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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.

Subtotal coil embolization followed by subsequent flow diversion is often pursued for treatment of acutely ruptured aneurysms. Owing to the need for anti-platelet therapy, the optimal time of safely pursuing flow diversion treatment has not been fully elucidated. In this study, we aim to demonstrate the safety and feasibility of staged treatment of acutely ruptured aneurysms with early coil embolization followed by flow diversion prior to discharge.A retrospective study to evaluate clinical outcomes of patients who presented with aneurysmal subarachnoid hemorrhage and underwent coil embolization followed by subacute flow diversion treatment during the same hospitalization.A total of 18 patients are included in our case series. Eight patients presented with Hunt-Hess (H-H) grade 2 bleed, 6 patients with H-H grade 3, and 2 patients each with H-H grade 4 and H-H grade 1. Eight patients required placement of an external ventricular drain on admission. After initial coil embolization, 12 achieved Raymond-Roy grade 2 occlusion, and 6 attained grade 3a/b occlusion. The mean duration between coil embolization and subsequent flow diversion was 9.83 days (range: 1-30). There were no instances of re-hemorrhage between initial coil embolization and subsequent flow diversion treatment. Sixteen patients had a minimum of 6-month follow-up, of which 15 were found to have complete occlusion, and 1 required subsequent clipping.Subtotal coil embolization followed by definitive treatment using flow diversion during the same hospitalization is feasible and achieves excellent aneurysm occlusion rates while avoiding dual anti-platelet therapy during the initial hemorrhage period.

The outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) were controversial, and they suggested that intervention is inferior to medical management for unruptured brain arteriovenous malformations (AVMs). However, several studies have shown that stereotactic radiosurgery (SRS) is an acceptable therapy for unruptured AVMs.To test the hypothesis that ARUBA intervention arm's SRS results are meaningfully inferior to those from similar populations reported by other studies.We performed a literature review to identify SRS studies of patients who met the eligibility criteria for ARUBA. Patient, AVM, treatment, and outcome data were extracted for statistical analysis. Regression analyses were pooled to identify factors associated with post-SRS obliteration and hemorrhage.The study cohort included 8 studies comprising 1620 ARUBA-eligible patients who underwent SRS. At the time of AVM diagnosis, 36% of patients were asymptomatic. The mean follow-up duration was 80 months. Rates of radiologic, symptomatic, and permanent radiation-induced changes were 45%, 11%, and 2%, respectively. The obliteration rate was 68% at last follow-up. The post-SRS hemorrhage and mortality rates were 8%, and 2%, respectively. Lower Spetzler-Martin grade (odds ratios [OR] = 0.84 [0.74-0.95], P = .005), lower radiosurgery-based AVM score (OR = 0.75 [0.64-0.95], P = .011), lower Virginia Radiosurgery AVM Scale (OR = 0.86 [0.78-0.95], P = .003), and higher margin dose (OR = 1.13 [1.02-1.25], P = .025) were associated with obliteration.SRS carries a favorable risk to benefit profile for appropriately selected ARUBA-eligible patients, particularly those with smaller volume AVMs. Our findings suggest that the results of ARUBA do not reflect the real-world safety and efficacy of SRS for unruptured AVMs.

Traditional Gamma Knife radiosurgery (GKRS) of brain arteriovenous malformations (AVMs) using digital subtraction angiography (DSA) requires head immobilization using a stereotactic frame.We describe our protocol of frameless GKRS using DSA while maintaining high spatial resolution for precision.This study is a retrospective review of patients with unruptured AVMs who underwent frameless GKRS. Magnetic resonance imaging and 3-dimensional DSA were obtained without a stereotactic frame for all patients. The imaging studies were merged for contouring of the AVM nidus. During GKRS treatment, patients were immobilized using an individually molded thermoplastic mask.Thirty-one patients were included in the analysis. The median age is 45.0 years (interquartile range [IQR]: 28.0-55.0). The median nidus size is 3.0 cm (IQR: 2.0-3.4). One patient had a Spetzler-Martin grade I, 11 had a grade II, 11 had a grade III, 6 had a grade IV, and 2 had a grade V AVM. Eleven patients underwent preradiosurgical embolization, 3 patients had previous microsurgical resection and/or embolization, and 1 patient had prior radiosurgery. The median administered dose was 20 Gy (IQR: 18.0-21.0). All patients completed their treatment with the planned radiation dose without complications.This is the first study that integrates DSA in the treatment planning of brain AVMs using GKRS without utilizing a stereotactic head frame. Frameless GKRS provides numerous advantages over frame-based techniques including improved patient experience and the capability of fractionation and thus expanding the eligibility of more AVMs for radiosurgery, while maintaining high spatial resolution of the AVM using angiography data.

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

The treatment of wide-necked and bifurcation aneurysms has become a common indication for the Woven Endobridge (WEB) device. In many instances, WEB embolization fails and retreatment strategies for the recanalized aneurysms have not been established and may be challenging.To report an experience with retreatment strategies after WEB failure in 7 cases involving various aneurysm shapes, sizes, and location using multiple strategies including endovascular modalities and microsurgical clip ligation.Data were retrospectively collected from 1 high-volume cerebrovascular center for 7 patients treated with a WEB device for an aneurysm who subsequently required retreatment for that same aneurysm from 2015 through January 2021.We identified 7 patients with WEB recurrences over a period of 6 years. Four patients initially presented with incidental findings, whereas 3 patients presented with subarachnoid hemorrhage. One patient was lost to follow-up and presented with a rerupture, whereas the 6 other patients were diagnosed with routine follow-up. Two patients received clip ligation, 2 had simple coil embolization, 1 had stent-assisted coil embolization, 1 had a flow-diverting stent, and 1 patient required 2 retreatments; he received stent-assisted coil embolization for the first retreatment and a simple coil embolization for the second retreatment. All patients had excellent angiographic outcomes and no complications.The authors conclude that aneurysm recurrence after WEB is very diverse, and no single modality can properly address all recurrences. Rather, an individualized approach based on aneurysm features, neurointerventionalist expertise, and patient preference should be implemented.

We aim to determine the incidence of decompressive hemicraniectomy (DHC) in the modern era of mechanical thrombectomy techniques and improved revascularization outcomes.We performed a retrospective analysis of 512 patients admitted with acute ischemic strokes with anterior circulation large-vessel occlusion that were treated by mechanical thrombectomy from 2010-2019. The primary endpoint was the need for surgical decompression. Secondary endpoints were infarct size, hemorrhagic conversion, and functional outcome at hospital discharge.Of the 512 patients, 18 (3.5%) underwent DHC at a median 2.0 days from stroke onset. The DHC group was significantly younger than the non-DHC group (P0.001), had worse reperfusion rates (P = 0.024) and larger infarct size (P0.001). Hemorrhagic conversion was more frequent in the DHC group but did not reach statistical significance (P = 0.08). From 2010-2015, 196 patients underwent a mechanical thrombectomy, 13 of whom (6.6%) required a DHC, while 316 patients underwent mechanical thrombectomy from 2016-2019 and only 5 patients required a DHC (1.6%; P = 0.002). Younger age (P0.001), urinary tract infection (P0.001) and increasing infarct size were significantly associated with needing a DHC. When controlling for other risk factors, higher thrombolysis in cerebral infarction score significantly reduced the need for decompressive hemicraniectomy (P = 0.004).This is one of the largest single-center experiences demonstrating that improved recanalization decreased the need for DHC without increasing the risk of hemorrhagic conversion.

The Woven EndoBridge (WEB) device is becoming increasingly popular for treatment of wide-neck aneurysms. As experience with this device grows, it is important to identify factors associated with occlusion following WEB treatment to guide decision making and screen patients at high risk for recurrence. The aim of this study was to identify factors associated with adequate aneurysm occlusion following WEB device treatment in the neurosurgical literature and in our case series. A systematic review of the present literature was conducted to identify studies related to the prediction of WEB device occlusion. In addition, a retrospective review of our institutional data for patients treated with the WEB device was performed. Demographics, aneurysm characteristics, procedural variables, and 6-month follow-up angiographic outcomes were recorded. Seven articles totaling 450 patients with 456 aneurysms fit our criteria. Factors in the literature associated with inadequate occlusion included larger size, increased neck width, partial intrasaccular thrombosis, irregular shape, and tobacco use. Our retrospective review identified 43 patients with 45 aneurysms. A total of 91.1% of our patients achieved adequate occlusion at a mean follow-up time of 7.32 months. Increasing degree of contrast stasis after WEB placement on the post-deployment angiogram was significantly associated with adequate occlusion on follow-up angiogram (p = 0.005) and with Raymond-Roy classification (p = 0.048), but not with retreatment (p = 0.617). In our systematic review and case series totaling 450 patients with 456 aneurysms, contrast stasis on post-deployment angiogram was identified as a predictor of adequate aneurysm occlusion, while morphological characteristics such as larger size and wide neck negatively impact occlusion.

Acute basilar artery occlusion accounts for 1% of all ischemic strokes but often leads to devastating neurological injury and mortality. Many institutions still opt for best medical therapy for these patients; however, there is increasing evidence that mechanical thrombectomy (MT) for these patients leads to better outcomes.To assess the safety and efficacy of MT for patients presenting with acute basilar artery occlusion (BAO).This study was a retrospective chart review of a prospectively maintained database for patients with acute BAO treated with MT from January 2014 through March 2022.Our study included a total of 74 patients. The mean age was 62.7 years, and 55.4% were male. The most common comorbidity was hypertension (73%). The mean door to puncture time was 75 minutes, and the mean procedure time was 54 minutes. 86.5% of patients had a good modified treatment in cerebral ischemia score (≥2b). There were 4 patients who had procedural complications and 3 who had symptomatic intracerebral hemorrhage. At 90 days, 62.5% of patients had a modified Rankin Scale, 0 to 3. The mortality rate was 32.4% and 2% during hospital admission and 90 days, respectively. On univariate analysis, adjunctive angioplasty/stenting and higher presenting National Institutes of Health Stroke Scale score were associated with modified Rankin Scale 4 to 6 at 90 days (P-value, .03 and.001, respectively). Shorter procedure time was associated with modified treatment in cerebral ischemia score ≥ 2b (P-value, .0015).Our findings showed that MT is safe and effective for patients presenting with acute BAO and is in conjunction with previous literature. The results from upcoming trials should hopefully establish MT as gold standard for these patients.

BackgroundThe mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke.ObjectiveTo describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort.MethodsWe conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020.ResultsThe total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002).ConclusionCOVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.

Background The radial approach has been gaining more widespread use by neurointerventionalists fueled by data from the cardiology literature showing better safety and overall reduced morbidity. Objective To present our institution's experience with the radial approach for neuroendovascular interventions in 614 consecutive patients who underwent a cumulative of 760 procedures. Methods A retrospective analysis was performed and identified neuroendovascular procedures performed via the upper extremity vasculature access site. Results Amongst 760 procedures, 34.2% (260) were therapeutic, and 65.7% (500) were nontherapeutic angiograms. Access sites were 71.5% (544) via a conventional radial artery, 27.8% (211) via a distal radial artery, 0.5% (4) via an ulnar artery, and 0.1% (1) via the brachial artery. Most of the procedures (96.9%) were performed via the right-sided (737), 2.9% (22) via the left-sided, and 0.1% (1) via a bilateral approach. Major access site complications occurred at a rate of 0.9% (7). The rate of transfemoral conversion was 4.7% (36). There was a statistically higher incidence of transfemoral conversion when repeat procedures were performed using the same access site. Also, there was no significant difference between nontherapeutic procedures performed using the right and left radial access, and conventional versus distal radial access. Procedural metrics improved after completion of 14 procedures, indicating a learning curve that should be surpassed by operators to reach optimal outcomes. Conclusion Radial artery catheterization is a safe and effective means of carrying out a wide range of neuroendovascular procedures associated with excellent clinical outcomes and an overall low rate of periprocedural complications.

Spontaneous intracerebral hemorrhage (sICH) is a disease process with high morbidity and mortality. In particular, hematoma expansion (HE) is a feared complication of sICH. With 15-40% of patients experiencing HE, it has become increasingly important to predict which sICH will remain stable and which will expand.With new treatment options being developed, it is becoming increasingly important to be able to predict which hemorrhages are at high versus low risk for expansion. The authors of this study hope to reexamine variables associated with hematoma expansion in hopes of generating newer data on risk factors for expansion.A retrospective analysis identified 334 patients who presented with sICH. The primary outcome was HE on follow up head CT. HE was defined as a greater than 33% increase or an absolute increase in 6 mL or more in overall volume between the two sets of CT images. Analysis was performed using unpaired t-test, Chi-square, and Fisher's exact tests, as appropriate.Of the 334 patients, 247 (74.0%) did not experience an expansion of their ICH while 87 (26.0%) did. Multivariable logistic regression was performed demonstrating ICH score of 3 or greater (4.76 (95% CI 2.60-8.72, p 0.001) , cortical location of the sICH (1.77 (95% CI 1.03-3.04, p = 0.038), and presence of a fluid level (6.46 (95% CI 2.28-18.3, p 0.001) as significant predictors of HE.Our study found that fluid-fluid levels on non-contrast CT, an ICH score 3 or greater, and lobar sICH were all more likely to expand.

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.

OBJECTIVE Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms. METHODS The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected. RESULTS Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0–2. Complete occlusion at follow-up was observed in 82.6% of patients. CONCLUSIONS PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.

Background The transradial access (TRA) is rapidly gaining popularity for neuroendovascular procedures as there is strong evidence for its benefits compared to the traditional transfemoral access (TFA). However, the transition to TRA bears some challenges including optimization of the interventional suite set-up and workflow as well as its impact on fellowship training. Objective To compare the learning curves of TFA and TRA for diagnostic cerebral angiograms in neuroendovascular fellowship training. Methods We prospectively collected diagnostic angiogram procedural data on the performance of 2 neuroendovascular fellows with no prior endovascular experience who trained at our institution from July 2018 until June 2019. Metrics for operator proficiency were minutes of fluoroscopy time, procedure time, and volume of contrast used. Results A total of 293 diagnostic angiograms were included in the analysis. Of those, 57.7% were TRA and 42.3% were TFA. The median contrast dose was 60 cc, and the median radiation dose was 14 000 μGy. The overall complication rate was 1.4% consisting of 2 groin hematomas, 1 wrist hematoma, and 1 access-site infection using TFA. The crossover rate to TFA was 2.1%. Proficiency was achieved after 60 femoral and 95 radial cases based on fluoroscopy time, 52 femoral and 77 radial cases based on procedure time, and 53 femoral and 64 radial cases based on contrast volume. Conclusion Our study demonstrates that the use of TRA can be safely incorporated into neuroendovascular training without causing an increase in complications or significantly prolonging procedure time or contrast use.

Background In patients with brain parenchyma extending beyond the craniectomy defect, cerebrospinal fluid diversion may be necessary to facilitate proper bone flap replacement during cranioplasty. In this study, we present our case series of patients who underwent ultrasound-guided ventricular puncture during cranioplasty and report periprocedural metrics and clinical outcomes. Methods A retrospective study of patients who presented for cranioplasty that required ultrasound-guided ventricular puncture was performed. We also describe our operative technique for safely and accurately performing ultrasound-guided ventricular puncture. Results Ten consecutive patients were included in the overall patient cohort, all of whom required intraoperative ventricular puncture to achieve brain relaxation. The mean time between decompressive hemicraniectomy and cranioplasty was 145.4 days (range 19–419). The mean duration of cranioplasty operation was 146 minutes (range 74–193). All patients underwent ultrasound-guided ventricular puncture, and 5 patients had an external ventricular drain left in place for postoperative intracranial pressure monitoring and possible cerebrospinal fluid drainage. There were no instances of pericatheter hemorrhage. One patient presented postoperatively with wound infection, and this same patient was the only one in the cohort who required subsequent ventriculoperitoneal shunt for symptomatic hydrocephalus. Conclusions Ultrasound-guided ventricular puncture is safe, feasible, and efficacious for use during cranioplasty to help facilitate bone flap replacement in patients with “full” brains, with an overall low rate of associated periprocedural complications. Although further studies are needed in a larger patient cohort, this technique should be considered to help reduce the morbidity associated with cranioplasty.

BackgroundThe Woven EndoBridge (WEB) device is approved in the USA for treatment of unruptured wide-neck bifurcation aneurysms. However, the safety and effectiveness of the WEB device in the treatment of ruptured intracranial aneurysms is not clear. We aim to evaluate the perioperative safety and effectiveness of the WEB device in patients with ruptured intracranial aneurysms.MethodsThis retrospective study, conducted at eight centers in the USA, included patients with ruptured intracranial aneurysms treated with the WEB device in the setting of subarachnoid hemorrhage (SAH). Safety outcomes included intraoperative complications such as vessel perforation, thromboembolic events, and postoperative hemorrhagic or thromboembolic complications based on radiologic imaging. The primary effectiveness outcome was adequate (complete and neck remnant) aneurysm occlusion, according to the Raymond–Roy classification.ResultsA total of 91 patients with 94 ruptured intracranial aneurysms were included (mean age 57.7±15.2 years; 68.1% women; 82.9% wide-necked). Aneurysms were located in the anterior communicating artery (42/94, 44.6%), middle cerebral artery (16/94, 17%), and basilar artery (15/94, 16%). Adequate occlusion was achieved in 48.8% (41/84) and 80.0% (40/50) at discharge and last follow-up (mean of 3.4 months), respectively. At discharge, procedural-related morbidity was 3.3% (3/91) and there was no procedure-related mortality. No re-rupture or delayed aneurysm rupture was observed.ConclusionsThis study demonstrates the perioperative safety and effectiveness of the WEB device for the treatment of patients with ruptured intracranial aneurysms in the setting of SAH, with low periprocedural morbidity and mortality. Long-term follow-up is warranted.

Mobile stroke units (MSUs) have been implemented worldwide for stroke care, but outcome data are lacking to show their efficacy specifically in patients undergoing mechanical thrombectomy (MT). Here, we include patients from our stroke network MSU and compare them to patients who arrived conventionally.A retrospective review of a stroke database was performed to identify patients who underwent MT after arrival via an MSU from August 2019 to December 2020. Demographic factors, past medical history, stroke characteristics, treatment variables, complications, and functional outcomes were recorded. These were compared to date-matched patients who underwent MT after arrival via conventional means.Seven patients were treated with MT after arriving by an MSU. These patients were compared to 50 date-matched patients who underwent thrombectomy after arrival through conventional means. No statistically significant difference between cohorts was observed in terms of demographic variables, comorbidities, stroke characteristics, or tissue plasminogen activator administration. Patients from the MSU cohort had significantly shorter time from symptom onset to groin puncture time (191.33 minutes ±77.53 vs. 483.51 minutes ±322.66, P = 0.034). Importantly, MSU-transferred patients had significantly better discharge functional status measured by using the modified Rankin Scale (1.86 ± 1.35 vs. 3.57 ± 1.88, P = 0.024). No significant difference in final thrombolysis in cerebral infarction score, complications, length of stay, or mortality was observed.Our pilot study demonstrates the efficacy of the MSU in decreasing door-to-puncture time and a concordant improvement in the discharge modified Rankin Scale score. Further prospective studies are needed to assess cost-efficacy and optimal protocol for MSUs in stroke care.

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.

Background Carotid-cavernous fistulas (CCFs) are acquired pathological shunting lesions between the carotid artery and the cavernous sinus leading to elevated intraocular pressure (IOP). CCFs are commonly treated via endovascular embolization, which theoretically restores physiological pressure differentials. Objective To present our institutional data with CCF treated with embolization and discuss endovascular routes, recurrence rates, and dynamic IOP changes. Methods Retrospective analysis of 42 CCF patients who underwent Onyx (Covidien, Irvine, California) embolization and pre- and postoperative IOP measurement at a single institution. Results CCFs were 19.0% direct (type A) and 81.0% indirect (types B, C, or D). Onyx-18 liquid embolisate was used during all embolizations. Overall rate of total occlusion was 83.3% and was statistically similar between direct and indirect fistulas. Preoperative IOP was elevated in 37.5%, 100.0%, 75.0%, and 50% in type A, B, C, and D fistulas, respectively. Average ΔIOP was -7.3 ± 8.5 mmHg (range: -33 to +8). Follow-up time was 4.64 ± 7.62 mo. Full angiographic occlusion was a predictor of symptom resolution at 1 mo (P = .026) and 6 mo (P = .021). Partial occlusion was associated with persistent symptoms postoperatively at 1 mo (P = .038) and 6 mo follow-up (P = .012). Beyond 6 mo, negative ΔIOP was associated with continued symptom improvement. Recurrence occurred in 9.5% of patients, all of which were indirect CCFs. Conclusion Onyx embolization of CCF is an effective treatment for CCF and often results in the reversal of IOP elevation. Full occlusion predicts favorable clinical outcomes up to 6 mo. Postoperative IOP reduction may indicate favorable long-term clinical outcomes.

Herein, the authors present the case of a 54-year-old male diagnosed with coronavirus disease 2019 (COVID-19) during a screening test. The patient was asked to self-isolate at home and report with any exacerbations of symptoms. He presented later with pneumonia complicated by encephalopathy at days 14 and 15 from initial diagnosis, respectively. MRI of the brain showed bithalamic and gangliocapsular FLAIR signal abnormality with mild right-sided thalamic and periventricular diffusion restriction. A CT venogram was obtained given the distribution of edema and demonstrated deep venous thrombosis involving the bilateral internal cerebral veins and the vein of Galen. CSF workup was negative for encephalitis, as the COVID-19 polymerase chain reaction (PCR) test and bacterial cultures were negative. A complete hypercoagulable workup was negative, and the venous thrombosis was attributed to a hypercoagulable state induced by COVID-19. The mental decline was attributed to bithalamic and gangliocapsular venous infarction secondary to deep venous thrombosis. Unfortunately, the patient’s condition continued to decline, and care was withdrawn.

OBJECTIVE The objective of this study was to demonstrate the feasibility and safety of CorPath GRX robotic-assisted (RA) transradial (TR) carotid artery stenting (CAS) compared with manual TR CAS. METHODS The authors conducted a retrospective analysis of a prospectively maintained database and identified 13 consecutive patients who underwent TR CAS from June 2019 through February 2020. Patients were divided into 2 groups: RA (6 patients) and manual (7 patients). RESULTS Among 6 patients in the RA group with a mean age of 70.0 ± 7.2 years, technical success was achieved in all 6 (100%) procedures; there were no technical or access-site complications and no catheter exchanges. Transfemoral conversion was required in 1 (16.7%) case due to a tortuous aortic arch. There were no perioperative complications, including myocardial infarction, stroke, and mortality. The mean procedure duration was significantly longer in the RA group (85.0 ± 14.3 minutes [95% CI 69.9–100.0] vs 61.2 ± 17.5 minutes [95% CI 45.0–77.4], p = 0.0231). There was no significant difference in baseline characteristics, fluoroscopy time, contrast dose, radiation exposure, catheter exchanges, technical success, transfemoral conversion, technical or access-site complications, myocardial infarction, stroke, other complications, or mortality. CONCLUSIONS The authors’ results suggest that RA TR CAS is feasible, safe, and effective. Neurovascular-specific engineering and software modifications are needed prior to complete remote control. Remote control has important implications regarding patient access to lifesaving procedures for conditions such as stroke and aneurysm rupture as well as operative precision. Future clinical investigations among larger cohorts are needed to demonstrate reliable performance and patient benefit.

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 The femoral artery is the most common access route for cerebral angiography and neurointerventional procedures. Complications of the transfemoral approach include groin hemorrhages and hematomas, retroperitoneal hematomas, pseudoaneurysms, arteriovenous fistulas, peripheral artery occlusions, femoral nerve injuries, and access-site infections. Incidence rates vary among different randomized and nonrandomized trials, and the literature lacks a comprehensive review of this subject. Objective To gather data from 16 randomized clinical trials (RCT) and 17 nonrandomized cohort studies regarding femoral access-site complications for a review paper. We also briefly discuss management strategies for these complications based on the most recent literature. Methods A PubMed indexed search for all neuroendovascular clinical trials, retrospective studies, and prospective studies that reported femoral artery access-site complications in neurointerventional procedures. Results The overall access-site complication rate in RCTs is 5.13%, while in in non-RCTs, the rate is 2.78%. The most common complication in both groups is groin hematoma followed by access-site hemorrhage and femoral pseudoaneurysm. On the other hand, wound infection was the least common complication. Conclusion The transfemoral approach in neuroendovascular procedures holds risk for several complications. This review will allow further studies to compare access-site complications between the transfemoral approach and other alternative access sites, mainly the transradial approach, which is gaining a lot of interest nowadays.

OBJECTIVEMechanical thrombectomy (MT) is now the standard of care for acute ischemic stroke (AIS) secondary to large-vessel occlusion, but there remains a question of whether elderly patients benefit from this procedure to the same degree as the younger populations enrolled in the seminal trials on MT. The authors compared outcomes after MT of patients 80–89 and ≥ 90 years old with AIS to those of younger patients.METHODSThe authors retrospectively analyzed records of patients undergoing MT at their institution to examine stroke severity, comorbid conditions, medical management, recanalization results, and clinical outcomes. Univariate and multivariate logistic regression analysis were used to compare patients < 80 years, 80–89 years, and ≥ 90 years old.RESULTSAll groups had similar rates of comorbid disease and tissue plasminogen activator (tPA) administration, and stroke severity did not differ significantly between groups. Elderly patients had equivalent recanalization outcomes, with similar rates of readmission, 30-day mortality, and hospital-associated complications. These patients were more likely to have poor clinical outcome on discharge, as defined by a modified Rankin Scale (mRS) score of 3–6, but this difference was not significant when controlled for stroke severity, tPA administration, and recanalization results.CONCLUSIONSOctogenarians, nonagenarians, and centenarians with AIS have similar rates of mortality, hospital readmission, and hospital-associated complications as younger patients after MT. Elderly patients also have the capacity to achieve good functional outcome after MT, but this potential is moderated by stroke severity and success of treatment.

BackgroundThe transradial approach (TRA) has gained increasing popularity for neuroendovascular procedures. However, the experience with TRA in neuroangiography is still in early stages in most centers, and the safety and feasibility of this approach have not been well established. The purpose of this study is to report the safety and feasibility of TRA for neuroendovascular procedures.MethodsWe reviewed charts from six institutions in the USA to include consecutive patients who underwent diagnostic or interventional neuroendovascular procedures through TRA from July 2018 to July 2019. Collected data included baseline characteristics, procedural variables, complications, and whether there was a crossover to transfemoral access.ResultsA total of 2203 patients were included in the study (age 56.1±15.2, 60.8% women). Of these, 1697 (77%) patients underwent diagnostic procedures and 506 (23%) underwent interventional procedures. Successfully completed procedures included aneurysm coiling (n=97), flow diversion (n=89), stent-assisted coiling (n=57), balloon-assisted coiling (n=19), and stroke thrombectomy (n=76). Crossover to femoral access was required in 114 (5.2%). There were no major complications related to the radial access site. Minor complications related to access site were seen in 14 (0.6%) patients.ConclusionIn this early stage of transforming to the ‘radial-first’ approach for neuroendovascular procedures, TRA was safe with low complication rates for both diagnostic and interventional procedures. A wide range of procedures were completed successfully using TRA.

Background Spinal arteriovenous fistulas (AVFs) are a rare entity that can have devastating neurologic outcomes. Currently, these lesions are treated via open microsurgical resection or transarterial embolization with good success. However, some patients cannot be treated with a minimally invasive endovascular technique secondary to difficulty catheterizing their vascular anatomy. Our aim is to present a case of balloon-assisted Onyx embolization of a spinal AVF. Case Description We present the case of a 59-year-old male with progressive lower back pain with lower-extremity weakness. We performed a spinal angiogram where an AVF was identified with very torturous anatomy. The patient was originally treated with open microsurgical resection; however, ≈6 weeks later the fistula and symptoms returned. At that time, we were able to treat the lesion with the Scepter-C balloon. Conclusions We present a challenging case in which normal embolization microcatheters were unable to navigate difficult anatomy, but we were able to gain access and obliterate the fistula by using a balloon catheter.

Background and importance Carotid-cavernous fistulas (CCF) are pathological connections between carotid artery branches and the cavernous sinus. They can lead to a variety of symptoms, such as chemosis and double vision, or more insidious events, such as vision loss and intracranial hemorrhage. Although these patients are often treated by endovascular means, we describe a case in which the patient's CCF was not able to be accessed by usual methods and required an open surgical approach. Clinical presentation The patient had progressive chemosis, double vision, and periorbital pain. Angiogram showed an indirect type D CCF with cortical venous drainage with a large sylvian vein that was directly draining the fistula. The patient did not have a dilated superior ophthalmic vein, and the petrosal sinuses could not be catheterized. Therefore, because of the patient's increased risk for intracranial hemorrhage, she was taken to the operating room for an image guided burr hole for direct catheterization of the sylvian vein. From this point, the fistulous point could be catheterized, and the CCF was embolized using onyx. Follow-up angiogram showed complete occlusion. Conclusion This is the first report in literature of an indirect CCF being treated through a transsylvian approach with onyx. This combined open-surgical-and-endovascular approach was necessary to get full resolution of the lesion, and patient had rapid improvement of symptoms.

Machine learning algorithms have received increased attention in neurosurgical literature for improved accuracy over traditional predictive methods. In this review, the authors sought to assess current applications of machine learning for outcome prediction of neurosurgical treatment of intracranial aneurysms and identify areas for future research.A PRISMA-compliant systematic review of the PubMed, MEDLINE, and EMBASE databases was conducted for all studies utilizing machine learning for outcome prediction of intracranial aneurysm treatment. Patient characteristics, machine learning methods, outcomes of interest, and accuracy metrics were recorded from included studies.16 studies were ultimately included in qualitative synthesis. Studies primarily analyzed angiographic outcomes, functional outcomes, or complication prediction using clinical, radiological, or composite variables. The majority of included studies utilized supervised learning algorithms for analysis of dichotomized outcomes.Commonly included variables were demographics, presentation variables (including ruptured or unruptured status), and treatment used. Areas for future research include increased generalizability across institutions and for smaller datasets, as well as development of front-end tools for clinical applicability of published algorithms.

Background Bilateral hemispheric dysfunction is devastating to consciousness. We present a unique case of a patient who developed bilateral middle cerebral artery infarcts with significant neurological improvement post bilateral thrombolysis in cerebral infarction (TICI) 3 thrombectomies. Case Description The patient is a 64-year-old woman who presented 3 hours after her husband was awakened and found her with left hemiplegia. She had a history of atrial fibrillation and had her apixaban held for 5 days before the coronary angiogram that she received the day before arrival. Upon presentation, she was antigravity on the right side and withdrawing on the left side. Computed tomography angiogram showed a right M1 occlusion and an left M2 occlusion. Computed tomography perfusion revealed a mismatch with large penumbra, and she was taken for mechanical thrombectomy. Mechanical thrombectomy was performed using a combination of stent retriever and aspiration catheter with a TICI 3 revascularization. By the following morning, the patient was full strength on the right and antigravity on the left with a left facial droop. The patient recovered her speech and was fully oriented before leaving for rehabilitation on postoperative day 3. Conclusions The transient hypercoagulable state that was created with the withdrawal of apixaban likely increased our patient's risk of stroke. The literature supports continuing oral anticoagulants for endovascular procedures. The devastating consequences of thromboembolic events, whether stroke or pulmonary embolism, can be catastrophic, but luckily, mechanical thrombectomy provides the means to minimize the morbidity and mortality from bilateral infarctions.

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.

Background and Purpose: Epidemiological studies have shown racial and ethnic minorities to have higher stroke risk and worse outcomes than non-Hispanic Whites. In this cohort study, we analyzed the STAR (Stroke Thrombectomy and Aneurysm Registry) database, a multi-institutional database of patients who underwent mechanical thrombectomy for acute large vessel occlusion stroke to determine the relationship between mechanical thrombectomy outcomes and race. Methods: Patients who underwent mechanical thrombectomy between January 2017 and May 2020 were analyzed. Data included baseline characteristics, vascular risk factors, complications, and long-term outcomes. Functional outcomes were assessed with respect to Hispanic status delineated as non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic patients. Multivariate analysis was performed to identify variables associated with unfavorable outcome or modified Rankin Scale ≥3 at 90 days. Results: Records of 2115 patients from the registry were analyzed. Median age of Hispanic patients undergoing mechanical thrombectomy was 60 years (72–84), compared with 63 years (54–74) for NHB, and 71 years (60–80) for NHW patients ( P P P P Conclusions: Hispanic patients are less likely to have favorable outcome at 90 days following mechanical thrombectomy compared to NHW or NHB patients. Further prospective studies are required to validate our findings.

The Woven EndoBridge (WEB) device is becoming increasingly popular for treatment of wide-neck aneurysms. As experience with this device grows, it is important to identify factors associated with occlusion following WEB treatment to guide decision making and screen patients at high risk for recurrence. The aim of this study was to identify factors associated with adequate aneurysm occlusion following WEB device treatment in the neurosurgical literature and in our case series. A systematic review of the present literature was conducted to identify studies related to the prediction of WEB device occlusion. In addition, a retrospective review of our institutional data for patients treated with the WEB device was performed. Demographics, aneurysm characteristics, procedural variables, and 6-month follow-up angiographic outcomes were recorded. Seven articles totaling 450 patients with 456 aneurysms fit our criteria. Factors in the literature associated with inadequate occlusion included larger size, increased neck width, partial intrasaccular thrombosis, irregular shape, and tobacco use. Our retrospective review identified 43 patients with 45 aneurysms. A total of 91.1% of our patients achieved adequate occlusion at a mean follow-up time of 7.32 months. Increasing degree of contrast stasis after WEB placement on the post-deployment angiogram was significantly associated with adequate occlusion on follow-up angiogram (p = 0.005) and with Raymond-Roy classification (p = 0.048), but not with retreatment (p = 0.617). In our systematic review and case series totaling 450 patients with 456 aneurysms, contrast stasis on post-deployment angiogram was identified as a predictor of adequate aneurysm occlusion, while morphological characteristics such as larger size and wide neck negatively impact occlusion.

Background Cavernous-carotid fistulas (CCFs) can present with a variety of symptoms depending on the anatomy of the fistula and its venous drainage. Patients most commonly present with scleral injection, pulsatile exophthalmos, and/or chemosis. Case Description We report a patient who presented with intraparenchymal hemorrhage in the absence of any of the commonly associated ocular symptoms and signs. After multiple imaging studies, the CCF was diagnosed and treated with endovascular embolization that resulted in complete occlusion of the fistula and reflux of embolysate into one of its connecting veins. Conclusions The morphology of the venous drainage can lead to atypical hemorrhagic presentation, whereas dilatation of one of the tributary veins with cortical venous reflux should warn the interventionist the path the embolysate may follow. We provide our experience with this unique presentation and its treatment.

Background and Purpose—Radial artery catheterization is an alternate route of access that has started to gain more widespread use for neuroendovascular procedures, and there have been few studies that describe its safety and efficacy. We present our institution’s experience in performing neuroendovascular interventions via a transradial approach, with excellent clinical outcomes and patient satisfaction measures.Methods—We conducted a retrospective analysis and identified 223 patients who underwent 233 consecutive neuroendovascular interventions via radial artery access at our institution. The incidence of perioperative and postprocedural complications was investigated. We identified a subset of 98 patients who have undergone both transradial and transfemoral cerebral angiograms and compared clinical outcomes and patient satisfaction measures between the 2 groups.Results—The overall incidence of complications was low across all procedures performed via transradial access. Peri-procedurally, only 2 patients had symptomatic radial artery spasm, and there were no instances of iatrogenic complications (vessel dissection, stroke, and hemorrhage). In 10 cases (4.3%), the intended procedure could not be completed via a transradial approach, and, thus, femoral artery access had to be pursued instead. Ten patients complained of minor postprocedural complications, although none required therapeutic intervention. The mean procedure time was shorter for diagnostic angiograms performed via transradial versus transfemoral access (18.8±15.8 versus 39.5±31.1 minutes;P=0.025). Patients overall reported shorter recovery times with transradial access, and the majority of patients (94%) would elect to have subsequent procedures performed via this route.Conclusions—Radial artery catheterization is a safe and durable alternative to perform a wide range of neuroendovascular procedures, with a low rate of complications. On the whole, patients prefer transradial compared with transfemoral access.

Objectives Pediatric Chiari Type 1 Malformations (CM1) are commonly referred for neurosurgical opinion. The ideal management in children regarding surgical and radiographic decision making is not clearly delineated. Patients and methods We retrospectively reviewed our cohort of patients age 18 years and younger referred to a single neurosurgeon for CM1. Baseline MRIs of the spine were obtained. Non-operative patients had repeat imaging at 6–12 months. Patients who underwent an operation (decompression with/without duraplasty) had repeat imaging at 6 months. Results One hundred and thirty-two patients with mean age of 10 years met inclusion criteria. All patients had post-operative symptomatic improvement. We identified 26 patients with syrinx, 8 with scoliosis, 3 with hydrocephalus, and one had tethered cord. The average tonsillar descent was 8.1 mm in the non-operative group and 11.9 mm in the operative group. Ninety-five patients were managed conservatively (72%). Thirty-seven were offered surgery (28%), and 33 patients underwent intervention; 21 with duraplasty (64%) and 12 without (36%). Conclusions Pediatric patients with CM1 require both clinical and radiographic follow-up. Duraplasty may be performed if decompression fails to relieve symptomatology, but is not always needed. CM1 continues to present a challenge in surgical decision making. Adhering to a treatment paradigm may help alleviate difficult decision-making.

Rapid reperfusion of ischemic penumbra in patients with acute stroke is critical to neurological recovery. Achieving reperfusion after first-pass mechanical thrombectomy has been associated with improved patient outcomes. However, the predictors for obtaining first-pass reperfusion are not well known.A single-institution retrospective study of all patients who underwent mechanical thrombectomy at a tertiary care center from January 2010 until March 2019 was conducted to assess for predictors of first-pass reperfusion.A total of 257 patients were reviewed. Successful reperfusion was obtained in 63.4% of patients, and in 38% of patients on the first pass. On multivariate analysis, increasing door-to-puncture time was a negative predictor of FPR (OR 0.989, 95% CI = 0.980-0.997) and use of combined thrombectomy technique with stent-retriever and aspiration was a positive predictor of FPR compared to aspiration or stent-retriever alone (OR 4.441, 95% CI = 1.001-19.699).Combination therapy using stent-retriever and aspiration may increase the chance of obtaining FPR, whereas delays in starting the procedure after patient arrival may decrease the odds of FPR. Rapid thrombectomy initiation and procedural technique may play in optimizing rates of FPR and ultimately patient outcomes, however, randomized controlled trials assessing these variables are necessary to determine optimal treatment strategies.

The placement of cervical and intracranial stents requires the administration of antiplatelet drugs to prevent thromboembolic complications. Ticagrelor has emerged as the most widely used alternative in clopidogrel non-responders owing to its potent antiplatelet effects. Because ticagrelor does not require hepatic activation, many neurointerventionalists choose to forgo laboratory testing of platelet inhibition. In rare instances, patients may not achieve adequate platelet inhibition following ticagrelor administration. In this paper we review the mechanism of action of ticagrelor and its use in cerebrovascular procedures. We present two cases of ticagrelor non-responsiveness from two high-volume cerebrovascular centers, discuss their management, and propose an algorithm for managing ticagrelor non-responsiveness.

Background Machine learning algorithms depend on accurate and representative datasets for training in order to become valuable clinical tools that are widely generalizable to a varied population. We aim to conduct a review of machine learning uses in stroke literature to assess the geographic distribution of datasets and patient cohorts used to train these models and compare them to stroke distribution to evaluate for disparities. Aims 582 studies were identified on initial searching of the PubMed database. Of these studies, 106 full texts were assessed after title and abstract screening which resulted in 489 papers excluded. Of these 106 studies, 79 were excluded due to using cohorts from outside the United States or being review articles or editorials. 27 studies were thus included in this analysis. Summary of review Of the 27 studies included, 7 (25.9%) used patient data from California, 6 (22.2%) were multicenter, 3 (11.1%) were in Massachusetts, 2 (7.4%) each in Illinois, Missouri, and New York, and 1 (3.7%) each from South Carolina, Washington, West Virginia, and Wisconsin. 1 (3.7%) study used data from Utah and Texas. These were qualitatively compared to a CDC study showing the highest distribution of stroke in Mississippi (4.3%) followed by Oklahoma (3.4%), Washington D.C. (3.4%), Louisiana (3.3%), and Alabama (3.2%) while the prevalence in California was 2.6%. Conclusions It is clear that a strong disconnect exists between the datasets and patient cohorts used in training machine learning algorithms in clinical research and the stroke distribution in which clinical tools using these algorithms will be implemented. In order to ensure a lack of bias and increase generalizability and accuracy in future machine learning studies, datasets using a varied patient population that reflects the unequal distribution of stroke risk factors would greatly benefit the usability of these tools and ensure accuracy on a nationwide scale.

Introduction Novel machine learning (ML) methods are being investigated across medicine for their predictive capabilities while boasting increased adaptability and generalizability. In our study, we compare logistic regression with machine learning for feature importance analysis and prediction in first-pass reperfusion. Methods We retrospectively identified cases of ischemic stroke treated with mechanical thrombectomy (MT) at our institution from 2012–2018. Significant variables used in predictive modeling were demographic characteristics, medical history, admission NIHSS, and stroke characteristics. Outcome was binarized TICI on first pass (0-2a vs 2b-3). Shapley feature importance plots were used to identify variables that strongly affected outcomes. Results Accuracy for the Random Forest and SVM models were 67.1% compared to 65.8% for the logistic regression model. Brier score was lower for the Random Forest model (0.329 vs 0.342) indicating better predictive capability. Other supervised learning models performed worse than the logistic regression model, with accuracy of 56.2% for Naive Bayes and 61.6% for XGBoost. Shapley plots for the Random Forest model showed use of aspiration, hyperlipidemia, hypertension, use of stent retriever, and time between symptom onset and catheterization as the top five predictors of first pass reperfusion. Conclusion Use of machine learning models, such as Random Forest, for the study of MT outcomes, is more accurate than logistic regression for our dataset, and identifies new factors that contribute to achieving first pass reperfusion. The benefits of machine learning, such as improved predictive capabilities, integration of new data, and generalizability, establish ML as the preferred model for studying outcomes in stroke.