15 saccular aneurysms (50%) with a mean size of 8.1 mm (range, 1.7–38 mm), 13 fusiform aneurysms (47%) with mean size of 11.8 mm (range, 4.3–34 mm) and length of 11.4 mm (range, 3.4–33), and one 2.9 mm blister aneurysm. The overall procedural complication rate was 18% (5/28), and the neurologic morbidity and mortality rate was 11% (3/28). Excluding aneurysms in patients who died, angiographic follow up was available for 96% (26/27) of patients. Mean duration of follow up was 12 months (range, 3–59 months). At last angiographic follow up, 67% (18/27) of aneurysms were completely occluded and 81% (22/27) were completely or near-completely occluded. A total of 36 branch vessels in 21 patients were covered by at least one PED. At last angiographic follow up, 8% (3/36) of covered branch vessels were occluded, none of which were symptomatic. Conclusion Pipeline embolization of vertebrobasilar aneurysms is associated with a higher complication rate and lower occlusion rate compared with anterior circulation aneurysms, but may be a viable treatment option in select cases. Disclosures A. Wallace: None. M. Kamran: None. T. Madaelil: None. Y. Kayan: 2; C; Medtronic, Penumbra, MicroVention. A. Kansagra: None. J. Grossberg: None. J. Delgado Almandoz: 2; C; Medtronic, Penumbra, Microvention, Accriva Diagnostics. C. Moran: 2; C; Medtronic. A. Roy: None. D. Cross: None. B. Howard: None. C. Cawley: None. J. Dion: None. T. CreveCoeur: None. J. Osbun: 1; C; MicroVention.

Purpose Intracranial dural arteriovenous fistulas (dAVFs) constitute approximately 10%–15% of all intracranial vascular malformations. More rarely, these lesions can lead to intracranial hemorrhage. Early re-bleeding rates from unsecured, ruptured dAVFs have been reported as high as 50%. Therefore, early intervention is paramount. Our aim of this study was to investigate the angiographic and clinical outcomes of early endovascular intervention in this rare disease presentation. Methods A HIPPA compliant neuroendovascular procedural database was reviewed for all treated dAVFs from 1999 to 2017. Inclusion criteria for the study included: 1) hemorrhagic presentation and 2) early endovascular intervention defined as less than 48 hours from initial ictus. Clinical demographics, angiographic and procedural details (Anatomic location, Borden classification, route of embolization, material used during embolization, number of retreatments, and need for completion microsurgical ligation), as well as clinical and angiographic follow up outcomes (modified Rankin scale and occlusion status on last follow-up imaging) were recorded. Appropriate statistical analyses were performed on parametric and non-parametric variables as applicable (statistical significance, α=0.05). Results A total of 262 dAVFs were identified, of those only 18 patients met inclusion criteria. Overall, the majority of patients were male (12/18; 66%), with a median age of 56 years (IQR 46–68 years). Hemorrhagic presentations included isolated intraparenchymal hemorrhage (IPH) (8/18; 44%), isolated subarachnoid hemorrhage (SAH) (7/18; 39%), SAH with subdural hematoma/intraventricular hemorrhage (IVH) (2/18; 11%), and isolated IVH (1/18; 6%). Almost all the hemorrhagic dAVF were of the aggressive type (Borden type II/III, 17/18; 94%). Anatomically, the most common location was tentorial (8/18; 44%). The anterior fossa, torcula, superior sagittal sinus, and transverse/sigmoid sinus all proportionately were the next common location (2/18; 11%, each respective group). Foramen magnum and straight sinus were the least common locations (1/18; 6%, each respective group). Transarterial embolization was performed most commonly (15/18; 83%), followed by transvenous approach (3/18; 17%). nBCA glue or Onyx embolization was most commonly used (15/18; 83%) with coils used exclusively in all transvenous cases (3/18; 17%). At last clinical follow-up, two patients succumbed to complications related to initial hemorrhage with the majority of patients (14/16; 88%) achieving good clinical outcome (mRS=0–2). On imaging follow-up when residual dAVF or incomplete embolization was noted (5/12; 42%) all cases underwent endovascular retreatment. Overwhelmingly, endovascular re-treatment failed in the majority of the cases (3/5; 60%); requiring microsurgical ligation for completion therapy. In no instance was early or late re-bleeding observed on last clinical follow-up, median 5 months (IQR 2–19 months). Conclusion Early endovascular intervention for ruptured dAVFs is feasible and effectively secures these lesions with no re-bleeding. Attention must be paid to lesions, which are incompletely embolized/show residual filling, as microsurgical ligation is imperative for completion therapy. Disclosures T. Madaelil: None. J. Grossberg: None. M. Cawley: None. F. Tong: None. J. Dion: 5; C; Vice President, Scientific Affairs at MicroVention-Terumo. B. Howard: None.

Background Since its introduction in the early 90 s, endovascular treatment of cerebral aneurysms has had a steady upward trend and is the primary mode of treatment for most currently diagnosed cerebral aneurysms. Concurrently, the need for retreatment of cerebral aneurysms after prior endovascular treatment has also continued to grow, some of which can only be treated with microsurgical techniques. The factors that dictate outcomes in this group of patients are still not completely understood. Objective To study factors contributing to patient outcomes after microsurgical treatment of aneurysms with prior endovascular treatment. Methods Records were retrospectively reviewed for aneurysms treated after prior endovascular treatment. Demographics, treatment details and imaging were reviewed for all patients. A systematic review for these aneurysms was also conducted. Results A total of 86 aneurysms were identified from the retrospective review. Mean age at the time of initial treatment was 50±12.42 years. Most patients initially presented with subarachnoid hemorrhage prior to initial endovascular treatment, with only 10 (13.70%) patients presenting with incidentally discovered lesions. mRS at discharge after initial treatment was good (0–3) in 81.4% of cases. Functional outcomes at the last known follow-up revealed a mRS of 0–3 in 71 (83.5%) patients. Only the maximum diameter of aneurysm was found to be a significant predictor of surgical complications (Wald χ2=5.72, p=0.0168) with an odds ratio of 1.84 (95% CI: 1.10, 2.93) for a 5 mm increase in maximum diameter. Systematic review identified 37 studies that were used to pool data on 370 total 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. Conclusion 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. Disclosures A. Roy: None. L. Phillips: None. B. Howard: None. D. Barrow: None. J. Grossberg: 1; C; GRA. 4; C; NTI.

Purpose Carotid web is an intimal variant of fibromuscular dysplasia that has been associated with recurrent ischemic strokes in the young. The accuracy of different diagnostic tests is unknown. The objective of the present study is to evaluate the diagnostic performance of different imaging modalities for the detection of carotid webs. Methods Using an institutional neurovascular database, we retrospectively identified consecutive patients diagnosed with carotid web and internal carotid artery atherosclerosis. Multimodality imaging including at minimum neck CT angiography (CTA) at baseline plus either Digital Subtraction Angiography (DSA) and/or carotid Ultrasound (US) was mandatory. CTA images were evaluated by two readers (neurointerventionist#1 and diagnostic neuroradiologist) in a consensus read for confirmation of diagnosis, and degree of stenosis based on NASCET criteria. DSA studies were evaluated by two blinded readers (neurointerventionists #2 and #3) to categorize the presence or absence of carotid web or atherosclerotic plaque in individual carotid arteries. US studies were evaluated by two blinded readers (two neurosonology-credentialed stroke neurologists) to characterize diagnosis (carotid web vs atherosclerosis vs normal), degree of certainty, and the degree of stenosis. In the setting of discrepancies, consensus read was obtained. The performance of DSA and of US was compared to CTA. Results Median age of the cohort was 57 years (IQR 46–61 years) with 36.4% (12/33) male gender. Overall comorbidities included 60.6% (20/33) hypertension, 33.3% (11/33) hyperlipidemia, 21.2% (7/33) diabetes mellitus, and 27.3% (9/33) smoking. Multimodal imaging was available for 33 carotid arteries. Twenty-eight carotids had CTA and DSA available for review. DSA readers identified correctly all normal vessels, but diagnosed carotid webs less frequently (43%, 12/28; DSA group vs 50%, 14/28; CTA group) and atherosclerosis more frequently (43%, 12/28; DSA group vs 36%, 10/28; CTA group) when compared to CTA. Inter-rater correlation for the two DSA readers (κ=0.86, p Conclusion CTA and DSA should be preferred imaging modalities to diagnose and characterize carotid webs. Disclosures T. Madaelil: None. R. Nogueira: None. J. Grossberg: None. A. Anderson: None. C. Barreira: None. D. Haussen: None.

Background and purpose Smoking is a well-established risk factor for stroke. However, several studies have shown that smokers with stroke have better outcomes after thrombolysis, a phenomenon commonly known as the smoking-thrombolysis paradox. We investigated whether clinical and procedural outcomes differ between smokers and non-smokers with large vessel occlusion stroke after endovascular therapy. Methods We reviewed our prospectively collected endovascular database at a tertiary care academic institution between Sep 2010-December 2016. All patients that underwent endovascular therapy for anterior circulation large vessel occlusion acute ischemic stroke were included and categorized into two groups: (1) current smokers and (2) non-smokers. The 2 groups were then matched for age, baseline NIHSS and glucose levels using a weighted Euclidian distance method. Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. Results A total of 326 (163 matched pairs) qualified for the study. Smokers had higher rates of dyslipidemia (48.5% vs 28.8%, p Conclusion Our data shows that smoking is not associated with outcomes in patients with large vessel occlusion stroke treated with mechanical thrombectomy. Disclosures J. Grossberg: 1; C; Georgia Research Alliance. 4; C; NTI. M. Bouslama: None. D. Haussen: None. M. Frankel: None. R. Nogueira: None.

Objectives The aim of this study was to identify the optimal endovascular approach in patients with acute stroke with tandem lesions. Background At present, there is no consensus about the ideal technical strategy for the endovascular treatment of patients with acute ischemic stroke with tandem lesions of the extracranial internal carotid artery (ICA) and intracranial cerebral arteries. Methods This was an international, multicenter registry with a total of 482 patients with acute ischemic stroke and tandem lesions. Patients were treated by intracranial thrombectomy as well as 1 of the following 4 strategies: 1) acute carotid artery stenting of the extracranial ICA with antithrombotic agents; 2) acute carotid artery stenting of the extracranial ICA without antithrombotic agents; 3) balloon angioplasty of the extracranial ICA; and 4) intracranial thrombectomy alone. The main outcome endpoints of the study were the degree of recanalization and the 90-day clinical outcome. The safety endpoints were symptomatic intracerebral hemorrhage and all causes of mortality at 90 days. Results Using univariate analysis, the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction grades 2B and 3) and favorable clinical outcome after 90 days were significantly higher after acute carotid stenting with antithrombotic therapy and thrombectomy compared with the group with thrombectomy alone. After adjusting for confounding variables, acute stenting with antithrombotic therapy was independently associated with successful recanalization (odds ratio: 2.4; 95% confidence interval: 1.25 to 4.59; p = 0.008). The rates of symptomatic intracerebral hemorrhage and 90-day mortality were comparable among all 4 treatment groups. Conclusions Acute stenting of the extracranial ICA with antithrombotic therapy in combination with intracranial thrombectomy is associated with higher recanalization rates in treatment of patients with acute stroke with tandem lesions.

Background Little is known on the outcomes of nonagenarians treated with endovascular therapy for acute large vessel occlusion stroke. It is unclear whether they have worse clinical outcomes than octogenarians. Methods We reviewed our prospectively collected endovascular database at a tertiary care academic institution between Sep 2010-Dec 2016. All patients older than 80 years that underwent endovascular therapy for large vessel occlusion acute ischemic stroke were included and categorized into two groups: 80–89 years (octogenarians), and 90–99 years (nonagenarians). Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. Results Thirty-one nonagenarians and 181 octogenarians were treated over the 6 year study period. When compared with octogenarians, nonagenarians had lower glucose levels (121±26 vs 138±46, p Conclusions Our study shows that there is no significant difference in procedural and clinical outcomes between nonagenarians and octogenarians treated with endovascular therapy. Baseline stroke severity and successful reperfusion are the main drivers of favorable functional outcome in patients≥80 years-old. Disclosures J. Grossberg: 1; C; Georgia Research Alliance. 4; C; NTI. M. Bouslama: None. D. Haussen: None. M. Frankel: None. R. Nogueira: None.

Introduction Large Vessel Occlusion (LVO) for Acute Ischemic Stroke (AIS) remains a public health issue as there is significant morbidity and mortality when left untreated. Timely recognition, therefore, is of utmost significance, as there are validated therapeutic options involving cerebrovascular reperfusion. Best patient care relies on tailored and expeditious clinical identification, using multimodal neuroimaging and facilitating referrals to comprehensive centers. Artificial Intelligence (AI)-guided technologies applied to medical fields are being used increasingly and may improve LVO recognition. We present an AI-based algorithm for LVO detection. Methods A multi-center retrospective analysis of CTAs, randomly picked from retrospective cohort of AIS patients, with and without anterior circulation LVOs, admitted at three tertiary stroke centers, from 2014–2017, was performed. CTAs were analyzed and graded by experienced stroke neurologists for presence and site of occlusion to establish the ground truth. These same studies were analyzed by Viz-AI-Algorithm v3.04 – a Convolutional Neural Network programmed to detect MCA-M1 and/or ICA-T occlusions. Our primary analysis included ICA-T and/or MCA-M1 LVOs versus non-LVOs/more distal occlusions. Our secondary analysis also included proximal MCA-M2 vs non-LVOs. Results Interim analysis of 875 CTAs, of three tertiary stroke centers, show: 49.5% males, bNIHSS 15[IQR 10–20], bASPECTS 10[8–10]. Of all, 45.9% were considered as having LVO, and homogenous baseline characteristics among groups was found. Primary analysis shows an accuracy of 86%, sensitivity of 90.1%, specificity of 82.5, PPV of 81.8 and NPV of 90.6; AUC 86.3% (95% CI 0.83–0.90, p≤0.001) and ICC 84.1% (95% CI 0.81–0.86; p≤0.001). Maximal running time of the algorithm was under five minutes. Conclusion Viz-AI-Algorithm has an impressive performance for detection of proximal intracranial LVO recognition. Endeavors to optimize detection of the MCA-M2 and all intracranial ICA occlusions have been enforced, as well as posterior circulation. So far, this is the first AI-algorithm for detecting intracranial anterior circulation LVOs. Disclosures C. Barreira: None. M. Bouslama: None. J. Lim: None. A. Al-Bayati: None. Y. Saleem: None. T. Devlin: None. D. Haussen: None. M. Froehler: None. J. Grossberg: None. B. Baxter: None. M. Frankel: None. R. Nogueira: None.

Introduction Intracerebral hemorrhages (ICHs) are a source of significant mortality and morbidity worldwide, and even those who survive the insult have a higher future mortality than the general population.1 Given this, prompt recognition, hematoma volume and location, differentiation from intraventricular hemorrhage (IVH) and the presence of hydrocephalus are known features related to unfavorable outcomes. An artificial intelligence (AI) fully automated detection system is thought to ameliorate ICH detection and measurement, which could potentially improve condition recognition and patient prognosis. Methods A retrospective analysis of non-contrast CTs (NCCTs) from a single center, randomly picked from prospective cohort of acute stroke patients, was done to compare the semi-automated expert-based (OsiriX MD v.9.0.1) ratings versus AI algorithm ratings. NCCTs from 2014 to 2017, for both ICH (presence and volume) and other neuroimaging findings (such as IVH) and non-ICH subjects were analyzed. Same scans were rated by Viz-ICH® v2.0 – an Artificial Intelligence Automated Convolutional Neural Network. Results Preliminary analysis of subjects: 689 NCCTs were evaluated – of those, 537 had ICH and 152 were non-ICH (control group). ICH group findings: mean age 59.3±13.5, bNIHSS 13[4–22], ICH volume of 26.6±36 cc, males 56.4% hypertension 86.2% and presence of IVH 51.7% of them. Intraclass Correlation Coefficient (uncontrolled for IVH): α=96.1% (IC95%=0.900–0.933; p≤0.001) and sensitivity 94.5%. Maximal running time of the algorithm was under 15s. Conclusion The presence and volume of ICHs can be accurately predicted by AI Viz-ICH Algorithm, with good differentiation from IVH and other neuroimaging findings. The software has the potential for appropriate and rapid diagnosis of these patients. Disclosures C. Barreira: None. M. Bouslama: None. J. Ratcliff: None. G. Pradilla: None. H. Rahman: None. A. Al-Bayati: None. D. Haussen: None. J. Grossberg: None. M. Frankel: None. R. Nogueira: None.

Introduction: Symptomatic intracranial hemorrhage represents one of the most feared complications of endovascular reperfusion. We aim to describe a series of patients that experienced immediate reperfusion injury with active intraprocedural extravasation within the territory of the deep penetrating arteries and provide real-time correlation with CT “spot sign.” Methods: This was a retrospective analysis of patients that suffered reperfusion injury with active arterial extravasation during endovascular stroke treatment in two tertiary care centers. Results: Five patients were identified. Median age was 63 (58–71) years, 66% were male. Median NIHSS was 13.5 (9.5–23.0), platelet level 212,000 (142,000–235,000), baseline systolic blood pressure 152 (133–201) mm Hg, and non-contrast CT ASPECTS 7.0 (6.5–9.0). Two patients were taking aspirin and one had received intravenous thrombolysis. There were three middle cerebral artery M1, one internal carotid artery terminus, and one vertebrobasilar junction occlusion. Three patients had anterior circulation tandem occlusions. Stroke etiology was extracranial atherosclerosis (n = 2), intracranial atherosclerosis (n = 2), and cervical dissection (n = 1). The median time from onset to puncture was 5.5 (3.9–8.6) h. Intravenous heparin was administered in all patients (median dose of 4,750 [3,250–6,000] units) and intravenous abciximab in four. All tandem cases had the cervical lesion addressed first. Four lenticulostriates and one paramedian pontine artery were involved. Intraprocedural flat-panel CT was performed in four (80%) cases and provided real-time correlation between the active contrast extravasation and the “spot sign.” The bailout included use of protamine, blood pressure control, and balloon guide catheter or intracranial compliant balloon inflation plus coiling of targeted vessel. All patients had angiographic cessation of bleeding at the end of the procedure with parenchymal hemorrhage type 1 in one case and type 2 in four. Three patients had modified Rankin score of 4 and two were dead at 90 days. Conclusions: Active reperfusion hemorrhage involving perforator arteries was observed to correlate with the CT “spot sign” and to be associated with poor outcomes.

Background and Purpose: We have observed that large vessel occlusion acute strokes (LVOS) due to intracranial atherosclerotic disease (ICAD) present with more benign CT perfusion (CTP) profiles, which we presume to potentially represent enhanced collateralization compared to embolic LVOS. We aim to determine if CTP profiles can predict ICAD in LVOS. Methods: Retrospective review of a prospectively collected interventional stroke database from September 2010 to March 2015. Patients with intracranial ICA/MCA-M1/M2 occlusions and CTP were dichotomized into ICAD versus non-ICAD etiologies. Ischemic core (relative cerebral blood flow < 30%) and hypoperfusion volumes were estimated by automated CTP. Results: A total of 250 patients met the inclusion criteria, comprised of 21 (8%) ICAD and 229 non-ICAD etiologies. Baseline characteristics were similar between groups, except for higher HbA1c levels (p < 0.01), LDL cholesterol (p < 0.01), systolic blood pressure (p < 0.01), and lower rate of atrial fibrillation (p < 0.01) in ICAD patients. There were no significant differences in volumes of baseline ischemic core (p = 0.54) among groups. ICAD patients had smaller Tmax > 4 s, Tmax > 6 s, and Tmax > 10 s absolute lesions, and a higher ratio of Tmax > 4 s/Tmax > 6 s volumes (median 2 [1.6–2.3] vs. 1.6 [1.4–2.0]; p = 0.02). A Tmax > 4 s/Tmax > 6 s ratio ≥2 showed specificity = 73%/sensitivity = 52% for ICAD and was observed in 47.6% of ICAD versus 26.1% of non-ICAD patients (p = 0.07). Clinical outcomes were comparable amongst groups. Multivariate logistic regression revealed that Tmax > 4 s/Tmax > 6 s ratio ≥2 (OR 3.75, 95% CI 1.05–13.14, p = 0.04), higher LDL cholesterol (OR 1.1, 95% CI 1.01–1.03, p = 0.01), and higher systolic pressure (OR 1.03, 95% CI 1.01–1.04, p = 0.01) were independently associated with ICAD. Conclusion: An automated CTP Tmax > 4 s/Tmax > 6 s ratio ≥2 profile was found independently associated with underlying ICAD LVOS.

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 and Purpose— EmboTrap is a novel stent retriever designed to achieve rapid and substantial flow restoration in acute ischemic stroke secondary to large-vessel occlusions. Here, we evaluated EmboTrap’s safety and efficacy compared with established stent retrievers. Methods— ARISE II (Analysis of Revascularization in Ischemic Stroke With EmboTrap) was a single-arm, prospective, multicenter study, comparing the EmboTrap device to a composite performance goal criterion derived using a Bayesian meta-analysis from the pivotal SWIFT (Solitaire device) and TREVO 2 (Trevo device) trials. Patients at 11 US and 8 European sites were eligible for inclusion if they had large-vessel occlusions and moderate-to-severe neurological deficits within 8 hours of symptom onset. The primary efficacy end point was achievement of modified Thrombolysis in Cerebral Ischemia (mTICI) reperfusion scores of ≥2b within 3 EmboTrap passes as adjudicated by the core laboratory. The primary safety end point was a composite of symptomatic intracerebral hemorrhage and serious adverse device effects. Secondary end points included functional independence (modified Rankin Scale, 0–2) and all-cause mortality at 90 days. Results— Between October 2015 and February 2017, 227 patients were enrolled and treated with the EmboTrap device. The primary efficacy end point (mTICI ≥2b within 3 passes) was achieved in 80.2% (95% confidence interval, 74%–85% versus 56% performance goal criterion; P value, Conclusions— The EmboTrap stent-retriever mechanical thrombectomy device demonstrated high rates of substantial reperfusion and functional independence in patients with acute ischemic stroke secondary to large-vessel occlusions. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT02488915.

BackgroundLonger stent retrievers have recently become available and have theoretical advantages over their shorter counterparts. We aim to evaluate whether stent retriever length impacts reperfusion rates in stroke thrombectomy.MethodsThis was a retrospective analysis of a prospectively collected thrombectomy database in which equal diameter (4 mm) stent retrievers were used as the first-line strategy for intracranial internal carotid or middle cerebral artery M1 or M2 occlusions along with a balloon guide catheter from June 2011 to March 2017. The population was dichotomized into long (Trevo 4×30 mm/Solitaire 4×40 mm) or short (Trevo 4×20 mm/Solitaire 4×20 mm) retrievers. The primary outcome was first-pass modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 reperfusion.ResultsOf 1126 thrombectomies performed within the study period, 420 were included. Age, gender, National Institutes of Health Stroke Scale, ASPECTS, IV tissue plasminogen activator use, stroke etiology, occlusion site, time from last-known-normal to puncture, distribution of Trevo and Solitaire, and the use of newer generation local thromboaspiration devices were comparable between the long and short retrievers. The short retriever group had more frequent hypertension, dyslipidemia, and atrial fibrillation. First-pass mTICI 2b/3 reperfusion was more common in the long retriever group (62% vs 50%; P=0.01). Parenchymal hematomas type 2, subarachnoid hemorrhage, 90-day modified Rankin Scale score 0–2, and mortality were comparable. Multivariable analysis indicated that long retriever (OR 2.2; 95% CI 1.3 to 3.6; P=0.001), radiopaque device (OR 2.1; 95% CI 1.2 to 3.4; P=0.003), and adjuvant local aspiration (OR 2.4; 95% CI 1.3 to 4.3; P=0.003) were independently associated with first-pass reperfusion.ConclusionsThe use of longer stent retrievers is an independent predictor of first-pass mTICI 2b/3 reperfusion. First-pass reperfusion was also associated with the use of radiopaque devices and adjuvant local aspiration.

Objective Consensus regarding selection of synthetic versus autologous flap reimplantation for cranioplasty after decompressive craniectomy has not been reached and the multiple factors considered for each patient make comparative analysis challenging. This study examines the association between choice of material and related complications. Methods A systematic literature review and meta-analysis were performed using PubMed for articles reporting delayed cranioplasty after decompressive craniectomy using a cohort design comparing autologous bone and synthetic implants. Extracted data included implant material and incidence of infection, reoperations related to implant, wound complications, and resorption. Results One randomized controlled trial and 11 cohort studies were included for a total of 1586 implants (950 bone, 636 synthetic). Autologous implants had significantly more reoperations than did synthetic implants (n = 1586 implants; odds ratio [OR], 1.91; 95% confidence interval [CI], 1.40–2.61). Reoperations were most often because of resorption (54%, n = 159/295) followed by infection (41%, n = 121/295). The pooled incidence of resorption in autologous implants was 20% (n = 159/791). Among the other outcomes, there was no significant difference for infections (n = 1586; OR, 1.24; CI, 0.82–1.88) or wound complications (n = 678; OR, 0.56; CI, 0.22–1.45). For the trauma subpopulation, there was no significant difference in infection rate with either material (n = 197; OR, 1.89; CI; 0.59–6.09). Conclusions Autologous implants had significantly more reoperations primarily because if the intrinsic risk of resorption (level of evidence 3b).

Background: Optimal selection paradigms for large vessel occlusion acute stroke endovascular therapy are yet to be established. Previous studies have shown the benefit of adjusting infarct size to age. We sought to study the impact of age-adjusted final infarct volumes (FIV), a surrogate for pre-reperfusion infarct core, on functional outcomes and determine the ideal thresholds for good outcome discrimination (90-day mRS 0-2). Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between 9/2010- 8/2016. All patients that underwent endovascular therapy for large vessel occlusion anterior circulation acute ischemic stroke were stratified into five age groups: (G1) Conclusions: Age-adjusted infarct volume represents a strong outcome discriminator substitute and might help refine patient selection for stroke endovascular therapy

Background: Hyperglycemia on admission is known to be associated with poor outcome after intravenous or intra-arterial thrombolysis treatment in patient with acute ischemic stroke. However, its effect on mechanical thrombectomy outcomes remains elusive. We investigated whether clinical and procedural outcomes differ between normoglycemic and hyperglycemic patients with large vessel occlusion stroke after endovascular therapy. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between 9/2010-12/2016. Hyperglycemia was defined as admission serum glucose >140mg/dl. All patients that underwent ET for anterior circulation large vessel occlusion acute ischemic stroke were included and categorized into two groups according to their glycemic status. Baseline and procedural characteristics, as well as outcome parameters were compared. Results: A total of 931 patients qualified for the study of which 289 (31%) had hyperglycemia on admission. Those with hyperglycemia were older (p=0.001), had more comorbidities and more severe strokes as assessed by the NIHSS (19[15-23] vs 17[13-21], p=0.01). In univariate analysis, Hyperglycemic patients had lower rates of successful reperfusion (mTICI2b-3, 85.4% vs 90.6%,, p=0.02) and 90-day good outcomes (mRS 0-2, 32.7% vs 52.3%, p Conclusions: Our study confirms that hyperglycemia is associated with poorer procedural and clinical outcomes in patients undergoing mechanical thrombectomy for large vessel occlusion strokes.

Introduction: Approximately 2/3 of all AIS present with NIHSS 0-5. While it has been demonstrated that LVO can be found in ~10-20% of all low NIHSS patients, outcome data in this population remains scarce. Indeed, only 14/1766 patients in the recent endovascular RCTs had baseline (b) NIHSS in the 0-5 range. Yet, the presence of LVO in the setting of low NIHSS is associated with ~10-fold increase in subsequent deterioration. We aim to describe the outcomes in a large cohort of low NIHSS patients undergoing thrombectomy. Methods: Patients derived from a large prospective multicenter international stent-retriever registry (Trevo Registry, n=2,010). Baseline and outcome variables were compared according to bNIHSS 0-8 vs >8 and bNIHSS 0-5 vs >5. The primary and secondary efficacy endpoints were the rates of 90-day mRS 0-2 and mTICI 2b-3, respectively. Safety endpoints included sICH and 90-day mortality. Results: A total of 1,985 patients were included. As compared with patients with higher baseline NIHSS, low baseline NIHSS (0-8, n=342; 0-5, n=160) patients were younger, had less comorbidities and better functional status, more frequently had MCA-M2 or vertebrobasilar occlusions, less frequently received IV tpa, and underwent thrombectomy at later times (Table 1). The reperfusion outcomes were nearly the same. There were no significant differences in procedure-related complications, which were overall low (Table 2). The rates of 90-day mRS 0-2 were significantly higher in the lower NIHSS patients (p Conclusion: Despite safe and efficacious endovascular reperfusion, low-NIHSS LVO patients have a relatively high proportion of bad outcomes. This supports the notion that many of "mildly" presenting patients do not fare well. A randomized clinical trial including immediate endovascular treatment in this patient population is warranted.

Introduction: The recent thrombectomy trials were largely limited to patients with small strokes on presentation. Methods: Patients derived from a large prospective multinational stent-retriever registry (Trevo Registry, n=2,010). Baseline NCCT SPECTS and CTP Core Volumes (rCBF70mL if age 50mL if age >70-80 years; >30mL if age >80 years) vs. not on CTP. The primary and secondary efficacy endpoint were the rates of 90-day mRS 0-2 and mTICI 2b-3, respectively. Safety endpoints included sICH and 90-day mortality. Results: As compared with patients with higher baseline ASPECTS (n=1037), low baseline ASPECTS (0-4, n=78; 5, n=78) patients were younger, had higher stroke severity, and tend to have less comorbidities and undergo thrombectomy at later times (Table 1a). TICI-3 reperfusion was higher in the higher-ASPECTS group but other reperfusion outcomes were nearly the same. Safety outcomes were comparable. Rates of 90-day mRS 0-2 were significantly higher in the high-ASPECTS group (p Conclusion: Patients with large baseline cores as measured by either NCCT or CTP may still achieve favorable outcomes with endovascular treatment. A randomized clinical trial in this patient population is warranted.

Background: Longer stent retrievers have become recently available and may enhance device purchase distal to the clot (increasing chances of rolling clot out) and prevent misplacement. We aim to evaluate if the device length impacts reperfusion rates in stroke thrombectomy. Methods: Retrospective analysis of a prospectively collected databank. Inclusion: thrombectomies in which 4mm stent-retrievers were used as the first-line strategy from Sep2010-Mar2017. Population was dichotomized into Long (Trevo4x30mm/Solitaire4x40mm) or Short (Trevo4x20mm/ Solitaire4x20mm) retrievers. Primary outcome was first-pass reperfusion (modified TICI2b-3 with first pass). Results: Of 1204 thrombectomies within the study period, 594 were included. Age, gender, NIHSS, ASPECTS, and IV-tPA use (41vs41%;p=1.00) were comparable between groups. Long device arm included more MCA M1 [72vs60%;p Conclusions: The use of longer stent retrievers is an independent predictor of first pass reperfusion. First pass reperfusion predicted good clinical outcome at 90 days.

Background: Obesity has been associated with increased morbidity and mortality in the general population. However, several reports have described lower mortality rates in overweight or obese patients as compared to normal weight ones. Several studies have investigated the phenomenon, commonly known as the obesity paradox, with mixed results thus far. We sought to determine whether clinical outcomes differ between patients with acute ischemic stroke after endovascular therapy according to their body mass index (BMI). Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients that underwent endovascular therapy for acute large vessel occlusion acute ischemic stroke were categorized according to their BMI into four groups (1) underweight (BMI30). Baseline characteristics, procedural radiological as well as outcome parameters were compared. Results: A total of 926 patients qualified for the study of which 20 (2.2%) were underweight, 253 (27.3%) had a normal weight, 315 (34%) were overweight and 338 (36.5%) obese. When compared with normal weight (reference) overweight patients had higher rates of dyslipidemia as well as diabetes and higher glucose and HbA1c levels while obese patients were younger, less often smokers and had higher rates of hypertension as well as diabetes and higher glucose and HbA1c levels. Other baselines characteristics including NIHSS and ASPECT scores as procedural characteristics were comparable between groups. In terms of outcomes, rates of successful reperfusion (mTICI 2b-3), parenchymal hematomas, 90-Day good clinical outcomes (modified Rankin scale, mRS 0-2) and 90-day mortality were comparable between BMI groups. On multivariate analysis, BMI was not associated with good outcomes nor mortality whether as a continuous variables or a categorical variable comparing groups with normal weight patients (reference) two by two. Conclusions: In stroke patients treated with mechanical thrombectomy, BMI does not seem to be associated with outcomes. However, patients who are overweight or obese have more co-morbities and should strive for a normal weight.

Background: The impact of oversized stent-retrievers in reperfusion rates during thrombectomy is unclear. Devices matching the vessel diameter may lead to proportionally larger cells and facilitate device-clot integration. We aim to evaluate if the device diameter may impact reperfusion rates in stroke thrombectomy. Methods: This is a retrospective analysis of a prospectively collected database from a single comprehensive stroke center. We included patients with intracranial carotid occlusions in which stent-retrievers (Trevo or Solitaire devices) were used as the first strategy, from September 2010-March 2017, and compared the 4mm vs 6mm diameter groups. 3mm devices and other retriever-like devices were excluded. Primary outcome was first pass reperfusion (modified TICI2b-3 with the first device pass). Results: Of the 1204 thrombectomies performed within the study period, 150 met inclusion criteria (Trevo: 64/Solitaire: 86/6mm device:67 /4mm: 83). Age, gender, comorbidities and the use of IV tPA were comparable between groups. NIHSS was similar between the 4mm vs 6mm devices (19[14-22] vs 18.5[14-22];p=0.64), as well as time from last normal to puncture (403[260-626] minutes vs 344 [209-816];p=0.54), and ASPECTS (7[6-9] vs 8[7-9];p=0.25), respectively. Patients with 4mm devices had less tandem disease (11% vs 28%,p=0.01). The use of local aspiration was similar between groups (7vs9%p=0.76) for the 4mm and 6mm devices. First-pass mTICI2b-3/mTICI3 reperfusion was achieved in similar proportion between the 4mm vs 6mm groups: 52%vs.56%;p=0.62 / 32%vs22%;p=0.20, respectively. Parenchymal hematomas (16% vs 9%;p=0.22) and subarachnoid hemorrhage (5% vs 7%;p=0.74) were similar between the 4mm and 6mm arms. Independent outcome at 3months was more common in the 4mm vs 6mm groups (28%vs50%;p=0.03). Multivariable analysis indicated mRS0-2 at 90-days independently associated with first-pass reperfusion and demonstrated no impact of device diameter on first-pass reperfusion. Conclusions: The use of 6mm stent retrievers for intracranial carotid occlusions had demonstrated benefit over 4mm devices for chances of first pass reperfusion.

Background: Thromboaspiration and stent retriever thrombectomy perform similarly in anterior circulation large vessel occlusions. We aim to compare performance of modern thromboaspiration against stent retriever technology in basilar artery occlusions. Methods: This was a retrospective analysis of a prospectively collected databank in a comprehensive stroke center. Inclusion criteria: thrombectomies in which stent-retrievers (Trevo or Solitaire) or modern thromboaspiration devices (Penumbra 5max, 64 or 68) were used as the first-line strategy from Sep2010-Mar2017. We excluded cases of combined retriever plus local aspiration. Primary outcome was first-pass reperfusion (modified TICI2b-3 with first pass). Results: Of 1204 thrombectomies within the study period, 68 patients were included (48 retrievers and 20 thromboaspiration cases). Age, gender, comorbidities, systolic blood pressure, NIHSS, IV tPA use, and last known normal to puncture times were comparable between groups. First-pass reperfusion was achieved in 58% of the retriever group vs 55% in the aspiration group (p=1.00). Parenchymal hematoma type-2 was observed in 2% vs 0% in the retriever and aspiration groups (p=1.00), respectively. At 90 days, good outcome (mRS0-2) was observed in 31% of the stent retriever patients compared to 41% in the aspiration group (p=0.55) while mortality was 53% and 41% (p=0.56), respectively. Conclusions: Stent retrievers and modern thromboaspiration were observed to have similar performance in achieving first pass reperfusion in patients with basilar artery occlusions. Further studies are warranted.

Background and Purpose: Smoking is a well-established risk factor for stroke. However, several studies have shown that smokers with stroke have better outcomes after thrombolysis, a phenomenon commonly known as the smoking-thrombolysis paradox. We investigated whether clinical and procedural outcomes differ between smokers and non-smokers with large vessel occlusion stroke after endovascular therapy. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between Sep 2010-Dec 2016. All patients that underwent endovascular therapy for anterior circulation large vessel occlusion acute ischemic stroke were included and categorized into two groups: (1) current smokers and (2) non-smokers. The 2 groups were then matched for age, baseline NIHSS and glucose levels using a weighted Euclidian distance method. Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. Results: A total of 326 (163 matched pairs) qualified for the study. Smokers had higher rates of dyslipidemia (48.5% vs 28.8%, p Conclusion: Our data shows that smoking is not associated with outcomes in patients with large vessel occlusion stroke treated with mechanical thrombectomy.

Background: Patients who are admitted during off-hours (nights and weekends) are thought to have worse outcomes. This might be explained by delayed times to treatment. We sought to determine the effect of off-hour presentation on processes of care and outcomes at a comprehensive stroke center. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between Sep 2010-Dec 2016. All patients that underwent endovascular therapy for large vessel occlusion acute ischemic stroke were included and categorized into two groups: those arriving during regular hours (weekday 7AM-7PM) or off-hours. The 2 groups were then matched for age, baseline NIHSS and glucose levels using a weighted Euclidian distance method. Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. Results: 926 (463 pairs) patients were included. Patients presenting off-hours had higher rates of hypertension (78.2% vs 66.7%, p Conclusions: Our study shows that patients presenting off-hours have similar picture to puncture times and clinical outcomes as those presenting during regular hours.

Background: Little is known on the outcomes of nonagenarians treated with endovascular therapy for acute large vessel occlusion stroke. It is unclear whether they have worse clinical outcomes than octogenarians. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between Sep 2010-Dec 2016. All patients older than 80 years that underwent endovascular therapy for large vessel occlusion acute ischemic stroke were included and categorized into two groups: 80-89 years (octogenarians), and 90-99 years (nonagenarians). Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. Results: Thirty-one nonagenarians and 181 octogenarians were treated over the 6-year study period. When compared with octogenarians, nonagenarians had lower glucose levels (121±26 vs 138±46, p Conclusions: Our study shows that there is no significant difference in procedural and clinical outcomes between nonagenarians and octogenarians treated with endovascular therapy. Baseline stroke severity and successful reperfusion are the main drivers of favorable functional outcome in patients ≥80years old.

Introduction: Acute ischemic stroke (AIS) treatment relies on prompt clinical suspicion, neuroimaging findings and stroke neurologists’ referrals, especially for Large Vessel Occlusion (LVO) patients. Recent advances in artificial intelligence have revolutionized the field of computer vision. We propose the use of artificial-intelligence based algorithm for detection of LVOs in AIS setting. Methods: We performed a multi-center retrospective analysis of CTAs, randomly picked from a prospective cohort of AIS adult patients, with and without LVOs, admitted at comprehensive stroke centers, from 2014 to 2016. An experienced stroke neurologist graded the CTAs for the presence of occlusion and occlusion sites. Concurrently, studies were analyzed by Viz-AI-Algorithm® v3.04 - a Convolutional Neural Network programed to detect MCA-M1 and/or ICA-T occlusions. The primary analysis included ICA-T and/or MCA-M1 LVOs versus more distal occlusions or no LVOs. The secondary analysis included any ICA and/or MCA-M1 and/or M2 LVOs versus more distal occlusions or no LVOs. Results: Analysis of 500 CTAs is ongoing and will be fully presented at the ISC. Interim results are available in 152 CTAs (Age, 64.1+/-15.7; bNIHSS 16 [IQR, 10-22]; bASPECTS 8 [IQR, 6-10]). Data was enriched for LVO (82.2%). For the primary analysis, the algorithm obtained sensitivity of 0.97 and specificity of 0.52, with a PPV of 0.74 and NPPV of 0.91, and overall accuracy of 0.78. For the secondary analysis (M2 and proximal ICA included), the algorithm obtained sensitivity of 0.92 and specificity of 0.75, with a PPV of 0.92 and NPPV of 0.75, and overall accuracy of 0.88. Maximal running time of the algorithm was under five minutes. Conclusion: The Viz-AI-Algorithm performs remarkably well for proximal intracranial LVOs. Endeavors on optimization of MCA-M2 LVO detection are being implemented. To the best of our knowledge, this is the first AI-algorithm for detecting intracranial LVOs.

Background: Carotid web is a shelf-like lesion in the posterior aspect of the internal carotid bulb and represents an intimal variant of fibromuscular dysplasia. Carotid webs have been associated with recurrent strokes and traditionally treated with surgical excision. We report a multicenter experience of stenting in patients with symptomatic carotid webs. Methods: Retrospective review of patients admitted to three comprehensive stroke centers identified to have a carotid web with otherwise negative stroke workup that underwent stenting. A carotid web was defined by the presence of a shelf-like/linear, smooth filling defect in the posterior aspect of the carotid bulb diagnosed by neck CT/MR angiography and confirmed with conventional angiography. Results: Twenty patients with symptomatic (80% Stroke/20% TIA) carotid webs were stented. Median age was 48[41-61] years, 7(35%) were male, and 15(75%) Black. Median NIHSS was 11[2-16] while ASPECTS 8[7-8]. Eight (40%) received intravenous thrombolysis and 10 (50%) thrombectomy. All patients were stented on dual antiplatelets (aspirin and clopidogrel[17] or ticagrelor[3]) at a median 9[4-30]days after the last vascular event. Closed-cell stents were used in 75% of cases (XACT [14] and Wallstent [1]) while open-cell stents in 25% (Acculink[5]). No cases required angioplasty for residual stenosis had to be performed. DIstal embolic protection was used in 19 cases (SpiderFX[18] and Emboshield_NAV6[1]) while proximal protection in 1 (MoMa). No periprocedural events occurred with the exception of two cases of hypotension/bradycardia (one requiring 24-hour vasopressors). No parenchymal hematomas were observed but one patient developed vaginal hemorrhage requiring discontinuation of one antiplatelet at 2 months. Modified Rankin Scale 0-2 (independence) at 90 days was recorded in 95% of patients. Clinical follow-up post stent occurred for a median of 4 [2-12] months and no follow-up cerebrovascular events were noted. Follow-up vascular imaging was performed in 95% patients at a median of 3[2-12]months and were all unremarkable. Conclusions: Stenting for symptomatic carotid web appears to be a valid, safe, and effective alternative to surgical piecemeal resection. Further studies are warranted.

Overlapping surgery (OS) is common. However, there is a dearth of evidence to support or refute the safety of this practice.To determine whether OS is associated with worsened morbidity and mortality in a large series of neurosurgical cases.A retrospective cohort study was completed for patients who underwent neurosurgical procedures at Emory University Hospital, a large academic referral hospital, between January 1, 2014, and December 31, 2015. Patients were operated on for pathologies across the spectrum of neurosurgical disorders. Propensity score weighting and logistic regression models were executed to compare outcomes for patients who received nonoverlapping surgery and OS. Investigators were blinded to study cohorts during data collection and analysis.The primary outcome measures were 90-day postoperative mortality, morbidity, and functional status.In this cohort of 2275 patients who underwent neurosurgery, 1259 (55.3%) were female, and the mean (SD) age was 52.1 (16.4) years. A total of 972 surgeries (42.7%) were nonoverlapping while 1303 (57.3%) were overlapping. The distribution of American Society of Anesthesiologists score was similar between nonoverlapping surgery and OS cohorts. Median surgical times were significantly longer for patients in the OS cohort vs the nonoverlapping surgery cohort (in-room time, 219 vs 188 minutes; skin-to-skin time, 141 vs 113 minutes; both P .001). Overlapping surgery was more frequently elective (93% vs 87%; P .001). Regression analysis failed to demonstrate an association between OS and complications, such as mortality, morbidity, or worsened functional status. Measures of baseline severity of illness, such as admission to the intensive care unit and increased length of stay, were associated with mortality (intensive care unit: odds ratio [OR], 25.5; 95% CI, 6.22-104.67; length of stay: OR, 1.03; 95% CI, 1.00-1.05), morbidity (intensive care unit: OR, 1.85; 95% CI, 1.43-2.40; length of stay: OR, 1.06; 95% CI, 1.04-1.08), and unfavorable functional status (length of stay: OR, 1.03; 95% CI, 1.02-1.05).These data suggest that OS can be safely performed if appropriate precautions and patient selection are followed. Data such as these will help determine health care policy to maximize patient safety.

The use of balloon guide catheters in acute ischemic stroke intervention has been associated with improved reperfusion rates and clinical outcomes. This technique acts by promoting flow arrest and subsequent reversal to capture the thrombus debris that may be generated during the clot retrieval process. However, to the best of our knowledge, the use of BGC to remotely aspirate and remove intracranial thrombus has not been previously described. We report a three case series of patients with acute ischemic stroke from supraclinoidal internal carotid artery occlusions treated with remote aspiration thrombectomy through a BGC placed at the cervical internal carotid artery, leading to complete reperfusion without the need for intracranial catheterization. Remote thrombectomy in the setting of intracranial internal carotid artery occlusion may constitute a relatively fast and inexpensive initial thrombectomy maneuver. Further investigation is warranted.

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.