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

Purpose To evaluate the diagnostic accuracy of computed tomography angiography (CTA) acquired with shuttle technique (CTAs) and helical CTA (CTAh) for vasospasm, using digital subtraction angiography (DSA) obtained within 24 h as reference standard. Methods Thirty-six patients with suspected vasospasm in the setting of aneurysmal subarachnoid hemorrhage (ASAH, 30/36) or acute inflammatory/infectious conditions (6/36) who underwent CTAs (17/36) or CTAh (19/36) followed by DSA within 24 h were identified retrospectively. Presence of vasospasm in the proximal cerebral arterial segments was assessed qualitatively and semi-quantitatively on CTA and subsequent DSA. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated. Inter-rater variability was assessed using Cohen's kappa. Results On CTAs, 35% of patients had low and 65% had high vasospasm burden. On CTAh, 37% had low and 63% had high vasospasm burden. ROC analysis demonstrated an AUC of 0.87 for CTAs (95%CI 0.67–1.00, p = 0.015) and 0.88 for CTAh (0.72–1.00, p = 0.028). Cohen's kappa was 0.843 (95%CI 0.548–1.000). Thresholding with Youden's J index, CTAs had a sensitivity of 85.71% (95%CI 48.69 to 99.27) and specificity of 66.67% (35.42 to 87.94). CTAh had sensitivity of 100% (56.55 to 100.00) and specificity of 78.57% (52.41 to 92.43). Conclusion CTAs and CTAh yielded similar sensitivity, specificity, and AUC values on ROC analysis for the detection of vasospasm using DSA as reference standard. Our findings suggest that CTAs is a promising alternative to CTAh especially in patients requiring serial imaging, given its potential advantages of decreased radiation exposure, contrast dose, and cost-effectiveness.

Pre-clinical evidence suggests bevacizumab (BV) depletes the GBM peri-vascular cancer-stem cell niche. This phase I/II study assesses the safety and efficacy of repeated doses of superselective intra-arterial cerebral infusion (SIACI) of BV after blood–brain barrier disruption (BBBD). Date of surgery was day 0. Evaluated patients received repeated SIACI bevacizumab (15 mg/kg) with BBBD at days 30 ± 7, 120 ± 7, and 210 ± 7 along with 6 weeks of standard chemoradiation. Response assessment in neuro-oncology criteria and the Kaplan–Meier product-limit method was used to evaluate progression free and overall survival (PFS and OS, respectively). Twenty-three patients with a median age of 60.5 years (SD = 12.6; 24.7–78.3) were included. Isocitrate dehydrogenase mutation was found in 1/23 (4%) patients. MGMT status was available for 11/23 patients (7 unmethylated; 3 methylated; 1 inconclusive). Median tumor volume was 24.0 cm3 (SD = 31.1, 1.7–48.3 cm3). Median PFS was 11.5 months (95% CI 7.7–25.9) with 6, 12, 24 and 60 month PFS estimated to be 91.3% (95% CI 69.5–97.8), 47.4% (26.3–65.9), 32.5% (14.4–52.2) and 5.4% (0.4–21.8), respectively. Median OS was 23.1 months (95% CI 12.2–36.9) with 12, 24, and 36 month OS as 77.3% (95% CI 53.6–89.9), 45.0% (22.3–65.3) and 32.1% (12.5–53.8), respectively. Repeated dosing of IA BV after BBBD offers an encouraging outcome in terms of PFS and OS. Phase III trials are warranted to determine whether repeated IA BV combined with Stupp protocol is superior to Stupp protocol alone for newly diagnosed GBM.

At the time of this writing, the coronavirus disease 2019 pandemic continues to be a global threat, disrupting usual processes, and protocols for delivering health care around the globe. There have been significant regional and national differences in the scope and timing of these disruptions. Many hospitals were forced to temporarily halt elective neurointerventional procedures with the first wave of the pandemic in the spring of 2020, in order to prioritize allocation of resources for acutely ill patients and also to minimize coronavirus disease 2019 transmission risks to non-acute patients, their families, and health care workers. This temporary moratorium on elective neurointerventional procedures is generally credited with helping to “flatten the curve” and direct scarce resources to more acutely ill patients; however, there have been reports of some delaying seeking medical care when it was in fact urgent, and other reports of patients having elective treatment delayed with the result of morbidity and mortality. Many regions have resumed elective neurointerventional procedures, only to now watch coronavirus disease 2019 positivity rates again climbing as winter of 2020 approaches. A new wave is now forecast which may have larger volumes of hospitalized coronavirus disease 2019 patients than the earlier wave(s) and may also coincide with a wave of patients hospitalized with seasonal influenza. This paper discusses relevant and practical elements of cessation and safe resumption of nonemergent neurointerventional services in the setting of a pandemic.

BACKGROUND AND PURPOSE: Dural venous sinus stenosis has been associated with idiopathic intracranial hypertension and isolated venous pulsatile tinnitus. However, the utility of characterizing stenosis as intrinsic or extrinsic remains indeterminate. The aim of this retrospective study was to review preprocedural imaging of patients with symptomatic idiopathic intracranial hypertension and pulsatile tinnitus, classify the stenosis, and assess a trend between stenosis type and clinical presentation while reviewing the frequencies of other frequently seen imaging findings in these conditions. MATERIALS AND METHODS: MRVs of 115 patients with idiopathic intracranial hypertension and 43 patients with pulsatile tinnitus before venous sinus stent placement were reviewed. Parameters recorded included the following: intrinsic or extrinsic stenosis, prominent emissary veins, optic nerve tortuosity, cephalocele, sella appearance, poststenotic fusiform enlargement versus saccular venous aneurysm, and internal jugular bulb diverticula. χ2 cross-tabulation statistics were calculated and recorded for all data. RESULTS: Most patients with idiopathic intracranial hypertension (75 of 115 sinuses, 65%) had extrinsic stenosis, and most patients with pulsatile tinnitus (37 of 45 sinuses, 82%) had intrinsic stenosis. Marked optic nerve tortuosity was more common in idiopathic intracranial hypertension. Cephaloceles were rare in both cohorts, with an increased trend toward the presence in idiopathic intracranial hypertension. Empty sellas were more common in idiopathic intracranial hypertension. Cerebellar tonsils were similarly located at the foramen magnum level in both cohorts. Saccular venous aneurysms were more common in pulsatile tinnitus. Internal jugular bulb diverticula were similarly common in both cohorts. CONCLUSIONS: In this cohort, most patients with idiopathic intracranial hypertension had extrinsic stenosis, and most patients with pulsatile tinnitus had intrinsic stenosis. Awareness and reporting of these subtypes may reduce the underrecognition of potential contributory stenoses in a given patient’s idiopathic intracranial hypertension or pulsatile tinnitus.

BackgroundIdiopathic intracranial hypertension is a disease of raised intra-cranial pressure of unknown etiology. Lateral cerebral venous sinus stenosis (VSS) has been increasingly reported in these patients, and stenting has emerged as an alternative treatment for medically refractory symptoms. Treatment efficacy on meta-analysis appears promising, but identifying which patients are likely to benefit most, and which are likely to require repeat procedures, is currently unclear.MethodsWe retrospectively reviewed a prospectively collected database of 79 patients treated with venous sinus stenting at a single academic center with minimum follow-up of 18 months. We extracted baseline clinical data, as well as manometry at lumbar puncture and during angiography, and used logistic regression to identify parameters that could predict stent failure.ResultsRetreatment rate after successful VSS was 13.9%. Lumbar puncture opening pressure (OP) was shown to significantly predict treatment failure (ß=0.06; OR=1.064 (1.003–1.135); P=0.039). This effect remained significant when age, sex and body mass index were added to the model (ß=0.06; OR=1.066 (1.002–1.140); P=0.043). OP was correlated with venous sinus manometry readings in the superior sagittal and transverse sinus pre-stent placement, as well trans-stenotic gradient (PConclusionsHigher lumbar puncture OP was associated with an increased risk of stent failure in transverse sinus stenting for idiopathic intracranial hypertension, although the performance of this model as a linear discriminator was poor. Further studies are required to better assess which patients are at greatest risk of treatment failure.

A 47-year-old live kidney-donor woman presented with headaches and blurred vision. Neuro-ophthalmological examination demonstrated papilledema and right eye inferior nasal defect. Brain MRV showed no sinus thrombosis but solitary right venous sinus draining the torcular Herophili to right jugular bulb. Lumbar puncture revealed elevated CSF opening pressure of 40 cm H2O with normal composition. She was diagnosed with idiopathic intracranial hypertension (IIH). She did not tolerate medical management and declined CSF diversion surgery. Cerebral angiography and venography showed venous outflow drainage from torcular Herophili through a solitary occipital sinus which has distal severe stenosis and pressure gradient of 10 mmHg. Balloon angioplasty and stenting of the occipital sinus were performed. Post-stenting, the stenosis and pressure gradient resolved. At 3-months follow-up, her symptoms and papilledema had resolved and CSF opening pressure was normal at 15 cm H2O. Aberrant cerebral venous anatomy may cause IIH and can be treatable with neuroendovascular techniques.

Mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion has been shown to significantly improve outcomes. However, despite efficient rates of recanalization (60–90%), the rates of functional independence remain suboptimal (14–58%), most likely due to pathways of cell death in the brain that have already committed despite successful reperfusion. Pharmacologic neuroprotection provides a potential means of preventing this inevitable damage through targeting excitotoxicity, reactive oxygen species, cellular apoptosis, and inflammation. Numerous clinical trials using various neuroprotective agents have failed, but the majority of these trials did not include endovascular reperfusion, and thus the drugs were not reaching the therapeutic target. Intra-arterial delivery of neuroprotective agents via the guide catheter already in place for mechanical thrombectomy could provide a way to deliver high doses directly to the affected territory while limiting systemic exposure. Agents that have shown promise via the intra-arterial route in preclinical as well as some clinical models include magnesium sulfate, verapamil, cold saline, stem cells, and various combined approaches. Targeted hypothermia, achieved with intra-carotid infusion of cold saline, may provide an effective means of achieving hypothermia of the ischemic tissue while avoiding the systemic effects that have limited its use previously. Combination therapy of targeted hypothermia and a cocktail of drugs that provide anti-excitotoxic, anti-oxidant, anti-apopototic, and anti-inflammatory effects may provide an ideal approach that deserves further study in clinical trials.

Intracranial venous sinus stenting is gaining acceptance as an effective treatment for idiopathic intracranial hypertension (IIH). The typical approach is via femoral venous and arterial access for transvenous stenting with simultaneous angiography. These patients are at an above average risk for groin complications considering obesity is typically associated with IIH and the need for heparinization and dual antiplatelet therapy. Here, we describe cerebral venography, angiography, and venous sinus stenting via a single upper extremity. We utilize a transradial approach for angiography and a venous access via the brachial or basilic vein. Over a series of 28 consecutive procedures, we were able to successfully access the intracranial venous sinuses via the arm without access site complications. This method offers the advantages of immediate patient mobilization after the procedure and more easily monitored and compressible access sites for easier post-procedural care.

Idiopathic intracranial hypertension denotes raised intracranial pressure in the absence of an identifiable cause and presents with symptoms relating to elevated ICP, namely headaches and visual deterioration. Treatment of IIH aims at reducing intracranial pressure, relieving headache and salvaging patients' vision. Surgical interventions are recommended for medically refractory IIH and include CSF diversion techniques, optic nerve sheath fenestration, bariatric surgery and venous sinus stenting. Prospective studies on the surgical options for IIH are scant and no evidence-based guidelines for the surgical management of medically refractory IIH have been established. A search in Cochrane Library, MEDLINE and EMBASE from 1 January 1985 to 19 April 2019 for controlled or observational studies on the surgical treatment of IIH (defined in accordance with the modified Dandy or the modified Friedman criteria) in adults yielded 109 admissible studies. VSS improved papilledema, visual fields and headaches in 87.1%, 72.7% and 72.1% of the patients respectively, with a 2.3% severe complication rate and 11.3% failure rate. CSF diversion techniques diminished papilledema, visual field deterioration and headaches in 78.9%, 66.8% and 69.8% of the cases and are associated with a 9.4 severe complication rate and a 43.4% failure rate. ONSF ameliorated papilledema, visual field defects and headaches in 90.5, 65.2% and 49.3% of patients. Severe complication rate was 2.2% and failure rate was 9.4%. This is currently the largest systematic review for the available operative modalities for IIH. VSS provided the best results in headache resolution and visual outcomes, with low failure rates and a very favourable complication profile. In light of this, VSS ought to be regarded as the first-line surgical modality for the treatment of medically refractory IIH.

BACKGROUND Aneurysm recurrence after coiling has been associated with aneurysm growth, (re)hemorrhage, and a greater need for follow-up. The second-generation HydroCoil Embolic System (HES; MicroVention, Inc) consists of a platinum core with integrated hydrogel and was developed to reduce recurrence through enhancing packing density and healing within the aneurysm. OBJECTIVE To compare recurrence between the second-generation HES and bare platinum coil (BPC) in the new-generation Hydrogel Endovascular Aneurysm Treatment Trial (HEAT). METHODS HEAT is a randomized, controlled trial that enrolled subjects with ruptured or unruptured 3- to 14-mm intracranial aneurysms amenable to coiling. The primary endpoint was aneurysm recurrence using the Raymond-Roy scale. Secondary endpoints included minor and major recurrence, packing density, adverse events related to the procedure and/or device, mortality, initial complete occlusion, aneurysm retreatment, hemorrhage from target aneurysm during follow-up, aneurysm occlusion stability, and clinical outcome at final follow-up. RESULTS A total of 600 patients were randomized (HES, n = 297 and BPC, n = 303), including 28% with ruptured aneurysms. Recurrence occurred in 11 (4.4%) subjects in the HES arm and 44 (15.4%) subjects in the BPC arm (P = .002). While the initial occlusion rate was higher with BPC, the packing density and both major and minor recurrence rates were in favor of HES. Secondary endpoints including adverse events, retreatment, hemorrhage, mortality, and clinical outcome did not differ between arms. CONCLUSION Coiling of small-to-medium aneurysms with second-generation HES resulted in less recurrence when compared to BPC, without increased harm. These data further support the use of the second-generation HES for the embolization of intracranial aneurysms. VIDEO ABSTRACT

Histiocytic neoplasms are rare hematologic disorders characterized by pathologic infiltration of activated histiocytes in affected tissues. The treatment of histiocytic neoplasms, including Langerhans cell histiocytosis (LCH) and non-LCH, has advanced in recent years owing to targeted kinase inhibitors (BRAF and MEK) as patients with somatic mutations in the mitogen activated protein kinase (MAPK) pathway derive robust and durable responses with these therapies.1 However, there are patients with non-LCH who do not benefit from targeted therapies, particularly those with histiocytic infiltration of the nervous system, which is associated with mortality in 1 non-LCH disorder. BRAF and MEK inhibitors have limited penetration into the nervous system and worsening neurologic disease despite targeted therapy has been observed.2 These treatments can be limited or contraindicated by disease-related organ dysfunction or comorbidities. The subset of patients without MAPK alterations may not benefit from targeted therapies.

Objective We sought to assess the diagnostic yield of advanced noninvasive imaging in the evaluation of patients with pulsatile tinnitus. Background Pulsatile tinnitus can be caused by high-risk cerebrovascular pathologies such as arteriovenous fistulae. The role of advanced noninvasive imaging, including magnetic resonance angiography and magnetic resonance venography, in the diagnostic evaluation of pulsatile tinnitus is not well defined. Design and methods We performed a retrospective cohort study of patients presenting for outpatient diagnostic evaluation of pulsatile tinnitus from January 2018 to March 2020 at Weill Cornell Medicine. Patients with non-pulsatile tinnitus and established etiologic diagnoses were excluded. Systematic chart abstraction was summarized using standard descriptive statistics. Univariate logistic regression was used to identify factors associated with nondiagnostic noninvasive imaging. Results A total of 187 patients (139 (74.3%) women) took part in this study, with a mean age of 48.6 years (standard deviation ( SD) = 15.5 years) and a mean body mass index (BMI) of 26.9 kg/m2 ( SD = 6.1 kg/m2). Of the 187 patients, 121 (64.7%) underwent exclusively noninvasive imaging, and 66 (35.3%) patients also had digital subtraction angiography (DSA). In patients who had exclusively noninvasive imaging, 62 (51.2%) patients received a diagnosis. In patients who underwent noninvasive and DSA imaging, 14 (21.2%) patients received a diagnosis based on DSA. Patients who were older at symptom onset (odds ratio (OR) = 1.05; 95% confidence interval (CI) 1.01–1.09) and those with a lower BMI (OR = 0.88, 95% CI 0.77–0.98) were more likely to have nondiagnostic noninvasive imaging. Conclusion Noninvasive cerebrovascular imaging often uncovers the etiology of pulsatile tinnitus. DSA remains useful for additional evaluation for patients with specific associated features.

Pre-clinical evidence suggests bevacizumab (BV) depletes the GBM peri-vascular cancer-stem cell niche. This phase I/II study assesses the safety and efficacy of repeated doses of superselective intra-arterial cerebral infusion (SIACI) of BV after blood-brain barrier disruption (BBBD).Date of surgery was day 0. Evaluated patients received repeated SIACI bevacizumab (15 mg/kg) with BBBD at days 30 ± 7, 120 ± 7, and 210 ± 7 along with 6 weeks of standard chemoradiation. Response assessment in neuro-oncology criteria and the Kaplan-Meier product-limit method was used to evaluate progression free and overall survival (PFS and OS, respectively).Twenty-three patients with a median age of 60.5 years (SD = 12.6; 24.7-78.3) were included. Isocitrate dehydrogenase mutation was found in 1/23 (4%) patients. MGMT status was available for 11/23 patients (7 unmethylated; 3 methylated; 1 inconclusive). Median tumor volume was 24.0 cm3 (SD = 31.1, 1.7-48.3 cmRepeated dosing of IA BV after BBBD offers an encouraging outcome in terms of PFS and OS. Phase III trials are warranted to determine whether repeated IA BV combined with Stupp protocol is superior to Stupp protocol alone for newly diagnosed GBM.

Right-sided aortic arch with an isolated left subclavian artery is a very rare congenital anatomical variant that can lead to subclavian steal syndrome. We present a case of an asymptomatic patient who was incidentally found to have this variant on CT angiography with QMRA evidence of retrograde flow in the left vertebral artery consistent with subclavian steal phenomena. Since patients often remain asymptomatic until their compensatory mechanisms become compromised later in life, serial monitoring using non-invasive hemodynamic studies such as QMRA may guide treatment.

Background and purpose This retrospective study evaluates the safety and effectiveness of preoperative endovascular embolization in patients who underwent temporomandibular joint (TMJ) replacement surgery. Material and methods We included all patients treated with preoperative embolization of the internal maxillary artery (IMAX) between June 2016 and January 2019. All patients were treated by the same surgeon using standard surgical approaches and procedures. Periprocedural adverse events, blood loss during surgery and clinical follow-up are reported. Results Fourteen patients (12 females, median age 32.5) were treated with 21 embolizations of the IMAX (bilateral embolizations in seven patients) prior to TMJ replacement surgery with prosthetic joints (TMJ Concepts prostheses). Seven patients presented with TMJ ankylosis/degenerative joint disease/post-trauma deformity, four patients with Idiopathic Condylar Resorption and resultant mandibular displacement/hypoplasia, two patients with rheumatoid arthritis-associated condylar degeneration and resultant loss of mandibular position, and 1 patient being re-reconstructed following management of a prosthetic joint infection. Seven patients underwent bilateral prosthetic joint replacement. Four patients underwent additional facial skeletal surgery as part of their treatment. The mean blood volume loss during TMJ surgery was approximately 370 cc (range 100–800 cc). Joint space-specific blood loss was not recorded, but, as per the surgical team, was significantly decreased when compared to non-embolized patients. There were no intra-procedural complications. The median clinical follow-up was 3.5 months (range 1–24 months). The modified Rankin scale (mRS) was 0 before the procedure and at last clinical follow-up in all patients. After TMJ surgery, three patients reported paresthesia of the trigeminal nerve likely related to the residual condyle resection and two patients had mild facial nerve weakness (Temporal and/or Marginal Mandibular branch) related to the surgical exposures. Conclusion Endovascular preoperative embolization of the IMAX is feasible, safe and likely effective in reducing blood volume loss in complex TMJ replacement surgery.

Hypoperfusion Intensity Ratio (HIR), defined as Tmax10s/Tmax6s on computed tomography perfusion (CTP), and stroke mechanisms have been independently correlated with angiographic collaterals and patient outcomes. Slowly developing atherosclerotic stenosis may foster collateral development, whereas cardioembolic occlusion may occur before collaterals mature. We hypothesized that favorable HIR is associated with large artery atherosclerosis (LAA) stroke mechanism and good clinical outcome.Retrospective study of consecutive endovascularly-treated stroke patients with intracranial ICA or MCA M1/M2 occlusions, who underwent CTP before intervention, between January 2018 and August 2021. Patients were dichotomized into LAA+ or LAA- based on presence of LAA on angiography. HIR was dichotomized into favorable (HIR+) or unfavorable (HIR-) groups based on published thresholds. Good early outcome was defined as discharge mRS of 0-2. Bivariate and multivariable logistic regression were performed.143 patients met inclusion. 21/143 were LAA+ (15%) and 65/143 (45%) were HIR+. HIR+ was significantly more frequent in LAA+ patients (67% vs. 42%, p= 0.035). Controlling for demographics, stroke severity, imaging findings, and medical comorbidities, LAA+ remained independently associated with HIR+ (OR 5.37 [95% CI 1.43 - 20.14]; p=0.013) as did smaller infarction core volume (30 mL of CBF30%: OR 7.92 [95% CI 2.27 - 27.64]; p = 0.001). HIR+ was not associated with good clinical outcome.Large artery atherosclerosis was independently associated with favorable HIR in patients undergoing mechanical thrombectomy. While favorable HIR was associated with smaller pre-treatment core infarcts, reflecting more robust collaterals, it was not associated with good clinical outcome.

Background This report addresses the feasibility of virtual injection software based on contrast-enhanced cone-beam CTs (CBCTs) in the context of cerebrovascular lesion embolization. Intracranial arteriovenous malformation (AVM), dural arteriovenous fistula (AVF) and mycotic aneurysm embolization cases with CBCTs performed between 2013 and 2020 were retrospectively reviewed. Cerebrovascular lesions were reviewed by 2 neurointerventionalists using a dedicated virtual injection software (EmboASSIST, GE Healthcare; Chicago, IL). Points of Interest (POIs) surrounding the vascular lesions were first identified. The software then automatically displayed POI-associated vascular traces from vessel roots to selected POIs. Vascular segments and reason for POI identification were recorded. Using 2D multiplanar reconstructions from CBCTs, the accuracy of vascular traces was assessed. Clinical utility metrics were recorded on a 3-point Likert scale from 1 (no benefit) to 3 (very beneficial). Results Nine cases (7 AVM, 1 AVF, 1 mycotic aneurysm) were reviewed, with 26 POIs selected. Three POIs were in 2nd order segments, 8 POIs in 3rd order segments and 15 POIs in 4th order segments of their respective arteries. The reviewers rated all 26 POI traces – involving a total of 90 vascular segments – as accurate. The average utility score across the 8 questions were 2.7 and 2.8 respectively from each reviewer, acknowledging the software’s potential benefit in cerebrovascular embolization procedural planning. Conclusion The operators considered CBCT-based virtual injection software clinically useful and accurate in guiding and planning cerebrovascular lesion embolization in this retrospective review. Future prospective studies in larger cohorts are warranted for validation of this modality.

Introduction Current methods for angioplasty and stenting of the intracranial vasculature for neurointervention are limited. The Wingspan Stent System is Food and Drug Administration (FDA) approved with human device exemption for a limited patient group and despite numerous prospective registries and trials demonstrating reasonable safety, still carries warnings from the FDA for its use. Given these limitations, we present the technical nuances and outcomes of the off-label use of the Resolute Onyx drug-eluting stent (DES) for neurointerventional purposes. Methods Retrospective chart review of all patients undergoing a neurointerventional procedure with the Resolute Onyx DES was done from January 2017–2021. The Resolute Onyx is a coronary balloon-mounted drug-eluting (zotarolimus) single wire laser cut stent. Technical details and procedural outcomes were collected. Results In total 40 patients had attempted placement of the Resolute Onyx DES with procedural success in 95% of patients. The most common vessel stented was the basilar artery, 30% (12/40). The most common indication was intracranial atherosclerotic disease in 62.5% (25/40) patients, followed by acute stroke in 17.5% (7/40) of patients. The technical and procedural outcomes were excellent with only one technical complication (2.5%). Conclusions This series describes the initial technical safety and utility of utilizing a new generation balloon-mounted drug-eluting stent for neurointerventional purposes. This stent offers the potential for improved navigability, delivery, and outcomes compared to current neurointerventional options and warrants further study.

Objectives This prospective study evaluates the effectiveness and safety of venous sinus stenting for patients with isolated pulsatile tinnitus and lateral sinus stenosis. Methods Patients with isolated pulsatile tinnitus and lateral sinus stenosis with a minimum trans stenotic gradient of 4 mm Hg were treated with stenting. Pulsatile tinnitus before and after treatment was assessed with the Tinnitus Handicap Inventory (THI). Periprocedural adverse events, neurological complications, clinical and radiographic follow-up were also recorded. Results A total of 42 patients (41 females and 1 male) were included in the study (median age of 37.5 years). Thirty patients had post-stenotic fusiform and 12 had post-stenotic saccular venous sinus aneurysm. In addition to stenting, coils were used to treat the patients with saccular venous aneurysms. The median follow-up was 5 months (range 1 to 34 months). Most patients had complete (39/42) or near-complete (2/42) resolution of their pulsatile tinnitus post-procedure. There were no serious adverse events. Conclusion Stenting of the lateral venous sinus is a safe and effective treatment for patients with isolated pulsatile tinnitus due to venous sinus stenosis.

Background Venous sinus stenting (VSS) is an accepted and minimally invasive treatment for adult idiopathic intracranial hypertension (IIH) associated with lateral sinus stenosis (LSS). The efficacy and safety of venous sinus stenting (VSS) in children with IIH has not been established. Methods This is a retrospective analysis of IIH patients 18 years of age or younger with LSS treated with VSS at our institution. Included patients have fulminant disease course or are refractory or intolerant to medical management. Results Eight patients were identified; 4 males and 4 females. Mean age is 13.4 years (range 4–18). All patients had severe headaches, 5 had blurred vision, 3 had diplopia and 3 had pulsatile tinnitus. Papilledema was present in 4 patients. Three patients had prior surgical procedures. Four patients were intolerant to medical management, 3 were refractory and 1 had fulminant course. Cerebral venography demonstrated severe stenosis of the dominant sinus in 6 patients and of bilateral co-dominant sinuses in 2 patients. Six patients had intrinsic stenosis and 2 had extrinsic stenosis. Venous sinus stenting (VSS) resulted in improvement of symptoms, papilledema and normalization of CSF opening pressure in 7 patients. No immediate complications were observed. Mean follow-up period is 21 months (range 6–42). Two patients required re-stenting; one responded well and the other had persistent symptoms and underwent subsequent surgical procedures of CSF diversion, suboccipital decompression and duraplasty which were also ineffective. Conclusion VSS may provide a viable option for pediatric IIH patients who are intolerant to medication, have failed conservative management or prior surgical interventions, or present with fulminant disease.

Purpose The purpose of this study was to report the technique for intraprocedural guidance of endovascular Venous Sinus Stenting procedures using 3-Dimensional (3D) Magnetic Resonance Venography (MRV) as an overlay on live biplanar fluoroscopy. Materials and methods Venous sinus stenting procedures performed between April and December, 2017 with 3D MRV fusion for live guidance were reviewed in this study. A thin-slice, contrast-enhanced MR Venogram was used to create 2 3D models – vessels and skull – for procedural guidance via augmented fluoroscopy (Vessel ASSIST, GE Healthcare, Chicago, IL). The skull model was used in the registration of the 3D overlay on both the frontal and lateral planes, which required 1–2 min of procedural time. The vessel model was used to mark landmarks such as the cortical vein ostia and stenosis on the 3D overlay fused with biplanar fluoroscopy. The retrospective imaging review was conducted by 3 neurointerventionalists and relied on a consensus confidence ranking on a 3-point Likert scale from 1- low confidence to 3- high confidence. The neurointerventionalists first reviewed the conventional 2-dimensional pre-stent deployment fluoroscopy images and then reviewed the corresponding images with the 3D MRV overlay. They ranked their confidence in their understanding of cortical venous anatomy for each group. Statistical analysis was performed using a Paired T Test at a 99% confidence interval. Results Ten cases were included in the retrospective image review. Operator confidence regarding the location of cortical veins was significantly increased using 3D MRV fusion during venous sinus stenting procedures (1.9 vs 2.9, p = .001). Conclusion 3-Dimensional MRV fusion is feasible and helpful in understanding the venous sinus anatomy and location of important cortical veins during venous sinus stenting procedures.

Idiopathic intracranial hypertension (IIH) is a disorder characterized by long-standing elevated intracranial pressure (ICP). As the name applies, no uniform cause has been identified. IIH is typically characterized by headaches, pulsatile tinnitus, and visual deterioration. Anomalies in cerebrospinal fluid (CSF) absorption are implicated in the pathophysiology of IIH. Non-invasive imaging of the brain parenchyma and the cerebral venous sinus has improved, and research has gained a better understanding of the role of cerebral venous sinus stenosis. Both have led to a better delineation of the role of arachnoid granulations (AG) and the glymphatic system in the development of IIH. IIH may occur as a result of restrictions of CSF absorption from the venous system, and or the congestion and overflow of the glymphatic system. Elucidating these mechanisms will lead to greater understanding of its underlying pathophysiologic mechanisms.

Pathologic vertebral compression fractures (VCF) are relatively common in patients with metastatic cancer and can significantly affect quality of life. Historically, these painful and sometimes debilitating fractures have been treated conservatively with pain medications and bracing. Minimally invasive vertebral augmentation procedures (VAP), including vertebroplasty and kyphoplasty, are now available and have been proven to alleviate pain and improve quality of life for select patients. Diagnosing symptomatic pathologic compression fractures and identifying those patients who would benefit from VAP in a timely manner are essential. This includes understanding the potential complications and absolute contraindications of VAP so as to minimize the potential risks while carefully selecting those patients who are likely to benefit based on their clinical history, physical exam findings, and diagnostic imaging. Radiofrequency ablation is a recently described procedure that can be performed as a stand-alone therapy or in conjunction with VAP for pathologic VCF to provide pain relief and potentially aid in local tumor control.

Myxomas are slowly growing benign neoplasms and represent the most common tumor of the heart. Embolism from cardiac myxoma occurs in 30–45% of patients and in at least half of the cases cerebral arteries are affected leading mainly to embolic ischemic strokes and rarely to delayed intracranial aneurysm formation. We present two cases with delayed intracranial aneurysmal formation 14 years and 18 years after cardiac myxoma resection. To the best of our knowledge these two cases represent the longest time interval between aneurysm detection after complete cardiac myxoma resection with no recurrence confirmed by transesophageal echocardiogram. Our study also provides the longest clinical and radiological follow-up on this type of lesion.

Background and Purpose Risk factors for hemorrhagic transformation of ischemic stroke after mechanical thrombectomy (MT) are not well established. We conducted a study to determine if prominent angiographic cerebral vascularity following recanalization with thrombectomy (angiographic blush) is associated with hemorrhagic transformation. Methods Using the Cornell AcutE Stroke Academic Registry, we identified stroke patients who had thrombectomy and achieved recanalization of anterior circulation large-vessel occlusion between 2012 and 2015. The exposure variable was presence of angiographic blush after recanalization, defined as capillary blush with or without early venous drainage. The primary outcome was volume of hemorrhagic transformation on brain imaging after thrombectomy, as determined by semiautomated volumetric analysis on computed tomography or magnetic resonance imaging among those adjudicated to have hemorrhagic conversion by neuroradiology investigators blinded to angiography results. Using a doubly robust estimator with propensity scores and outcome regression adjusting for demographics and known risk factors for hemorrhagic transformation, we evaluated whether angiographic blush after recanalization is associated with an increased volume of hemorrhagic transformation. Results Among 48 eligible patients, 31 (64.6%) had angiographic blush and 26 (54.2%) had radiographic hemorrhagic transformation (mean volume, 7.6 ml). Patients with angiographic blush averaged lower thrombolysis in cerebral infarction scores and more often received intravenous thrombolysis. In adjusted analysis, angiographic blush was associated with an increased volume of hemorrhagic transformation: mean volume, 10.3ml (95% CI, 3.7-16.9 ml) with blush versus 1.8ml (95% Confidence Interval (CII = Confidence Interval), 0.1-3.4 ml) without (P = .01). Conclusions Presence of angiographic blush after MT was independently associated with the volume of hemorrhagic transformation.

PurposeThe impact of venous sinus stenting (VSS) on vein of Labbé (VOL) drainage is poorly understood. The purpose of the study is to examine the incidence and potential high risk factors of impaired VOL drainage among idiopathic intracranial hypertension (IIH) patients following VSS.Materials and methodsInstitutional review board approved prospective evaluation of all IIH patients who underwent VSS over a 5 year period (January 2012 to December 2017) at Weill Cornell Medical Center constituted the study population. Patient demographics, procedural details (laterality of stenting, balloon angioplasty, number of stents, and stent diameters), morphology of the VOL and changes in the flow in the VOL, type of sinus stenosis, and transverse sinus symmetry were evaluated. We used χ2 analysis to evaluate impaired VOL drainage against other variables. Statistical significance was set at 0.05.Results70 consecutive patients (67 women, 3 men) with a mean age of 31±9.8 years underwent VSS. Stenosis was extrinsic in 63% (n=44) and intrinsic in 37% (n=26) of patients. Impaired drainage of the VOL was detected in 9/70 (13%) patients. Ipsilateral VOL was recognized as dominant in 20% (n=14), co-dominant in 51% (n=36), and non-dominant in 29% (n=20) of patients. Impaired VOL drainage was significantly associated with ipsilateral VOL dominance (P=0.001) and stent diameter of ≥9 mm (P=0.042). All patients demonstrated widely patent VOL on follow-up contrast enhanced MR venography at 3 months and 24 months.ConclusionImpaired drainage of the ipsilateral VOL is a potential consequence of VSS with 13% incidence, and has significant association with ipsilateral superficial cortical venous drainage via dominant VOL and stent diameter of ≥9 mm.Clinical trial registrationNCT01407809.

Background and purpose This retrospective study evaluates the safety and mid-term and long-term effectiveness of stent-assisted coil embolization of anterior communicating artery (Acomm) aneurysms treated with the LVIS Jr stent. Materials and methods All patients treated with the LVIS Jr stent for Acomm aneurysms between June 2015 and March 2018 were included in the analysis. Details of the procedure’s periprocedural adverse events, immediate aneurysm occlusion rates, and clinical and angiographic follow-up assessment were collected. Results A total of 25 patients with 25 aneurysms were included. Eighteen aneurysms were found incidentally. Seven patients presented with seven ruptured aneurysms: Six were remotely ruptured and one acutely ruptured. Twenty-four patients were treated successfully and one technical failure is reported. The parent arteries measured 1.4 mm to 2.9 mm in diameter (mean, 2.3 mm). Intraprocedural thromboembolic complications occurred in two patients (8%) and an intraoperative aneurysm rupture in one patient (4%). Immediate complete aneurysm occlusion was noted in 18 out of 25 patients (72%). Clinical follow-up ranged from three months to 36 months (mean, 15.8 months) and the imaging follow-up ranged from two to 35 months (mean, 14.2 months). Complete aneurysm occlusion was achieved in 14 out of 20 patients (70%) at last angiographic follow-up. Of the two patients with in-stent thrombosis, one patient had an acutely ruptured aneurysm and the other patient was treated with an LVIS Jr stent in a Y configuration. Neurological morbidity and mortality rate were 0%. Conclusions Complex, wide-necked Acomm aneurysms can be effectively treated with stent-assisted embolization using LVIS Jr stents.

AimsWe report the cerebrospinal fluid opening pressure (CSF-OP) measurements obtained before and after venous sinus stenting (VSS) in 50 patients with idiopathic intracranial hypertension.MethodsThe CSF-OP was measured with a spinal tap 3 months before and 3 months after treatment. All data were prospectively collected and included patient demographics, weight (kg), body mass index (BMI), acetazolamide daily dosage (mg), procedural details, complications, venous sinus pressures (mm Hg), trans-stenotic pressure gradient (mm Hg), transverse sinus symmetry, and type of venous sinus stenosis.ResultsThe average pretreatment CSF-OP was 37 cm H2O (range 25–77) and the average post-treatment CSF-OP was 20.2 cm H2O (range 10–36), with an average reduction of 16.8 cm H2O (P2O in 40/50 patients. The average acetazolamide daily dose decreased from 950 mg to 300 mg at the time of 3-month follow-up (PConclusionsWe provide evidence that there is a significant decrease in CSF-OP in patients with idiopathic intracranial hypertension 3 months after VSS, independent of acetazolamide usage or weight loss.

In this article, we report three cases of dural arteriovenous fistulas of the hypoglossal canal treated via transvenous approach. We also perform a review of the literature on the endovascular management of this type of lesions with particular attention to the dangerous extracranial-intracranial anastomoses that can occur at this level.

Background Endovascular treatment of middle cerebral artery (MCA) aneurysms has traditionally been considered difficult due to complex branching patterns, frequent involvement of parent vessels within the aneurysm neck, and a high incidence of thromboembolic complications. Methods The cases of 93 MCA aneurysms treated with endovascular intervention at our institution between 2003 and 2015 were retrospectively reviewed. Demographic, clinical, and radiographic variables were recorded and analyzed. Results Immediate complete or near-complete occlusion was achieved in 81 (90%) cases. At the longest follow up of 6 months or greater, 83.3% of the aneurysms were stable-to-improved in the Raymond occlusion classification, 8.3% were found to have minor recanalization not requiring retreatment, and 8.3% required retreatment due to significant recanalization. Thromboembolic events occurred in 18 (19.3%) of cases, but only 1 resulted in permanent vessel occlusion and only 1 resulted in permanent neurologic impairment. Thrombus was resolved with intra-arterial thrombolysis or mechanical thrombectomy in 17 of the 18 cases. There were only two cases resulting in morbidity (2.15%). There was no statistically significant correlation between aneurysm location, size, morphology, or use of adjuvant device with radiographic outcome or thromboembolic event. Conclusions While the rate of thromboembolic events in our series was 19%, the overall morbidity was only 2%. This highlights the fact that even complex MCA aneurysms can safely and effectively be treated by endovascular means with or without the use of balloon or stent assistance, as long as the interventionalist is astutely aware of the possibility of thrombus formation and acts accordingly with thrombolytic therapy when necessary.

Idiopathic intracranial hypertension causes headache, papilledema and visual field loss, typically in obese women of childbearing age. Its anatomical underpinnings remain unclear, but a stenosis at the junction of the transverse and sigmoid sinuses has been recognized in the majority of patients through venography. The stenosis may result from intrinsic dural sinus anatomy or extrinsic compression by increased intracranial pressure, but in either case, its stenting has been shown to lead to an improvement in symptoms of intracranial hypertension and papilledema in multiple retrospective, non-controlled studies. Prospective, controlled trials are needed to confirm its efficacy and safety.

Venous sinus stenting is an accepted and minimally invasive treatment for idiopathic intracranial hypertension associated with significant venous sinus stenosis. There is inherent difficulty in navigating past the region of venous stenosis in order to safely deliver and deploy a stent. We have developed the “Cobra” technique, which allows for the safe and efficient navigation past regions of high-grade venous sinus stenosis.

PURPOSE: To study the feasibility, safety, and durability of the dual stent-assisted coil embolization (DSCE) technique using low-profile visualized intraluminal support (LVIS) device. METHODS: Retrospective review of our aneurysm database to identify all the patients treated with LVIS stent-assisted embolization between July 2015 and June 2017 was performed. 15% of the patients with Y- or X-configuration DSCE constituted the study population. Patient demographics, clinical presentation, aneurysm characteristics (location, dome, and dome/neck ratio), periprocedural complications, immediate and follow-up angiographic and clinical outcomes were reported. RESULTS: Twelve patients (15%) with unruptured, wide-necked branching aneurysms underwent DSCE using LVIS Junior stents. M:F—1:11. Mean age of 60 ± 11 years. 75% (n = 9) aneurysms are located in anterior circulation. Recurrent aneurysms were treated in 17% (n = 2). Mean aneurysm diameter was 8 ± 3.4 mm and the dome/neck ratio was 1.6 ± 0.4. Periprocedural complications were noted in 25% (n = 3; transient in-stent thrombus = 2 and iatrogenic rupture = 1) with no clinical sequelae. Immediate aneurysm obliteration following DSCE was noted in all (100%) patients. Mean time-of-flight (TOF) magnetic resonance angiography (MRA) follow-up was 10 ± 6 months (Range: 5–19 months). Mean clinical follow-up was 12 ± 6 months (Range: 5–21 months). Stable neck recurrence was demonstrated in 25% (n = 3). The average modified Rankin Score (mRS) at prestent, 24-hour poststent, and last clinical follow-up were: 0.5 (Range: 0–1), 0.75 (Range: 0–1), and 0.5 (Range: 0–1), respectively. CONCLUSION: We report the first dedicated DSCE experience with LVIS Junior stents in the literature. DSCE with LVIS Junior stents for intracranial complex wide-neck branching aneurysms is feasible, safe, and effective with good clinical outcomes.

Introduction Venous sinus Stenting (VSS) is an emerging treatment for patients with IIH. However, VSS is currently performed with stents designed for stenting atherosclerotic arterial stenosis. The River™ stent has been specifically designed for treating the stenosis of the transverse-sigmoid sinuses and has the following characteristics: easy navigability through the tortuosity of the sigmoid sinus; 7 cm long length to cover the venous sinuses from the torcula to the mid sigmoid segment; two zones of radial force to address the intrinsic stenosis at the sigmoid transverse junction (stiffer zone) and extrinsic stenosis of the mid transverse sinus (softer zone); and large open cells to adapt to the triangular shape of the venous sinus without occluding cortical veins. Methods The River trial is a single arm pivotal trial designed for HDE approval of the River™ stent (Serenity Medical Inc, Redwood City, CA). The trial will enroll 39 subjects in 7 clinical sites. Subjects must have proven IIH and >50% stenosis of the sigmoid-transverse sinus with pressure gradient >8 mm Hg. Subjects can be enrolled on visual criteria: visual field deficit from – 6 db to – 30 db resistant to medical therapy >2 weeks; or on headaches criteria: severe headaches defined by Headache Impact Test (HIT-6) >59 resistant to medical therapy >4 weeks. The patients need to be on dual antiplatelet therapy (aspirin and clopidogrel) for 3 months and aspirin monotherapy for 9 more months. The primary safety endpoint is the rate of major adverse event (any neurological complication plus need for any surgical procedure for IIH) at 12 months. The primary efficacy endpoint is a composite at 12 months of clinical improvement and absence of significant venous stenosis. Secondary endpoints at 12 months include opening pressure on lumbar puncture, individual ophthalmology endpoints, change in pulsatile tinnitus, change in medications, change in quality of life scores. Results Enrollment started in September 2018. Four sites are active at the time of submission of this abstract and three other sites are in the process of certification. Eleven subjects have been enrolled. In all 11 cases the catheterization with the River™ stent was extremely easy and the stent was deployed as expected. In two patients with severe stenosis from arachnoid granulation, post-stent angioplasty was performed. There was resolution of the trans-stenotic gradient in all cases. There was no stent-thrombosis. There was no impairment of flow in the cortical veins draining into the stented segment. There were no major neurological adverse events or device related complications. None of the enrolled patients reached the 12-month follow-up time point and therefore we cannot report on primary and secondary endpoints but an update of the trial with intermediate clinical results will be presented at the conference. Conclusion We provide early/interim results of the use of the River stent. This novel stent has been effective for the treatment of venous sinus stenosis without any short-term serious adverse events or device related complications. Disclosures A. Patsalides: None.