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Chronic subdural hematoma (CSDH) is an increasingly prevalent disease in the aging population. Patients with CSDH frequently suffer from concurrent vascular disease or develop secondary thrombotic complications requiring antithrombotic treatment.To determine the safety and impact of early reinitiation of antithrombotics after middle meningeal artery embolization for chronic subdural hematoma.This is a single-institution, retrospective study of patients who underwent middle meningeal artery (MMA) embolizations for CSDH. Patient with or without antithrombotic initiation within 5 days postembolization were compared. Primary outcome was the rate of recurrence within 60 days. Secondary outcomes included rate of reoperation, reduction in CSDH thickness, and midline shift.Fifty-seven patients met inclusion criteria. The median age was 66 years (IQR 58-76) with 21.1% females. Sixty-six embolizations were performed. The median length to follow-up was 20 days (IQR 14-44). Nineteen patients (33.3%) had rapid reinitiation of antithrombotics (5 antiplatelet, 11 anticoagulation, and 3 both). Baseline characteristics between the no antithrombotic (no-AT) and the AT groups were similar. The recurrence rate was higher in the AT group (no-AT vs AT, 9.3 vs 30.4%, P = .03). Mean absolute reduction in CSDH thickness and midline shift was similar between groups. Rate of reoperation did not differ (4.7 vs 8.7%, P = .61).Rapid reinitiation of AT after MMA embolization for CSDH leads to higher rates of recurrence with similar rates of reoperation. Care must be taken when initiating antithrombotics after treatment of CSDH with MMA embolization.

Background and Purpose: The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. Methods: We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council. Results: Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (P P P Conclusions: In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.

Introduction: Intracranial atherosclerotic disease (ICAD) is a common cause of refractory stroke. Randomized clinical trials failed to prove the safety and efficacy of the endovascular treatment options of symptomatic ICAD (sICAD). However, there are many concerns regarding inclusion criteria in these trials which made them less effective than standard medical management. Herein, we aim to study the safety and efficacy of drug-eluting balloon mounted stents (DES) in the treatment of sICAD. Methods: A retrospective review of endovascular database from 10 comprehensive stroke centers inside and outside the USA from January 2017 to January 2020 was reviewed. Patients were included if they had symptomatic intracranial stenosis ≥70% in the target vessel, failed best medical management, and underwent intracranial stenting with DES. The primary outcome was the occurrence of ischemic stroke, hemorrhage, or mortality within 72 hours of the procedure. Secondary outcomes included rates of symptomatic and angiographic recurrence within 6 months of the procedure. Results: There was a total of 129 patients, the median age was 65 [58-72] years, 40 (31%) were females. The intracranial stenotic lesions were located in anterior circulation in 74 (57.4%) of cases [24 (18.6%) supraclinoid ICA, 5 (3.9%) cavernous ICA, 17 (13.2%) petrous ICA, 5 (19.4%) MCA-M1, and 3 (2.3%) M2] and in posterior circulation in 55 (42.6%) of cases [36 (27.9) vertebral artery V4 segment, 18 (14%) basilar and 1 (0.7%) PCA]. Recurrent stroke was the qualifying event in 101 (78.3%) while transient ischemic attacks (TIA) were identified in 28 (21.7%) of cases. The median time from the qualifying event to stenting was 6 [2-24] days. Strokes were reported within 72 hours of the procedure; 2 (1.6%) ischemic, 2 (1.6%) hemorrhagic strokes and 2 (1.6%) patients suffered inpatient mortality. The median follow-up time was 6 [3-6.75] months. Among 99 patients who had clinical follow up 2 (2%) had TIA and 6 (6.1%) had strokes. Fifty-one patients had follow-up imaging of whom symptomatic ISR was reported in 8 (15.7%). Conclusion: Our study has shown that in appropriately selected patients with sICAD, endovascular treatment using DES is safe and effective. Prospective randomized clinical trials are warranted.

Background and Purpose: Noncontrast head CT and CT perfusion (CTP) are both used to screen for endovascular stroke therapy (EST), but the impact of imaging strategy on likelihood of EST is undetermined. Here, we examine the influence of CTP utilization on likelihood of EST in patients with large vessel occlusion (LVO). Methods: We identified patients with acute ischemic stroke at 4 comprehensive stroke centers. All 4 hospitals had 24/7 CTP and EST capability and were covered by a single physician group (Neurology, NeuroIntervention, NeuroICU). All centers performed noncontrast head CT and CT angiography in the initial evaluation. One center also performed CTP routinely with high CTP utilization (CTP-H), and the others performed CTP optionally with lower utilization (CTP-L). Primary outcome was likelihood of EST. Multivariable logistic regression was used to determine whether facility type (CTP-H versus CTP-L) was associated with EST adjusting for age, prestroke mRS, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, LVO location, time window, and intravenous tPA (tissue-type plasminogen activator). Results: Among 3107 patients with acute ischemic stroke, 715 had LVO, of which 403 (56%) presented to CTP-H and 312 (44%) presented to CTP-L. CTP utilization among LVO patients was greater at CTP-H centers (72% versus 18%, CTP-H versus CTP-L, P Conclusions: We identified an increased likelihood for undergoing EST in centers with lower CTP utilization, which was not associated with worse clinical outcomes or increased hemorrhage. These findings suggest under-treatment bias with routine CTP.

Introduction Proximal cervical internal carotid artery stenosis greater than 50% merits revascularization to mitigate the risk of stroke recurrence among large-vessel anterior circulation strokes undergoing mechanical thrombectomy. Carotid artery stenting necessitates the use of antiplatelets, and there is a theoretical increased risk of hemorrhagic transformation given that such patients may already have received intravenous thrombolytics and have a significant infarct burden. We investigate the outcomes of large-vessel anterior circulation stroke patients treated with intravenous thrombolytics receiving same-day carotid stenting or selective angioplasty compared to no carotid intervention. Materials and methods The study cohort was obtained from the National (Nationwide) Inpatient Sample database between 2006 and 2014, using International Statistical Classification of Diseases, ninth revision discharge diagnosis and procedure codes. A total of 11,825 patients with large-vessel anterior circulation stroke treated with intravenous thrombolytic and mechanical thrombectomy on the same day were identified. The study population was subdivided into three subgroups: no carotid intervention, same-day carotid angioplasty without carotid stenting, and same-day carotid stenting. Outcomes were assessed with respect to mortality, significant disability at discharge, hemorrhagic transformation, and requirement of percutaneous endoscopic gastronomy tube placement, prolonged mechanical ventilation, or craniotomy. Results This study found no statistically significant difference in patient outcomes in those treated with concurrent carotid stenting compared to no carotid intervention in terms of morbidity or mortality. Conclusions If indicated, it is reasonable to consider concurrent carotid stenting and/or angioplasty for large-vessel anterior circulation stroke patients treated with mechanical thrombectomy who also receive intravenous thrombolytics.

Background: Endovascular treatment (EVT) of large vessel anterior circulation stroke has become standard of care. Emerging clinical trials have shown effectiveness of EVT for anterior circulation strokes beyond 6 hours after stroke onset. In addition to imaging criteria, it is important to understand clinical and demographic predictors of poor outcomes in this subgroup. Methods: A hospital based stroke registry was used for retrospective analysis of 225 consecutive cases of large vessel anterior circulation strokes. Poor outcome was defined as >1/3 middle cerebral artery territory infarct (MCAI) on MRI diffusion weighted imaging or on CT scan performed approximately 24 hours from treatment. Multivariate logistic regression model was used to identify demographic and clinical predictors of poor outcome. IBM - SPSS version 24 was used for data analysis. Results: In the study cohort, 31.25% patients had 1/3 MCAI had higher admission NIHSS (National Institute of Health Stroke Scale) (19.37 Vs 15.52, p1/3 MCAI after controlling for clinical and demographic variables in multivariate logistic regression analysis. Conclusion: SBP on initial presentation predicted >1/3 MCAI in large vessel anterior circulation strokes treated with EVT. This finding was in a setting of non-significant difference in DBP on initial presentation, SBP and DBP at 24 hours in >1/3 MCAI versus

Introduction: Mechanical thrombectomy (MT) for the treatment of acute ischemic stroke (AIS) in patients with large vessel anterior circulation occlusion has become a standard of care. Our study examines the risk of hemorrhagic transformation (HT) in patients that also underwent emergent carotid stenting (approximately 10%) during MT which potentially requires immediate antiplatelet use to prevent stent thrombosis. Methods: A hospital based stroke registry was used for retrospective analysis of 225 consecutive cases of large vessel anterior circulation strokes. Parenchymal hematoma (PH - PH1 and PH2) type of HT on 24 hour CT or MRI was defined as primary outcome. The study cohort was divided into carotid stenting and non stenting group. Baseline clinical and demographic characteristics were compared with uni-variate analysis. Multivariate logistic regression model was used to identify demographic and clinical predictors of PH. Results: Seventeen patients (7.55%) required immediate carotid stenting. 2 patients (11.8%) in the stenting group had PH compared to 24 (11.9%) in the non-stenting group (p=0.98). Intravenous thrombolytic was given to 59.2% patients in non-stenting group compared to 64.7% in stenting group (p=0.82). 52.9% were immediately started on antiplatelet or anticoagulation (29.4% - eptifibatide, 5.9% aspirin + clopidogrel, 17.6% heparin) in stenting group. In non stenting group 5% patient were immediately started on antiplatelet or anticoagulation (1.5% - eptifibatide, 1% aspirin + clopidogrel, 2% heparin, 0.5% aspirin alone). None of the patients in either group who had been started on antiplatelet or anticoagulation had PH. Multivariate analysis remained insignificant with small sample size. Conclusion: In this small, single center study, emergent carotid stenting during mechanical thrombectomy for large vessel anterior circulation stroke did not increase the risk of hemorrhagic transformation despite the early use of antiplatelet or anticoagulant medication or prior administration of intravenous thrombolytics.

Objective To assess the safety and efficacy of the Pipeline Embolization Device (PED) for endovascular treatment of complex, distal posterior cerebral artery (PCA) aneurysms. Methods We conducted a retrospective review of patients who underwent endovascular treatment of complex PCA aneurysms with PED from November 2012 to December 2015. A total of 4 patients were identified and treated. Twelve-month angiographic and clinical follow-up was available for all patients. Results Mean aneurysm size (largest diameter) was 10.0 mm, and all aneurysms originated at the P2 segment or beyond. Technical success was achieved in all patients. All patients were treated with a single PED; adjunctive intrasaccular coil was also placed in one patient. All patients achieved a favorable postprocedural outcome (modified Rankin Scale score = 0) with no new neurologic deficits. No patients experienced neurologic complications or perforator infarction, and presenting symptoms resolved in all patients. Follow-up cerebral angiography at 12 months in 3 patients showed complete occlusion (Raymond-Roy Occlusion Classification class 1) and minimal residual aneurysm filling (Raymond-Roy Occlusion Classification class 2) in 1 patient. A small degree of focal stenosis was present in 2 patients within the PED at 12-month follow-up that was associated with mild decrease in flow within the distal PCA branches. Conclusions PED use provides a practical and viable treatment option for complex, distal PCA aneurysms. Based on our limited institutional experience, PED use for treatment of complex, distal PCA aneurysms in select patients appears safe and effective.

Background: Endovascular thrombectomy (EVT) substantially increases the likelihood of good outcome in acute ischemic strokes due to large vessel occlusion (LVO). Expediting EVT to achieve faster reperfusion is an important factor that correlates with good outcome. Ultra-early intervention in the first 3 “golden” hours from onset was not well characterized in recent trials. Objective: We sought to assess the impact of early treatment within the first 3 hours on clinical outcomes in large, real life, world-wide practice. Methods: We analyzed a multicenter international prospective cohort study of LVO patients treated with stent retriever thrombectomy (TREVO Registry) between11/2013 and 4/2016. We stratified patients based on treatment time, onset to groin puncture (GP), into 3 groups: 0-3, 3-6, >6 hrs. 90 day mRS was the primary outcome (0-2 good outcome). Logistic regression modeling was performed to evaluate the impact of treatment within the golden 3 hours on outcomes and to determine the independent factors associated with EVT initiation within 3 hours. Results: In the 905 patients, GP occurred in: 23.1% 0-3 hrs, 44.3% 3-6 hrs and 32.6% >6 hrs. Table 1 shows similar baseline characteristics among the groups. Patient-level predictors of treatment within 3 hrs were age (aOR 1.1 per decade of age ≥18) and good ASPECTS (aOR 1.2 per point). No hospital-level predictors of early treatment were found. Patients treated within 3 hrs have a higher likelihood of good outcome as compared to those treated >3 hrs (aOR 2.0, 95% CI 1.4-2.9; p Conclusion: Early thrombectomy of LVO strokes, within the first three hours provides the highest impact compared with later time windows. Streamlining processes to deliver rapid intervention within 3 hours would improve clinical outcomes.

De novo intracerebral arteriovenous malformations (AVMs) are exceedingly rare with only seven reported cases in the literature. Although generally considered congenital by nature, the lesions do not manifest themselves clinically until the third or fourth decades of life. However, with the advent of improved imaging modalities and more frequent surveillance, an increasing number of de novo cases are being found challenging the concept AVMs develop in the perinatal/antenatal period. Alternatively, this phenomenon could represent a distinct entity in which lesion development occurs after birth. A PubMed search of "de novo cerebral arteriovenous malformation" was performed in which seven reported cases were found. The mean age at diagnosis was 14.7 years with a mean follow-up imaging study of 5.8 years. Lesion location was supratentorial in all previously described cases. This case involves an 18-year-old male with congenital hydrocephalus and seizures diagnosed at 7 months of age. The patient underwent a ventriculoperitoneal shunt and was followed frequently by a neurologist. The last diagnostic imaging was an unremarkable MRI of the brain at age 12. Seven years later, the patient presented with an intracerebral hemorrhage. A CT angiogram demonstrated a large brainstem AVM with an intraparenchymal hemorrhage and intraventricular extension. This case is unique in that it is the first infratentorial de novo AVM. The congenital nature of AVMs is challenged with the increasingly described series of patients with previously documented normal radiographic imaging. This suggests there may be a subset of patients genetically predisposed to postnatal development of AVMs.

STUDY DESIGN This is a case report. OBJECTIVE To report a 3-dimensional (3D) rotational C-arm conebeam computed tomography (CT) (DynaCT) angiography generating computed tomographic data concurrently with spinal angiographic datasets. This technology allowed 3D modeling of the anterior spinal arterial supply in juxtaposition to a hypervascular tumor mass, thus affording unprecedented guidance in presurgical planning. SUMMARY OF BACKGROUND DATA An enhanced demonstration of spatial relationships between the vascular elements and their adjacent soft-tissue structures is needed to visualize the minute anterior spinal artery optimally. METHODS A 76-year-old male with a history of renal cell carcinoma metastasis to the T6 vertebra 1 year prior, presented with worsening myelopathy caused by severe spinal cord compression at T6 level, and a plan for surgical decompression was established. Because of the hypervascular nature of this renal cell carcinoma metastasis, preoperative embolization was requested to minimize blood loss during the operation. A digital subtraction angiogram identified the major arterial contribution to the tumor to also supply the radiculomedullary branch to the anterior spinal artery. To further characterize this blood supply, a rotational DynaCT angiography was performed. RESULTS The rotationally acquired data were processed generating volumetric CT datasets demonstrating the 3D relationships of the anterior spinal artery, the blood supply to the tumor and the adjacent soft-tissue and bony structures. A shared blood supply to both the tumor mass and the anterior spinal artery from the left T6 segmental artery was confirmed. The dual nature of this blood supply presented increased risk of ischemic spinal cord injury by possible nontarget embolization. Therefore, the embolization was deferred. CONCLUSION The DynaCT angiography precisely characterized the complex blood supply of a hypervascular vertebral tumor mass in relation to a shared arterial supply to the thoracic spinal cord. The optimal visualization properly aided presurgical planning. LEVEL OF EVIDENCE N/A.

Introduction: Periprocedural risk of ischemic stroke (IS) in patients undergoing endovascular treatment for unruptured intracranial aneurysms (EUIA) can be as high as 40%, with clinically significant strokes occurring in 3-10% of patients. There is limited data on how typical vascular risk factors can increase peri-procedural risk of IS and mortality in patients undergoing EUIA. Methods: We queried the Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS) data between 2004 and 2012. ICD-9 codes 437.3 (intracerebral unruptured aneurysm) and 39.72 (endovascular repair/embolization of head and neck vessel) were used to identify the study population. Multivariate logistic regression model was used to identify independent predictors of IS and mortality after controlling confounders including age, race, sex, atrial fibrillation (Afib), diseases of endocardium, alcohol, smoking, diabetes mellitus, hypertension, use of anticoagulants, use of antiplatelet agents, carotid artery stenosis, atherosclerosis and hyperlipidemia. We also investigated whether Afib, DM, hypertension and hyperlipidemia in possible combinations further increased the risk of IS and mortality. Results: A total of 50,478 EUC cases were identified, of which 10,600 (20.9%) reported an IS event. A total of 661 (0.01%) died of which 115 (17.4%) had an IS event. After controlling for confounders, age >70 (OR 1.521 95% CI 1.145- 2.020, P< 0.01) and diabetes (OR 1.426, 95%CI 1.092-1.861, p 70 (OR 2.472, CI 1.616-3.782, p Conclusions: In patients undergoing EUIA, Age >70 is an independent risk factor for IS and mortality. Diabetes independently increased risk of IS but not mortality; Afib independently increased risk of mortality but not IS.

Background: There is paucity of data on safety outcomes in the subgroup of patients who are on anticoagulation (AC) that undergo mechanical thrombectomy (MT) for anterior circulation large vessel stroke (AS). Methods: The Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS) data was queried between 2006 and 2010 using validated ICD 9 diagnostic codes for acute ischemic stroke. ICD-9 99.1 for IV tPA and ICD-9 procedure code 39.71 (mechanical thrombectomy) were used. Patients with AS treated with MT were divided into three groups: 1. On AC not receiving iv tPA, 2. On AC receiving iv tPA, 3. Not on AC. Group 3 was subdivided into 3a. Received iv tPA and 3b. Did not receive iv tPA. Mortality, hemorrhagic transformation (HT) and disability at discharge were used to compare outcomes. In addition to demographics, comorbid vascular risk factors, concurrent use of antiplatelet agents, in-hospital complications (DVT, PE, sepsis, hospital acquired infections) were controlled. Patients on novel oral anticoagulants were excluded. Results: A total of 10,475 AS patients received MT: Group 1- 398 (3.8%), Group 2 - 439 (4.1%), and Group 3 - 9638 (92.1%). Group 3A - 3918 (37.4%) and 3B - 5719 (54.6%). After controlling for confounders, there was no statistically significant increase in the risk of mortality, hemorrhagic transformation and disability at the time of discharge (Table) in Cohort 1 vs. to other cohorts. Conclusion: The subgroup of patients who are on AC receiving MT for AS with or without tPA did not have an increased risk of HT, mortality or disability.

Introduction: Recent clinical trials have established the efficacy of mechanical thrombectomy (MT) for the treatment of acute ischemic stroke (AIS) in patients with large vessel anterior circulation occlusion. There is limited data on outcomes and hemorrhagic transformation (HT) risk in patients that also underwent carotid stenting (approximately 10%) during MT which requires immediate antiplatelet use. Methods: We queried the Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS) (from 2006 to 2010) with ICD 9 diagnostic codes for AIS published by HCUP. ICD-9 99.1 was used for intravenous r-tPA and ICD-9 procedure code 39.71 (MT), 00.61 and 00.63 (for Carotid Stenting). This identified AIS patients who received MT w/wo carotid stenting. Primary outcomes were in-hospital mortality, HT (ICD9 430, 431, 432.0-432.9), and significant disability at discharge (to intermediate and long term skilled nursing facility). In addition to demographics, co-morbid vascular risk factors, use of anticoagulation/antiplatelet and in-hospital complications including DVT, PE, sepsis, and hospital acquired infections were controlled as confounders. Results: 10,475 (weighted N) patients received MT out of which 1175 (11.22%) patients also underwent carotid stenting. After controlling for age, sex, race, Atrial fib, diseases of endocardium, alcohol, tobacco use, diabetes mellitus, hypertension, long-term (current) use of antiplatelet, long-term (current) use of anticoagulation, carotid artery stenosis, hospital acquired infection, sepsis, DVT, PE, year and hyperlipidemia we found that patients receiving carotid stenting had no significant differences in mortality OR 1.02 (95% CI 0.687-1.518; p=0.9178), HT OR 1.183 (95% CI 0.678-2.066; p=0.5535), disability at discharge OR 0.817 (95% CI 0.562-1.189; p=0.2915) compared to controls. Diabetes was an independent predictor of mortality OR 1.375 (95% CI 1.007-1.877) and disability OR 1.446 (95% CI 1.057-1.978). Conclusion: Prevention of stent thrombosis with early antiplatelet use does not appear to increase the risk of HT in endovascularly treated AIS patients receiving carotid stenting. There was no significant increased risk of HT, mortality and morbidity in this subgroup.

Foreign material emboli following cerebral, cardiac, and peripheral catheterizations have been reported since the mid-1990s. Catheter coatings have been frequently implicated. The most recent surge of interest in this phenomenon within the neurointerventional community is associated with procedures using flow-diversion devices for the treatment of cerebral aneurysms. Following coil-supported Pipeline embolization in 4 cases and stent-supported coiling in 1, 5 patients developed multiple subcentimeter enhancing lesions, usually with surrounding edema and variable magnetic susceptibility in the vascular territories of the treated aneurysms. Conventional angiography findings were unrevealing. Laboratory work-up showed mild CSF protein elevation with no leukocytosis. Brain biopsy in 2 cases revealed granulomatous angiitis encasing foreign material, identical in stain appearance to a polyvinylpyrrolidone catheter coating. Corticosteroid administration typically produced clinical improvement. A heterogeneous radiographic and clinical course was noted, with rise and fall in the number of enhancing lesions in 2 patients and persistence in others. The etiology may be related to widespread adoption of increasingly sophisticated catheterization techniques.

The Pipeline embolization device is a flow diverting stent that is now available as an FDA approved treatment for giant wide-neck cavernous and supraclinoid aneurysms. This revolutionary device has made it possible to safely treat large wide necked aneurysms with excellent results. There is limited information on the impact of Pipeline on smaller secondary aneurysms. We present single center data regarding Pipeline’s efficacy in the treatment of these aneurysms. Methods: Since August 2012, 24 patients have been electively treated utilizing the Pipeline Embolization Device (PED) (Covidien, Mansfield, MA) at Hartford Hospital. Of these patients, 17 patients have had follow up angiograms and 9 (52%) had smaller secondary aneurysms that was covered by the Pipeline stent. For each patient where angiographic follow-up was available, the degree of secondary aneurysm occlusion was assessed utilizing the Raymond criteria. Results: All procedures were successfully completed and a total of 41 PEDS were implanted. No intraprocedural complications were present. During the clinical follow-up period, no major complications resulted. One patient developed a partial CN III and IV neuropathy secondary to thrombosis of a large cavernous aneurysm 4 days following treatment. The results of 6 month follow-up angiography demonstrated that out of a total of 9 cases, 8 cases (89%) with smaller secondary aneurysms resolved and 1 case (11%) improved significantly. In all cases where the smaller secondary aneurysm was occluded, the larger primary aneurysm was also occluded. The single case of significant improvement demonstrated that the primary aneurysm had also significantly decreased in size. Conclusion: Smaller secondary aneurysms are adequately treated by Pipeline stenting. In all cases, the primary aneurysm either improved significantly or totally occluded along with the secondary aneurysms. This suggests that the Pipeline device, in addition to treating large wide-necked aneurysms, can effectively treat smaller associated aneurysms without the need for additional endovascular coiling. Key Words: Pipeline embolization device, giant wide-neck cavernous and supraclinoid aneurysm, secondary aneurysms

A 46-year-old right-handed African American man presented to the emergency department after a 10-minute episode of sudden-onset left-hand weakness and slurred speech. His medical history was significant for a left cerebellar stroke 6 years ago. That event occurred during a physical training exercise and was thought to be secondary to a vertebral artery dissection.1,2 He was placed on aspirin 81 mg daily. The patient had minimal residual deficits, with left face numbness and left hypoacusis. He did not smoke, drink, or use recreational drugs. There was no family history of stroke or vascular disease. On initial examination, the patient was normotensive. His mental status was intact, with a Mini-Mental State Examination (MMSE) score of 30/30. There was no apraxia, aphasia, or visual field deficit. Cranial nerve examination had normal results with the exception of left hypoacusis and left facial numbness over the V1–V3 distribution to pinprick. Funduscopic examination revealed no papilledema or vasculopathy. Motor, sensory, and cerebellar examinations were normal. Deep tendon reflexes were 2+ throughout with bilateral plantar responses. Laboratory testing including a complete blood count, serum chemistry, coagulation panel, and liver function tests were normal. EKG showed normal sinus rhythm and no evidence of left ventricular hypertrophy. MRI showed no evidence of acute intracranial abnormalities; a chronic left cerebellar infarct was seen (figure 1). CT angiography demonstrated severe bilateral middle cerebral artery (MCA) stenosis, worse on the right, as well as an absent left vertebral artery which was confirmed by conventional angiography (figure 2A). Figure 1 Initial imaging Noncontrast head CT (A) on admission demonstrating chronic left cerebellar infarct. Fluid-attenuated inversion recovery (FLAIR) MRI on admission shows no evidence of ischemic changes in the middle cerebral artery territory (B). FLAIR was also negative (C). Figure 2 Initial cerebral angiogram Angiogram on admission (A), at time of cognitive decline (B), and poststent placement (C) …

Cat-scratch disease, caused by a pleomorphic Gram-negative rod known as the cat-scratch bacillus, has many rare and varied complications and unusual manifestations [1]. Recent reports [2-6] have described bacillary angiomatosis as a new manifestation of systemic cat-scratch disease seen in patients with AIDS who have cutaneous lesions, subcutaneous nodules, or osteolytic lesions. We report a case of bacillary angiomatosis that was manifested as a vascular softtissue mass in which cat-scratch bacilli were shown by electron microscopy. To our knowledge, no similar cases of softtissue masses in systemic cat-scratch disease have been reported. As our case illustrates, systemic cat-scratch disease has clinical and radiologic features that resemble both benign and malignant diseases. Although certain radiologic and dinical findings may suggest the diagnosis of systemic catscratch disease, a definitive diagnosis is made only on the basis of biopsy specimens examined by using either special stains or electron microscopy.

Interventional neuroradiology, referred to as intravascular surgery in the Soviet Union or endovascular surgery in Japan, is a discipline that has evolved from diagnostic angiographic techniques and has culminated largely in transarterial embolization operations. The method was first used for the treatment of an arteriovenous (AV) fistula 56 years ago. Thirty years later, transarterial embolization was applied to treat some vascular malformations of the brain. At present, improvements in techniques and the development of microcatheters permit the safe and reproducible catheterization of intracerebral, extracerebral, and spinal arteries in the fifth and sixth divisions (Figs. 8.1–8.9). Subsequent refinement in embolic materials and infusion cytotoxic agents, in conjunction with a better understanding and knowledge of functional vascular anatomy in the craniofacial, spinal, and cerebral circulations, have permitted application of neuroangiographic techniques to the management of increasingly complex problems (Table 8.1). These procedures can be used as the sole form of treatment or can be combined with other modalities.