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One of the defining narratives of the COVID-19 pandemic has been the acceptance and distribution of vaccine.Compare the outcomes of COVID-19 positive vaccinated and unvaccinated stroke patients.This is a single-center retrospective study of COVID-19-vaccinated and unvaccinated stroke patients between April 2020 and March 2022. All patients presenting with stroke regardless of treatment modalities were included. NIHSS was used to assess stroke severity. The primary outcome was functional capacity of the patients at discharge.The study cohort comprised 203 COVID-19 positive stroke patients divided into 139 unvaccinated and 64 fully vaccinated patients. At discharge, the mRS score was significantly lower in the vaccinated cohort (3[1-4] vs 4[2-5], OR=0.508, p=0.011). At 3 months of follow-up, the median mRS score was comparable between both cohorts.Although vaccination did not show any significant difference in stroke patient outcomes on follow-up, vaccines were associated with lower rates of morbidity and mortality at discharge among stroke patients during the pandemic.

OBJECTIVE Stent-assisted coil (SAC) embolization has been the mainstay endovascular treatment for bifurcation aneurysms. The recent introduction of the Woven EndoBridge (WEB) device has presented an alternative endovascular treatment modality for these aneurysms. Direct comparisons of outcomes between these two modalities are limited in the literature. Here, the authors compared the outcomes of bifurcation aneurysms treated with SAC and WEB devices. METHODS This retrospective single-center study comprised 148 bifurcation aneurysms that were treated endovascularly with SAC or WEB devices between 2011 and 2019. The primary outcome was complete occlusion of the aneurysm at 6 months on catheter angiography. RESULTS The SAC and WEB cohorts comprised 85 and 63 aneurysms, respectively. The baseline characteristics were well balanced after inverse probability weight (IPW) adjustment, except for smoking status. The 6-month complete occlusion rate was higher in the WEB cohort than the SAC cohort (67.4% vs 40.6%; unadjusted OR [95% CI] 3.014 [1.385–6.563], p = 0.005). However, this difference in complete occlusion rates did not remain significant after IPW adjustment and multiple imputations. The neck remnant rate was lower in the WEB cohort than the SAC cohort (20% vs 50%; OR [95% CI] 0.250 [0.107–0.584], p = 0.001), and this difference remained significant after IPW adjustment (OR [95% CI] 0.304 [0.116–0.795], p = 0.015) and multiple imputations. CONCLUSIONS Use of SAC and WEB demonstrated comparable 6-month complete occlusion rates for bifurcation aneurysms. WEB appeared to be associated with a lower rate of neck remnant at 6 and 12 months compared with SAC. WEB was also associated with fewer complications and decreased retreatment rates compared with SAC.

The transradial approach has increasingly been used for neurointerventions because of the improved safety profile compared with transfemoral. However, it is important to be aware of potential complications such as radial artery (RA) spasm, RA occlusion, pseudoaneurysm, extravasation, arteriovenous fistula, and wrist hematoma as well as their management.To present our institution's experience with the prevention and management of local access site complications associated with the transradial approach for neuroendovascular interventions.We conducted a retrospective analysis of a prospectively maintained database and identified 1524 consecutive neuroendovascular procedures performed using transradial access from April 2018 to February 2021.Among 1524 procedures, local transradial complications occurred in 1.7%. Major complications occurred at a rate of 1.2% including RA extravasation (0.3%), delayed RA occlusion (0.6%), pseudoaneurysm (0.1%), compartment syndrome (0.1%), infection (0.1%), and avulsion of the RA in 0.1% (1 of 1524) with no serious clinical consequence. Although RA occlusion is included in major complications, all cases were asymptomatic and did not require any intervention. Minor complications occurred at a rate of 0.5% including severe RA spasm (0.3%) and hematoma (0.3%). No patient in the cohort died or suffered from permanent disability from a complication related to the transradial approach.Transradial access for neurointervention has a low rate of local complications, particularly when taking appropriate prevention measures. Appropriate management of complications can prevent procedural failure and has low morbidity rates demonstrating the overall safety profile of transradial access even when complications occur.

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

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

The use of flow diverters for treating intracranial aneurysms has been widely used in the past decade; however, data comparing pipeline embolization device (PED; Medtronic Inc) and flow-redirection endoluminal device (FRED; MicroVention) in the treatment of intracranial aneurysms remain scarce.To compare the outcomes of PED and FRED in the treatment of intracranial aneurysms.This is a single-center retrospective review of aneurysms treated with PED and FRED devices. Patients treated with PED or FRED were included. Cases requiring multiple or adjunctive devices were excluded. Primary outcome was complete aneurysm occlusion at 6 months. Secondary outcomes included good functional outcome, need for retreatment, and any complication.The study cohort comprised 150 patients, including 35 aneurysms treated with FRED and 115 treated with PED. Aneurysm characteristics including location and size were comparable between the 2 cohorts. 6-month complete occlusion rate was significantly higher in the PED cohort (74.7% vs 51.5%; P = .017) but lost significance after inverse probability weights. Patients in the PED cohort were associated with higher rates of periprocedural complications (3.5% vs 0%; P = .573), and the rate of in-stent stenosis was approximately double in the FRED cohort (15.2% vs 6.9%; P = .172).Compared with PED, FRED offers modest 6-month occlusion rates, which may be due to aneurysmal and baseline patient characteristics differences between both cohorts. Although not significant, FRED was associated with a higher complication rate mostly because of in-stent stenosis. Additional studies with longer follow-up durations should be conducted to further evaluate FRED thrombogenicity.

OBJECTIVEThe advent of mechanical thrombectomy (MT) has become an effective option for the treatment of acute ischemic stroke in addition to tissue plasminogen activator (tPA). With recent advances in device technology, MT has significantly altered the hospital course and functional outcomes of stroke patients. The authors’ goal was to establish the most up-to-date reperfusion and functional outcomes with the evolution of MT technology.METHODSThe authors conducted a retrospective study of 403 patients who underwent MT for ischemic stroke at their institution from 2010 to 2017. They collected data on patient comorbidities, National Institutes of Health Stroke Scale (NIHSS) score on arrival, tPA administration, revascularization outcomes, and functional outcomes on discharge.RESULTSIn 403 patients, the mean NIHSS score on presentation was 15.8 ± 6.6, with 195 (48.0%) of patients receiving tPA prior to MT. Successful reperfusion (thrombolysis in cerebral infarction score 2B or 3) was achieved in 84.4%. Hemorrhagic conversion with significant mass effect was noted in 9.9% of patients. The median lengths of ICU and hospital stay were 3.0 and 7.0 days, respectively. Functional independence (modified Rankin Scale score 0–2) was noted in 125 (31.0%) patients, while inpatient mortality occurred in 43 (10.7%) patients.CONCLUSIONSAs MT has established acute ischemic stroke as a neurosurgical disease, there is a pressing need to understand the hospital course, hospital- and procedure-related complications, and outcomes for this new patient population. The authors provide a detailed account of key metrics for MT with the latest device technology and identify the predictors of unfavorable outcomes and inpatient mortality.

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

BackgroundThe coronavirus disease 2019 is associated with neurological manifestations including stroke.ObjectivesWe present a case series of coronavirus disease 2019 patients from two institutions with acute cerebrovascular pathologies. In addition, we present a pooled analysis of published data on large vessel occlusion in the setting of coronavirus disease 2019 and a concise summary of the pathophysiology of acute cerebrovascular disease in the setting of coronavirus disease 2019.MethodsA retrospective study across two institutions was conducted between 20 March 2020 and 20 May 2020, for patients developing acute cerebrovascular disease and diagnosed with coronavirus disease 2019. We performed a literature review using the PubMed search engine.ResultsThe total sample size was 22 patients. The mean age was 59.5 years, and 12 patients were female. The cerebrovascular pathologies were 17 cases of acute ischemic stroke, 3 cases of aneurysm rupture, and 2 cases of sinus thrombosis. Of the stroke and sinus thrombosis patients, the mean National Institute of Health Stroke Scale was 13.8 ± 8.0, and 16 (84.2%) patients underwent a mechanical thrombectomy procedure. A favorable thrombolysis in cerebral infarction score was achieved in all patients. Of the 16 patients that underwent a mechanical thrombectomy, the mortality incidence was five (31.3%). Of all patients (22), three (13.6%) patients developed hemorrhagic conversion requiring decompressive surgery. Eleven (50%) patients had a poor functional status (modified Rankin Score 3–6) at discharge, and the total mortality incidence was eight (36.4%).ConclusionsDespite timely intervention and favorable reperfusion, the mortality rate in coronavirus disease 2019 patients with large vessel occlusion was high in our series and in the pooled analysis. Notable features were younger age group, involvement of both the arterial and venous vasculature, multivessel involvement, and complicated procedures due to the clot consistency and burden.

Background The Neuroform Atlas stent™ (by Stryker, Fremont, California) represents the most recent widely available upgrade to intracranial stenting, providing a laser cut open cell stent with a diameter of 3.0 to 4.5 mm that is delivered through an 0.017-inch microcatheter. Objective To report our initial multicenter experience of the safety, efficacy, and feasibility of the Atlas stent used for treating aneurysms, as well as one case of intracranial stenosis and one carotid artery dissection as well as other pathologies. Methods A retrospective multicenter study of subjects treated with Atlas stent during the period 2018 to 2019. Results The total number of patients included in our analysis was 71 patients. The stent was utilized to treat 69 aneurysm cases. Of the aneurysms, 36% presented with acute rupture and 56% of the ruptured aneurysms were high grade. Mean aneurysm dimension was 7 mm with an average neck width of 4.1 mm. Around 30% had received prior treatment. Telescoping or Y-stent was used in 16% of cases. We did not observe any symptomatic major complications in our series. Asymptomatic major complications were seen in 7 patients (10.1%); technical complications occurred in 4.3%. Immediate modified Raymond-Roy-occlusion-outcome class I/II was observed in 87%, and this increased to 97.7% at latest follow-up, which was at 4 mo; 91.8% of patients achieved favorable clinical outcome, and mortality rate was 1.4%. Conclusion Our series demonstrates the safety, feasibility, and efficacy of the Atlas stent. The low complication rate and the high obliteration rate managing complex aneurysms, even in an acute ruptured setting, are notable.

Background Distal transradial catheterization in the anatomic snuffbox is an alternate route of access that has started to gain consideration for neuroendovascular procedures. Objective To assess the feasibility and outcomes and present our institution's experience in performing neuroendovascular procedures via distal transradial access (dTRA). Methods We conducted a retrospective analysis and identified 120 patients who underwent consecutive neuroendovascular procedures via dTRA in the anatomic snuffbox. Data collection was performed on indication for procedure, sheath size, number of vessels selectively catheterized, fluoroscopy time, procedure duration, radiation exposure, conversion to femoral approach, access site complication, and procedure success. Results Of 120 patients with an average age of 54.7 yr ± 14.7, 73 (60.8%) underwent diagnostic angiograms, 38 (31.7%) underwent follow-up angiograms, and 9 (7.5%) underwent therapeutic procedures. The overall mean number of vessels catheterized was 2.5 ± 0.1 per procedure, the mean procedure time was 68.3 min ± 43.4, the mean fluoroscopy time was 10.8 min ± 7.6, the mean contrast dose was 70.6 mL ± 39.1, and the mean radiation exposure was 27 672.2 mGycm2 ± 42 728.4. Successfully completed therapeutic procedures included aneurysm 1 (0.8%), arteriovenous malformation (AVM)/arteriovenous fistula/carotid cavernous fistula 7 (5.8%), and 1 (0.8%) other treatment. Three patients (2.5%) required adjunct transfemoral endovenous access for AVM embolization. Two minor complications (1.67%) were a local wrist hematoma and a radial artery vasospasm without any sequelae. Conclusion Distal radial artery catheterization in the anatomic snuffbox is a safe and effective access site to perform neuroendovascular procedures. Complications and conversion rate are low making it a safe alternative.

Background: Acute basilar artery occlusion (BAO) is generally associated with a poor prognosis and mortality rates up to 85% in non-recanalized patients. Emergent recanalization is essential to improve outcomes in this patient subgroup. Objective: To show that good patient outcomes, modified Rankin score (mRS) 0-2, can be achieved in patients presenting with acute BAO and poor or no neurological exam. Methods: We retrospectively analyzed the hospital course of a patient presenting with acute BAO and absent brainstem reflexes who underwent emergent revascularization. Results: The patient was discharge with cranial nerve III palsy but was otherwise neurologically intact. Conclusions: Patients presenting with acute BAO and poor or no neurological exam should be considered for emergent endovascular intervention. Despite the high risk of morbidity and mortality, this subgroup of patients can still have good functional outcomes.

Rescue stenting is used as a bailout technique during mechanical thrombectomy for stroke. We performed a retrospective study analyzing outcomes of patients that received a stent as a bailout measure and compared results to a control group.We identified all patients who underwent a mechanical thrombectomy for a large vessel occlusion between January 2010 and October 2019. Subjects with mTICI 0-2 A after at least three passes were defined as failed MT and constituted the control group (NSG-controls). Patients that received a rescue stent (RSG) formed the study group.Comparative analysis of patient demographics between NSG-controls and SRG was performed. Baseline characteristics and comorbidities were not significantly different between both groups. NIHSS at admission and IV t-PA were not significantly different among both groups (16.5 vs. 14.2, p = 0.19) and (39.4% vs. 29.4%, p = 0.30), respectively. There was no significant difference in procedural and post-procedural complications between both the groups. In the RSG, 24 patients (82.4%) achieved favorable revascularization outcomes. NIHSS at discharge (p = 0.01) was higher in the NSG-controls, while favorable functional outcome at three months (12% vs. 39.2%, p = 0.01) was observed at a higher proportion in the RSG. There was also a significant mortality difference, with 15.2% mortality in the RSG compared to 35.1% mortality in the NSG-controls (p = 0.03). In multivariate analysis, stenting was an independent predictor of favorable outcome (OR: 10.0, p = 0.009).Herein, we demonstrated that rescue stenting is a feasible, safe, and effective procedure to improve stroke outcomes and should be seriously considered if the primary mechanical thrombectomy is not successful.

Objective To present intraoperative observations that when recognized may facilitate the identification of patients at high risk of MT recanalization failure. We illustrate 4 cases of successful recanalization via rescue treatment with balloon angioplasty and/or stenting when such observations were noted. We also discuss the role of intracranial atherosclerotic disease in recanalization failure. Patients and methods We conducted a retrospective review of a prospectively maintained database for 450 stroke patients and identified 122 patients who underwent MT that failed to achieve recanalization. Operative notes were reviewed, and intraoperative nuances were discussed amongst neurointerventionalists. Results Intraoperative observations that may suggest a high risk of MT recanalization failure include resistance to microwire advancement, significant resistance to microcatheter advancement, temporary antegrade flow upon stent retriever (SR) deployment, temporary retrograde flow upon SR deployment with simultaneous aspiration, restricted SR expansion (“pinched device”), moderate resistance to total impedance of SR removal causing vessel/SR stretch on angiographic roadmap, and minimal recanalization after ≥3 device passes. Conclusion Intraoperative observations may facilitate early recognition of patients at high risk of MT recanalization failure. We suggest considering rescue treatment when such observations are noted to avoid prolonged procedure times, futile reperfusion, and reocclusion post-MT. Intracranial balloon angioplasty and/or stenting may be a safe and effective treatment in this patient subgroup. Stent placement may be considered depending on the patient’s antiplatelet status, angioplasty success, and concern for intracranial hemorrhage. Further studies amongst larger patient cohorts are needed.

Care for acute ischaemic stroke is one of the most rapidly evolving fields due to the robust outcomes achieved by mechanical thrombectomy. Large vessel occlusion (LVO) accounts for up to 38% of acute ischaemic stroke and comes with devastating outcomes for patients, families and society in the pre-intervention era. A paradigm shift and a breakthrough brought mechanical thrombectomy back into the spotlight for acute ischaemic stroke; this was because five randomised controlled trials from several countries concluded that mechanical thrombectomy for acute stroke offered overwhelming benefits. This review article will present a comprehensive overview of LVO management, techniques and devices used, and the future of stroke therapy. In addition, we review our institution experience of mechanical thrombectomy for posterior and distal circulation occlusion.

Background and purpose Flow-diversion therapy (FDT) for large and complex intracranial aneurysms is effective and considered superior to primary coil embolization. Data evaluating common treatment with both FDT and coiling continues to emerge, but information on outcomes remains scarce. This study aims to examine further the efficiency and outcomes correlated with joint FDT using pipeline embolization device (PED) and coiling compared to PED-alone in treating intracranial aneurysms. Materials and methods Comparative review and analysis of aneurysm treatment with PED in 416 subjects were conducted. Joint modality, PED, and coiling were compared to PED-alone for aneurysm occlusion, recurrence, retreatment, thromboembolic or hemorrhagic events, and functional outcome using the modified Rankin Scale. Data on patient demographics, aneurysm characteristics, clinical and angiographic follow up, were also collected. Both univariate analysis and multivariate logistic regression modeling using mixed-effects were performed. Results Total of 437 aneurysms were treated using PED of which 74 were managed with both PED and coiling. Average patient-age was 56 years, the majority were men (85%), an average aneurysm size was 9 mm, and the majority were saccular aneurysms (84%). Larger aneurysm size was associated with a poor outcome in patients with unruptured aneurysms (OR = 1.06). Adjusted regression analyses revealed no differences between treatment groups in thromboembolic or hemorrhagic events, aneurysm occlusion rate, residual flow on follow up angiography, or functional outcome. Conclusions Treatment of intracranial aneurysms with joint PED and coiling was safe with no increase in complications when compared to PED alone. Aneurysm occlusion rates and functional outcome with PED and coiling stays comparable to treatment with PED-alone.

Endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) has become the mainstay in treatment for these pathologies. Traditional techniques required the formation of a proximal plug of Onyx around the microcatheter prior to embolization to avoid reflux. Recently, dual-lumen balloon catheters have been introduced as a potential solution to this issue. We sought to compare our institutional experience with dual-lumen balloons to traditional microcatheters in the endovascular embolization of AVMs and DAVFs. A retrospective analysis of consecutive patients treated with Scepter between 2016 and 2020 was obtained. A control cohort treated with Marathon between 2012 and 2020 was also obtained. Variables collected included patient demographics, procedure times, pedicles treated, operative complications, obliteration rate, and retreatment rate. A total of 44 trial (30 DAVFs and 14 AVMs) and 25 control (15 DAVFs and 10 AVMs) subjects were identified. Average Scepter procedure times were 66.0 and 68.0 min for DAVFs and AVMs, respectively. Average Scepter volume of Onyx injected was 2.2 and 1.4 mL for DAVFs and AVMs, respectively. Complete angiographic occlusion Scepter rate was 86.7% and 50.0% for DAVFs and AVMs, respectively. The Scepter retreatment rate was 13.3% and 50.0% for DAVFs and AVMs, respectively. Predictors of angiographic occlusion included the number of pedicles (OR 0.54, 95%CI 0.30–0.97, p = 0.04). Predictors of retreatment included DAVF (OR 0.16, 95%CI 0.04–0.66, p = 0.01) and Marathon (OR 3.34, 95%CI 1.00–11.56, p = 0.05). Our study shows that dual-lumen balloon catheters are a viable option in the embolization of DAVFs and AVMs.

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

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

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

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

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

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

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

Objectives Limited data exists on the management and outcome of patients with isolated acute cervical internal carotid artery (cICA) occlusion presenting with normal neurologic exam after experiencing a period of neurological deficits. These patients are at risk for progressive neurologic deterioration but have not yet progressed to stroke. Current management is no intervention due to intervention risk of embolization. We aim to determine the optimal management of patients with isolated acute cICA occlusion presenting with a normal neurological exam after experiencing neurological deficits. Patients and methods Data was collected on 3 patients with acute cICA occlusion that presented with a normal neurological exam to our institution. Patient 1 was treated according to standard protocol, while patients 2 and 3 were treated according to the management discussed. Associations between perfusion imaging studies and clinical outcome were analyzed to determine stroke risk. A revascularization technique to minimize risk of distal embolization is described. Results A total of 3 consecutive patients with acute cICA occlusion were successfully revascularized. Patients 2 and 3 (66.67%) were neurologically intact post-operatively, while patient 1 (33.33%) had residual hemiparesis. It seems that MTT ≥ 200% or Tmax > 6 s is the optimal penumbra threshold predicting infarction and neurologic deterioration. There were no embolic complications as a result of endovascular therapy (EVT). Conclusion Cerebral perfusion imaging of patients presenting with normal neurological exam after experiencing neurological deficits is warranted to help identify patients at risk for stroke due to collateral failure. These patients should be monitored in the ICU for neurologic deterioration and given the option of intervention if mismatch is noted on CT perfusion imaging. Perfusion studies identifying penumbra and delayed MTT ≥ 200% or Tmax > 6 s are indicators for possible collateral failure. In patients undergoing intervention, we suggest a technique using proximal flow arrest to minimize risk of shower emboli. Further studies are needed to verify our findings.

Background and purpose Neurointerventionists have been recently enthusiastic in performing endovascular mechanical thrombectomy (MT) for acute ischemic strokes of their posterior circulation(PC). Prompt repermeabilization of the PC has been linked to an increased survival rate. We aim to study the prominence, the safety and the clinical influence of PC-MT. Methods Patient medical charts were retrospectively reviewed between 2010–2017. Data on intra-venous tissue plasminogen activator (IV-rtPA) administration, National Institute Health Stroke Scale (NIHSS; range, 0 to 42) at admission, Alberta Stroke Program Early CT Scores(ASPECTS), per-procedural complications, mortality, and clinical functional status evaluated with the modified Rankin Scale(mRS0–6) at latest follow-up, was gathered. The primary outcomes were: (1) safety of PC-MT, (2) functional independence on latest follow-up (mRS score Results Of 234 patients, 22 (average age 60 years, 41% female) had a MT performed for their PC stroke and constituted our population. All our patients, except one, had a basilar artery stroke. One patient had a vertebral artery stroke. 2/22 (9%) patients had a history of atrial fibrillation and 4/22 (18%) received IV-rtPA. The average NIHSS at admission was 19(SD=8.2), the average DWI-ASPECTS score was 5.4, the average CT-ASPECTS score was 7.3. 2/22 (9%) patients had tandem embolus, and 3/22 (13.6%) patients had reocclusion after endovascular therapy. The average time from onset of symptoms to procedure was 12 hours (SD=8.8). 11/22 (50%) patients had a delayed MT beyond 8 hours from onset of symptoms. 10/22 (45.5%) patients performed their MT with just Second Generation Stent-Retrievers(SGSR), 2/22 (9%) patients received therapy with large-bore aspiration catheters, 10/22 (45.5%) patients received a salvage thrombus aspiration after failed first-line stent-retrievers thrombectomy. 10/22 (45.5%) patients had a first-pass successful vessel recanalization mTICI >2. The average time of revascularization was 61.6 min (SD=31.50). 20/22 (91%) had a mTICI >2 b. The average patient follow-up was 95 days (SD=105 days). The average mRS on latest follow-up was 2.2. None of our patients died at latest follow-up. 63% had a decreased mRS score reflecting an amelioration of their functional status on latest follow-up. Conclusions We advocate for the usage of endovascular thrombectomy in patients with PC strokes. PC-MT should be performed safely beyond 8 hours from onset of symptoms. MT would reduce long-term morbi-mortality and stroke related disability in patients with PC strokes. Disclosures E. Atallah: None. K. Hafazallah: None. N. Chalouhi: None. S. Tjoumakaris: None. N. Herial: None. M. Gooch: None. R. Rosenwasser: None. H. Zarzour: None. P. Jabbour: None.

Background and purpose Decisions on the use of mechanical thrombectomy (MT) beyond 8 hours from onset of stroke symptoms remains fairly debatable. The adequate tools used for the triage of patients with acute ischemic stroke (AIS) symptoms has not been definitive yet. We studied the safety and the efficacy of delayed MT (>8 hours) with image-based selection criteria. Methods Data of prospectively treated patients was retrospectively collected between 2010–2017. Data on intra-venous tissue plasminogen activator(IV-rtPA), National Institute Health Stroke Scale (NIHSS; range, 0 to 42) at admission, per-procedure complications (IA/IV-tPA after failed MT, distal embolus, vessel dissection, re-occlusion after MT), mortality, and clinical functional status evaluated with the modified Rankin Scale(mRS0–6) at latest follow-up was gathered. The primary outcomes were: (1) safety and the feasibility of delayed (>8 hours) MT, (2) functional independence on latest follow-up(mRS score Results Of 234 patients (average age 64.4 years, 45.3% female) that constituted our population, 215 were included in our statistical analysis: 137patients in the group of patients who received MT 2. The average time of revascularization was 92.2 min (SD=97.10). 27/234 (11.5%) had a mTICI of 2b, and 172/234 (73.5%) had a mTICI of 3. The average patient follow-up was 123 days(SD=163 days). MT beyond 8 hours was not a predictor of disability or functional deterioration, of increased mortality, of per-procedural complications, of successful vessel repermeabilization. However, delayed thrombectomy was linked to a higher length of post-procedural hospital stay. Conclusions Patient selection for MT should not be primarily driven by time-based criteria. More objective dynamics such as image-based criteria should be further promoted as primary selection tools. Delayed MT after 8 hours should be a safe and highly efficacious first-line modality of treatment for strokes of anterior and posterior circulation. Disclosures E. Atallah: None. K. Hafazallah: None. S. Missios: None. R. Abbas: None. S. Tjoumakaris: None. N. Herial: None. M. Gooch: None. R. Rosenwasser: None. H. Zarzour: None. P. Jabbour: None.

Background The use of the pipeline embolization device (PED; Medtronic, Dublin, Ireland) in the posterior circulation has been limited and infrequently reported compared to other off-label utilizations. Posterior inferior cerebellar artery aneurysms (PICAA) constitute 1 of the least reported posterior circulation aneurysms treated with PED. No clinical studies have addressed the treatment of these aneurysms with flow diversion exclusively. Objective To appraise the feasibility and the safety of PED in the treatment of PICAAs. Methods Data on 12 consecutive patients, treated between 2011-2017 with PED for their PICAA, was retrospectively reviewed. To control confounding, we used multivariable logistic regression and propensity score conditioning. Results Of 534 patients, 12 (9/12, 75% males) were identified and constituted our study population. The average aneurysm size was 8.47 mm (SD = 2.6, 3.7-14). Patients were followed-up for an average of 10.3 months (SD = 11 mo). Two of 12 (16.7%) had a prior history of subarachnoid hemorrhage. Eight of 12 (67%) of the aneurysms were saccular, 3/12 (25%) were dolichoectatic, and 1/12 (8%) was a small blister aneurysm. Eleven of 12 (92%) aneurysms were treated with 1 PED; 2/12 (16.7%) patients received combined pipeline assisted coiling. All patients had a complete occlusion, regression, and resolution of their aneurysm(s). PED deployment was neither complicated with any hemorrhagic or clinically significant thromboembolic events nor with device migration in any of our patients. Three of 12 (25%) patients had a benign intrastent stenosis. No mortality, among our 12 patients, was noted throughout the follow-up period. Conclusion PED, deployed by specialized experts, should be safe in treating PICAA. It can be contemplated as a novel alternative treatment of aneurysms located at the PICA-VA bifurcation or within the PICA.

Background Thrombosed large intracranial aneurysms (TLIAs) are not continuously contemplated as stable lesions. Spontaneous recanalization of completely occluded large intracranial aneurysms has been described previously. Case Description We report a middle-aged patient presenting with agitation, acute headache, visual field defects, and left hemiparesis. A large thrombosed posterior communicating (PCom) artery aneurysm was identified with an infarct at the same arterial territory on neuroimaging studies. Digital subtraction angiography (DSA) performed 1 week later demonstrated complete recanalization of the TLIA. It was treated endovascularly with coils. The patient returned several days later with augmenting headaches due to quadrigeminal system subarachnoid hemorrhage. Repeat DSA showed filling of the coiled aneurysm from the internal carotid artery injection. The PCom artery was catheterized and deconstructed. The patient was discharged to home with no additional neurologic deficits. Conclusions TLIAs are insidious vascular lesions. They can cause nerve or vessel damage by a mass effect or through ischemic stroke by emitting emboli into distal vasculature. We advise close periodic radiologic follow-up for TLIAs.

Background Pipeline embolization device (PED; Medtronic, Dublin, Ireland) utilization is not limited to the treatment of giant wide-necked aneurysms. It has been expanded to handle small blisters, fusiforms, and dissecting intracranial aneurysms. Objective To report the use of the PED in various off-label distal cerebral circulation (DCC) arteries with a follow-up to assess clinical outcomes. Methods Between 2011 and 2016, of 437 consecutive patients, 23 patients with aneurysms located in DCCs were treated with PED. Data on patient presentation, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were gathered. To control confounding, we used multivariable logistic regression and propensity score conditioning. Results A total of 437 patients (mean age 52.12 years; 62 women [14.2%]) underwent treatment with PED in our institution. Twenty-three of 437 (5.2%) received a pipeline in a distal artery: 11/23 middle cerebral artery, 6/23 posterior cerebral artery, 3/23 anterior cerebral artery (A1/A2, pericallosal artery), and 3/23 posterior inferior cerebellar artery. Twenty percent of the aneurysms were treated in the past, 10% had previously ruptured, and 5.9% ruptured at presentation to our hospital. The mean aneurysm size was 9.0 ± 6 mm. The mean follow-up was 12 mo (SD = 12.5). In multivariable logistic regression, no associations were found between PED deployment in DCCs and aneurysm occlusion or thromboembolic complications. PED use in DCC was associated with a good clinical outcome. Twenty-two people of 23 (95%) had a good clinical outcome in the latest follow-up. Conclusion Treatment of DCC aneurysms with PED is technically challenging mainly because of the small caliber and tortuosity of the parent arteries. The results of this study further support the safety of flow diverters in the treatment of various distal aneurysms.

Spinal arachnoiditis (SA) is an extremely rare and delayed complication of subarachnoid hemorrhage (SAH). Little is known about its underlying pathogenesis and subsequent clinical course. A middle-aged patient presented with the worst headache of her life and a grade 3 SAH of the basal-cisterns and posterior fossa was identified on Computed Tomography scans (CT). Angiography revealed a ruptured dissecting aneurysm of the left vertebral artery (VA-V4), as well as an unruptured left Anterior Cerebral Artery (ACA-A1) aneurysm. The VA aneurysm was treated with flow diversion. The patient re-ruptured the stented aneurysm, another telescoping pipeline was placed. The patient developed polymicrobial ventriculitis, and returned several months later complaining of paraparesis and left sided weakness. Magnetic Resonance Imaging (MRI) revealed diffuse thecal dural thickening from the cervicomedullary junction to the sacrum. Loculations, diffuse edema and cord compression were noticed along the inferior surface of the cerebellum, and the cervico-thoracic spine with a T4-T6 syrinx. The patient underwent a posterior (T4-T8) spinal fusion and (T5-T7) decompression with arachnoid-cyst fenestration and placement of a subarachnoid-pleural shunt. On latest follow-up, the patient is weaning off the thoraco-lumbosacral orthosis and ambulating with a cane. SA is often a complicated two-staged disease in which a "free interval phase" separates the initial inflammatory reaction (IIR) from the late adhesive phase. Posterior fossa bleeding, warranting prolonged surveillance, additional bleeding and ventriculitis might augment the risk and the severity of arachnoiditis.

BACKGROUND AND IMPORTANCE Distal extracranial posterior inferior cerebellar artery (PICA) aneurysms are very rare lesions and have not been previously reported in association with a Chiari type I malformation (CMI). CLINICAL PRESENTATION A 56-year-old woman with a distal, low-lying, intradural-extracranial PICA aneurysm presented with a subarachnoid hemorrhage and was treated with coil embolization. The patient presented again 1 month later with symptoms of a CMI and was found to have tonsillar herniation and a large syrinx that appeared to be exacerbated by the coil mass. The patient was re-treated with a suboccipital craniectomy, C1-2 laminectomy, aneurysm trapping and excision, end-to-end PICA anastomosis, and expansile duraplasty. CONCLUSION Although just a single case, important teaching points regarding the angiographic appearance of a CMI and treatment options for distal PICA aneurysms that are situated below the foramen magnum can be learned. A low-lying caudal PICA loop should trigger a workup for a CMI. Caution should be taken when using coil embolization for aneurysms in the high cervical spinal canal. Bypass with aneurysm trapping and excision may be a superior treatment option in these cases because the posterior fossa and high cervical canal can be concomitantly decompressed. To our knowledge, this is the only case reported of a distal intradural-extracranial PICA aneurysm associated with a CMI.

Flow diversion has emerged as a highly effective treatment for intracranial aneurysms.To assess the yield of further angiographic follow-up in aneurysms that have achieved adequate occlusion after treatment with the Pipeline Embolization Device (PED; Medtronic Inc, Dublin, Ireland).This is a single-institution, retrospective study. Inclusion criteria were as follows: (1) patients with 1 or more aneurysms treated with PED, (2) available short-term (12 mo) follow-up digital subtraction angiography (DSA), (3) complete (100%) or near-complete (95%) occlusion on short-term follow-up DSA, and (4) available further angiographic follow-up (DSA, Magnetic Resonance Angiography (MRA), or Computed Tomography Angiography (CTA)).A total of 146 patients were identified. Aneurysm size was 8.4 ± 5.1 mm on average. Mean angiographic follow-up time was 29.7 ± 12.2 mo. On short-term follow-up DSA images, 132 (90.4%) had complete aneurysm occlusion and 14 (9.6%) had near-complete occlusion. Four patients (3%) had further DSA follow-up alone, 30 patients (21%) had further DSA and MRA/CTA follow-up, and 112 patients (76%) had further MRA/CTA follow-up alone. On further angiographic follow-up (DSA, MRA, and/or CTA), no patient had a decrease in the degree of aneurysm occlusion (recurrence) or required retreatment. Of the 14 patients with near-complete occlusion on initial DSA images, 7 patients (50%) progressed to complete aneurysm occlusion on further angiographic follow-up.This study did not find any diagnostic yield in repeating cerebral angiography in adequately occluded aneurysms with the PED. We do not recommend repeat angiographic follow-up once aneurysms have achieved complete occlusion with the PED unless clinically warranted.

Background Clopidogrel/aspirin antiplatelet therapy routinely is administered 7–10 days before pipeline aneurysm treatment. Our study assessed the safety and efficacy of a 600-mg loading dose of clopidogrel 24 hours before Pipeline Embolization Device (PED) treatment. Methods We performed a retrospective cohort study involving patients treated with pipeline from October 2010 to May 2016. A total of 39.7% (n = 158) of patients were dispensed a loading dose of 650 mg of aspirin plus at least 600 mg of clopidogrel 24 hours preceding PED deployment; 60.3% (n = 240) received 81–325 mg of aspirin daily for 10 days with 75 mg of clopidogrel daily preprocedurally. The mean follow-up was 15.8 months (standard deviation [SD] 12.4 months). modified Rankin Scale (mRS) was registered before the discharge and at each follow-up visit. To control confounding, we used multivariable logistic regression and propensity score conditioning. Results Of 398 patients, the proportion of female patients was ≈16.5% (41/240) in both groups and shared the same mean of age ≈56.46 years. Similarly, ≈12.2% (mean = 0.09; SD = 0.30) had a subarachnoid hemorrhage. A total of 92% (mean = 0.29; SD = 0.70) from the pretreatment group and 85.7% (mean = 0.44; SD = 0.91) of the bolus group had a mRS ≤2. In a multivariate analysis, bolus did not affect the mRS score, P = 0.24. Seven patients had a long-term recurrence, 2 (0.83%; mean = 0.01; SD = 0.10) from the pretreatment group. In a multivariable logistic regression, bolus was not associated with a long-term recurrence rate (odds ratio [OR] 1.91; 95% confidence interval [CI] 0.27–13.50; P = 0.52) neither with thromboembolic accidents (OR 0.99; 95% CI 0.96–1.03; P = 0.83) nor with hemorrhagic events (OR 1.00; 95% CI 0.97–1.03; P = 0.99). Three patients died: 1 who received a bolus had an acute subarachnoid hemorrhage. The mean mortality rate was parallel in both groups ≈0.25 (SD = 0.16). Bolus was not associated with mortality (OR 1.11; 95% CI 0.26–4.65; P = 0.89). The same associations were present in propensity score–adjusted models. Conclusions In a cohort receiving PED, a 600-mg loading dose of clopidogrel should be safe and efficacious in those off the standard protocol or showing

The first line of treatment in Cushing’s disease is surgical resection. All patients with clinical evidence of Cushing’s disease should receive a full work-up to determine the source of the hypercortisolemia. Referral to a neurosurgeon is only necessary if the source of the endocrinopathy is suspected to be the pituitary gland. However, we believe that neurosurgeons operating on patients with Cushing’s disease must understand the preoperative work-up and be secure in the results along with the endocrine team. Mistakes in diagnosis are a frequent event when dealing with these patients. We will not review all the endocrine testing here.

Cushing’s disease, as noted in this book, has very serious consequences for those affected. Accurate endocrine diagnosis is crucial as often the adenomas causing the ACTH excess are not large enough to be visualized on imaging studies. While a pituitary adenoma is causative in over 85 % of patients, this often needs confirmation with petrosal sinus sampling and measurements of circulating ACTH. Surgery with the intent of complete removal of the adenoma is usually the first-line of treatment. This is almost always done via a transsphenoidal approach with either microscopic or endoscopic techniques. In this chapter, we will discuss the imaging and surgical techniques for these microadenomas, as well as the more common reasons for failure of accurate diagnosis and treatment.

BACKGROUND Delayed ischemic events due to vasospasm are a well-known complication of aneurysmal subarachnoid hemorrhage (SAH). Severe vasospasm in other neurosurgical settings is not as well recognized. Delay in diagnosis and treatment of vasospasm in such settings may be associated with significant neurological morbidity. OBJECTIVE To present three cases of symptomatic delayed cerebral vasospasm after transsphenoidal resection of pituitary macroadenomas. METHODS Transsphenoidal resection in all cases was complicated by peritumoral hemorrhage with extension into the subarachnoid space. Two of the 3 patients required re-operation to evacuate the hematoma in the tumor bed because of progressive worsening neurological deficits. RESULTS All 3 patients developed vasospasm of the intracranial vessels, starting as early as postoperative day 5 and appearing as late as postoperative day 10. Comparisons to the non-vascular pre-operative magnetic resonance imaging studies confirmed the "de-novo" nature of the vasospasm based on the caliber of the flow voids. CONCLUSION Transsphenoidal surgery complicated by peritumoral hemorrhage is associated with a significant risk of neurological morbidity because of delayed cerebral vasospasm. Early recognition and management according to guidelines used for postaneurysmal SAH may help to improve outcomes in these patients.