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Introduction: Time-sensitive therapies can be delayed during weekends or off-hours. Regional systems of care require interfacility transfers from Primary Stroke Centers (PSC) to Comprehensive Stroke Centers (CSC). Door-in to door-out (DIDO) time, an emerging performance measure, is a modifiable factor in time to thrombectomy. Off-hours presentation has been associated with longer Door-To-Needle (DTN) time, however its effect on DIDO time is unknown. Hypothesis: Presentation during off-hours (before 8 AM, after 5 PM or on weekends) prolongs DIDO time. Methods: Retrospective review of transfers for CT perfusion or thrombectomy from 4 PSC to a CSC between 1/2017 and 6/2019. We used Mann-Whitney for hypothesis testing and Spearman’s correlation. Results: Sixty-seven persons were included, of which 36 were male, 31 received IV tPA, 40 presented during off-hours. Median (upper and lower quartile) for age, NIHSS, DTN and DIDO were 74 (61-83) years, 17 (12-23) points, 37 (31-54) and 98 (77-127) minutes, respectively. Off-hours presentation did not prolong DIDO time (p=0.32, image) nor affect any interval in the sequence door-in, non-contrast CT (nCT), IV tPA, CT Angiogram (CTA) initiation, CTA interpretation, door-out; or door-in at PSC to groin puncture (DTGP) time. Transport from PSC to CSC was slower off-hours (p=0.04). On post-hoc analyses, DIDO correlated with door-in to nCT interpretation time (r s =0.27, p=0.02), nCT interpretation to consulting neurointerventionalist (r s =0.59, ps =0.37, p=0.01); door-in to CTA initiation (r s =0.77, ps =0.61, ps =0.85, p Conclusions: Off-hours presentation is not associated with prolonged DIDO time in patients transferred for possible thrombectomy. Time to calling neurointerventionalist and initiation and interpretation of CTA contributes to DIDO, and may be targets for improvement to expedite transfers.

Introduction: The Inpatient (IP) FAST Stroke process was confusing to many and key people were missing in the current flow process. Pre-project, different processes were used to activate the emergency response for various conditions. Work done on improving stroke patient arrival in the Emergency Department to assessment/intervention (Door-to-needle (DTN) has successfully improved outcomes and efficiency to allow for Alteplase intervention to occur an average of 30 minutes or less on eligible patients for the past 2 years. Confusion and inefficiencies in the current Inpatient FAST Stroke Process has led to patient safety concerns. Objective of Project: To revise the inpatient Stroke FAST process by utilizing key aspects of the DTN flow to assure key personnel are present and expectations are clear. Methods: Interprofessional team with key area represented was chartered. Component of the Six Sigma Quality strategies were utilized for this project. Baseline information and feedback was gathered so consensus on current process could be reached. A root cause analysis with a fishbone diagram technique was used to identify gaps in the current process and revision priorities. The priorities identified included: Clarification of the IP Stroke activation process; revision to the IP FAST Stroke Team composition to expedite care delivery; and clarification of process mechanics, roles, and scopes. Results/Conclusions: Clarified IP activation process so our Rapid Response Team (RRT) will be initial response for ANY sudden change in condition. (Like EMS in field); then after their assessment, RRT will activate the Stroke FAST team as needed. The composition of the Stroke FAST team revised to expedite care delivery. (i.e. includes Neuro resident, NICU charge/designee, FAST Stroke Pharmacist, Transporter, etc.). To further improve efficiency mechanics (i.e. order process, CT location to use, etc.), roles, and care expectations were delineated as is found in this flow process.

Background and Issues: The Comprehensive Stroke Center (CSC) Program Coordinator (PC) started her role at the same time as the CSC recertification application was due. The required documentation and components of a program that need to be presented to reflect compliance with standards is extensive. By having less than 6 months to become familiar with the program, address gaps, educate staff, and partner with providers and other disciplines, and assure optimal patient care is provided; a team approach using a multitude of preparation/communication methods was needed. Purpose: The purpose of this program effort was to identify and implement strategies that prepare the organization for a successful CSC Recertification. Methods: Many approaches were used in the preparation process which included: Observe and shadow in key areas (ED, IP, NICU, IR, IP Rehab, Clinic, Neurocritical Care, Neuro IP Team and other areas); Review evidence to assure most current guidelines provide basis for program; Consolidate Primary and Comprehensive Stroke Center standards; Complete gap analysis; Engage Interprofessional team; Identify our documents which reflect standards compliance; Identify educational needs/provide education; Develop online resources and tools for constant accessibility; Collaborate on presentation materials; Communicate, communicate, communicate; Practice presentation and interaction; Complete a team walking tour of survey; Engage staff in a mock survey; Keep everyone updated via newsletters and staff meeting updates. Results and Conclusions: Team members and staff verbalized a high degree of readiness for the survey with the preparation methods utilized. Lessons learned include: Prioritize actions based on our patient-centered mission/vision/values; Realize that everything may not be in its final state before the survey but have a plan to ensure completion; Engaging the full team in the preparation process helps identify potential issues and solutions that may not have otherwise been known; Utilize technology to expedite communication and education; have a physical presence throughout the care process areas.

Importance The treatment effects of individual mechanical thrombectomy devices in large-vessel acute ischemic stroke (AIS) remain unclear. Objective To determine whether the novel 3-dimensional (3-D) stent retriever used in conjunction with an aspiration-based mechanical thrombectomy device (Penumbra System; Penumbra) is noninferior to aspiration-based thrombectomy alone in AIS. Design, Setting, and Participants This randomized, noninferiority clinical trial enrolled patients at 25 North American centers from May 19, 2012, through November 19, 2015, with follow-up for 90 days. Adjudicators of the primary end points were masked to treatment allocation. Patients with large-vessel intracranial occlusion AIS presenting with a National Institutes of Health Stroke Scale (NIHSS) score of at least 8 within 8 hours of onset underwent 1:1 randomization to 3-D stent retriever with aspiration or aspiration alone. The primary analyses were conducted in the intention-to-treat population. Interventions Mechanical thrombectomy using intracranial aspiration with or without the 3-D stent retriever. Main Outcomes and Measures The primary effectiveness end point was the rate of a modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2 to 3 with a 15% noninferiority margin. Device- and procedure-related serious adverse events at 24 hours were the primary safety end points. Results Of 8082 patients screened, 198 patients were enrolled (111 women [56.1%] and 87 men [43.9%]; mean [SD] age, 66.9 [13.0] years) and randomized, including 98 in the 3-D stent retriever with aspiration group and 100 in the aspiration alone group; an additional 238 patients were eligible but not enrolled. The median baseline NIHSS score was 18.0 (interquartile range, 14.0-23.0). Eighty-two of 94 patients in the 3-D stent retriever and aspiration group (87.2%) had an mTICI grade of 2 to 3 compared with 79 of 96 in the aspiration alone group (82.3%; difference, 4.9%; 90% CI, −3.6% to 13.5%). None of the other measures were significantly different between the 2 groups. Device-related serious adverse events were reported by 4 of 98 patients in the 3-D stent retriever with aspiration group (4.1%) vs 5 of 100 patients in the aspiration only group (5.0%); procedure-related serious adverse events, 10 of 98 (10.2%) vs 14 of 100 (14.0%). A 90-day modified Rankin Scale score of 0 to 2 was reported by 39 of 86 patients in the 3-D stent retriever with aspiration group (45.3%) vs 44 of 96 patients in the aspiration only group (45.8%). Conclusions and Relevance The present study provides class 1 evidence for the noninferiority of the 3-D stent retriever with aspiration vs aspiration alone in AIS. Future trials should evaluate whether these results can be generalized to other stent retrievers. Trial Registration clinicaltrials.gov Identifier:NCT01584609

Introduction Various thrombectomy devices promise high rates of recanalization and reduction of disability. A recent meta-analysis of the Solitaire device demonstrated its utility as safe and effective in revascularization of large vessel occlusions. The present analysis seeks to determine if good clinical outcome can similarly be achieved by the 3D Revascularization Device for patients with small score infarcts (ASPECTS 8-10). Methods The 3D trial sought to evaluate the safety and efficacy of the 3D Revascularization Device as compared to the Penumbra System alone in acute stroke intervention. Subjects meeting the per protocol study criteria and presenting with small core infarcts were included in the present analysis. Notwithstanding similarities in baseline characteristics between the 3D ASPECTS 8–10 patients compared to the Campbell cohort (Table I), only patients with small core infarcts were considered for the present analysis. Study outcome on the reduction of disability, defined as mRS 0-2 at 90 days, were compared with the Campbell Solitaire meta-analysis. Results In total, 105 of 198 patients met the study criteria. While ASPECTS 8-10 data could not be determined for the Campbell cohort, the median NIHSS (3D: 17 [IQR 12–21] vs Campbell: 17 [IQR 13–20] and ASPECTS (3D: 9 [IQR 8–10] vs 9 [IQR 7–10] scores were similar. Reduction of disability (mRS 0-2) data for available trials within the Campbell meta-analysis was extrapolated to evaluated to yield a weighted outcome of 57.7% at 90 days for ASPECTS 8–10 patients treated with the Solitaire device (Table II). Similarly, patients treated with the 3D Revascularization Device demonstrated comparable clinical outcomes, mRS 0–2 in 52.5% (figure 1). Conclusion Utility of the 3D Revascularization Device with the Penumbra System can achieve favorable long term clinical outcome similar to the use of Solitaire. Disclosures: A. Siddiqui: 2; C; Codman, Medtronic, Guide Point Global Consulting, Penumbra, Stryker, Microvention, W. L. Gore & Associates, Three Rivers Medical, Inc., Corindus, Inc., Amnis Therapeutics, Ltd.,CereVasc, LLC. D. Frei: 2; C; Penumbra, Inc., Codman, Microvention, Stryker, Siemens. 4; C; Penumbra, Inc. A. Yoo: 1; C; Neuravi, Inc., Penumbra, Inc.. J. Kirmani: None. O. Zaidat: 2; C; Penumbra, Inc.. D. Lopes: None. A. Turk: 1; C; Penumbra, Inc., Microvention, Stryker, Covidien, Medina Medical. D. Heck: 1; C; Penumbra, Inc.. 2; C; Stryker. B. Mason: None. D. Haussen: None. E. Levy: None. S. Mehta: None. M. Lazzaro: None. M. Chen: None. A. Dorfler: 1; C; Penumbra, Inc.. C. Derdeyn: None. L. Schwamm: None. D. Langer: None. R. Nogueira: None.

Introduction The efficacy of the endovascular treatment of acute ischemic stroke has been substantiated by several recent randomized clinical trials. While intra-arterial therapy has significantly evolved in recent years, anatomic cerebrovascular variants and disease burden can present challenges to timely recanalization. We present the first reported case of anterior-to-posterior mechanical clot retrieval with use of a stent retriever. Case description A 53-year-old man presented with basilar artery thrombosis. Endovascular mechanical clot retrieval was performed. The typical, antegrade, access to the basilar artery thrombus was precluded by the findings of a hypoplastic left vertebral artery and an occluded proximal right vertebral artery. Given a number of factors including the patient’s worsening symptoms and the high morbidity and mortality associated with basilar stroke, cross-circulation—anterior-to-posterior—intra-arterial therapy was performed. Thrombectomy of the basilar thrombus was achieved via the right internal carotid artery and right posterior communicating artery. Conclusion To our knowledge, we report the first case of cross-circulation, anterior-to-posterior thrombectomy, with the use of a stent-retriever device. Cross-circulation stroke treatment may be beneficial in cases of proximal vessel occlusion or anatomical constraints. Larger studies will need to evaluate the safety and efficacy of these approaches.

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) carries a high risk of morbidity and mortality. Endovascular coiling is an effective treatment option for ruptured aneurysms and offers certain advantages over microsurgical clipping. Thromboembolism is a known complication of endovascular therapy, but little has been reported regarding its causes. We hypothesized that platelet transfusion (PT) is a risk factor for thrombotic events (TE) during endovascular therapy. Methods: We retrospectively evaluated 84 patients presenting with aSAH to a Comprehensive Stroke Center in the United States between 2011 and 2015 who underwent endovascular treatment. In addition to TE related to endovascular aneurysm repair, charts were reviewed for variables including length of hospitalization, 3-month modified Rankin Scale (mRS), and smoking. Intergroup differences were evaluated with a Chi-squared and Student’s t-test. Logistic regression models were also fitted to the outcome of TE. Results: Patient demographics and clinical variables are seen in Table 1. 23% of patients incurred TE. Platelet transfusion was more common in patients with TE, but this association was not statistically significant in the logistic regression models (Table 2). In the adjusted model, active smoking and procedure length remained significantly associated with TE. Conclusion: To our knowledge, risk factors for thrombotic events in the setting of endovascular cerebral aneurysm treatment have not been previously reported. Procedure length and active smoking are associated with TE, and PT has a trend towards significance. After adjusting for potential confounders, active smoking remains the best predictor of TE (p=0.004), conferring an 11-fold risk.

Introduction: The effect of platelet transfusion (PT) has been studied in patients with intracerebral hemorrhage, but has not been reported for aneurysmal subarachnoid hemorrhage (aSAH). We investigated the effect of PT on the outcome of patients with aSAH. Methods: We retrospectively evaluated 84 patients admitted with aSAH to a Comprehensive Stroke Center in the United States between 2011 and 2015. Charts were reviewed for variables including length of hospitalization, 3-month modified Rankin Scale (mRS), and complications related to endovascular treatment of cerebral aneurysm. Intergroup differences were evaluated with the Chi-squared and Student’s t-test. mRS was evaluated using multivariate ordinal logistic regression. Variables with a univariate p-value Results: Patient demographics and clinical variables are seen in Table 1. 30% of patients received PT. PT was associated with male gender, Hunt-Hess score, Fisher Score, external ventricular drain placement, and longer hospital length of stay. After multivariate ordinal regression, PT was associated with higher mRS and there was a trend for association with Hunt-Hess score (Table 2). Conclusion: Our findings suggest that platelet transfusion is common in patients presenting with aSAH. Platelet transfusion in these patients is associated with longer hospital stay and a significantly lower rate of good clinical outcome, with a nearly 4- to 6-fold higher odds of a one-point increase in mRS at 3 months. The association of platelet transfusion to worse outcome in patients with aSAH warrants further study.

Introduction: The relative treatment effects for a stent retriever when used as an adjunct to aspiration versus aspiration alone remain unclear. The aim of this study was to demonstrate the safety and efficacy of the Penumbra stent retriever, 3D, when used in conjunction with the Penumbra Aspiration System (3D/PS), was non-inferior to the Penumbra Aspiration System (PS) alone. It remains controversial if a Per Protocol (PP) or an Intent-To-Treat (ITT) analysis is more appropriate for this study design. Hypothesis: PP and ITT analyses are comparable for a non-inferiority design trial. Materials and Methods: Patients presenting with symptoms of ischemic stroke within 8 hours of onset who had evidence of a LVO (diameter ≥2.5mm) and a NIH Stroke Scale ≥8 were assigned 1:1 to either treatment group. The primary endpoint for effectiveness was angiographic revascularization of the occluded target vessel at immediate post-procedure where the 3D/PS is non-inferior to PS by no more than 15%. Key secondary endpoints were 90 day functional independence as defined by a modified Rankin score 0-2, all-cause mortality and the incidence of symptomatic intracerebral hemorrhage. A Core Laboratory assessed imaging data. Results: The trial was terminated in June 2016 after the DSMB voted unanimously that recruiting additional subjects was judged to be both not feasible and unable to alter conclusions. A total of 198 patients were randomized at 25 sites: 98 to the 3D/PS and 100 to the PS alone group. The results indicate the 3D/PS was non-inferior to the PS alone in safety and effectiveness (difference in TICI 2-3=2.6%, 95%CI -5.8 to 11%). PP and ITT analyses showed similar results (Table). Conclusion: This is the first Class 1 evidence showing the similarity in safety and effectiveness of a stent retriever when used as an adjunct to aspiration versus aspiration alone in acute stroke from LVO. Both PP and ITT analyses showed similar results.

We sought to determine the long-term survival and natural history of vertebral artery origin stenosis (VAOS) as it relates to stroke.We retrospectively reviewed clinical data on patients admitted at a single institution for possible stroke between 2004 and 2007 and selected subjects who underwent angiography of the neck. We classified VAOS subjects as having "moderate" to "severe" (≥50%) occlusion. Age-, sex-, and race-matched control subjects with no evidence of VAOS on angiography were selected from our study population. Long-term follow-up data were collected and death certificates were searched for comparison among cases and controls. A Kaplan-Meier curve was plotted based on time to event (stroke or death).Fifty-eight of the 358 subjects were found to have VAOS (16.2%). Four subjects were excluded because of stenting; therefore, 54 cases and 54 matched controls were included for long-term follow-up analysis. In our study population, we calculated that the relative risk of having a stroke or dying in patients with VAOS was 6 times that of patients without VAOS (P.02). The observed 5-year survival rate for patients with VAOS was 67% (36/54) compared to 89% (48/54) in control subjects (P.01).Patients with VAOS are at a significantly higher risk of having a stroke or dying. Subsequent prospective, multicenter studies are needed to validate our results.

BACKGROUND Previous studies have demonstrated that cerebral dural sinus stenosis (DSS) may be a potential patho-physiological cause of idiopathic intracranial hypertension (IIH). Endovascular therapy for DSS is emerging as a potential alternative to treat IIH. Here, we present the results of our case series. METHOD We prospectively collected angiographic and manometric data on patients that underwent angioplasty/stenting for IIH. All patients had failed maximal medical therapy (MMT) and had confirmed sinus stenosis. Demographic, clinical and radiological presentation, and outcomes were collected retrospectively. RESULTS A total of 18 patients underwent 25 procedures. Demographics revealed a mean age of 30 (range 15-59), 83% (15/18) were female, 72% (13/18) were white, and mean body mass index of 36 (range 23-59.2). All patients presented with classic IIH. Symptom improvement or resolution was reported in 94% (17/18) of patients. All patients had resolution and/or stabilization/improvement of their papilledema. Headaches related to increased pressure improved in 56% (10/18). Re-stenosis and retreatment occurred in 33% (6/18). No procedural related complications were reported. CONCLUSION Dural sinus angioplasty and stenting is relatively safe, feasible, and clinically efficacious for patients with symptomatic sinus stenosis who have failed standard therapy. The long-term durability of patency and clinical improvement remains unknown.

Although uncommon in the general population, cerebral arteriovenous malformations (AVMs) can pose a significant health risk if a rupture occurs. Advances in noninvasive imaging have led to an increase in the identification of unruptured AVMs, presenting new challenges in management, given their poorly understood natural history. Over the past decade, there have been significant developments in the management and treatment of intracranial AVMs. This article discusses the pathophysiology, natural history, clinical presentations, and current treatment options, including multimodal approaches, for these vascular malformations.

BACKGROUND The effect of oversized intracranial stent implantation, and potential excessive neointimal hyperplasia from the chronic outward radial force, has not been reported. We sought to compare the angiographic narrowing associated with implantation of oversized stents. METHODS We reviewed an aneurysm database and identified patients treated with stent-assisted embolization involving a vessel size transition. Demographics and lesion characteristics were extracted. The relationship between lumen diameter and stent oversizing was compared. RESULTS Twenty vessels were identified in 18 patients, providing 80 paired data points. Mean follow-up time was 8 months (SD 6). The average oversizing in the smaller diameter parent vessel landing-zone was 1.75 mm. Mean change in lumen size from pre-stent implantation was not significantly different for any of the four sites. There was a significant difference in change of lumen size at the stent tines when compared with the respective mid-stent segment for both the proximal (P = 0.02) and distal (P = 0.0004) landing zones. CONCLUSIONS A small significant lumen loss occurs at stent tines when compared to midstent struts. However, there is no overall significant stenosis from highly oversized stents. Persistent luminal gain from the oversized stent radial force likely predominates over any neointimal hyperplasia.

Introduction: In the Solitaire With the Intention For Thrombectomy (SWIFT) trial, rescue therapy was used when the Solitaire or Merci device was unable to restore vessel patency. Markers for nonrecanalization in acute stroke have been reported for intravenous tissue plasminogen activator; however, similar predictors are not known for endovascular therapy. We sought to identify predictors and outcomes associated with rescue therapy in the SWIFT trial. Methods: Rescue therapy included the use of an alternative device, agent, or maneuver following failure to recanalize with three retrieval attempts using the initial device. Clinical, angiographic, and demographic data was reviewed. Results: Among a total of 144 patients enrolled, 43 (29.9%) required rescue therapy. We used the same baseline demographics for patients with and without rescue therapy. Rescue therapy was used in a higher percentage of patients randomized to the Merci group compared with the Solitaire group (43 vs. 21%, p = 0.009). Patients with rescue therapy experienced a longer recanalization time (p < 0.001), a lower percentage of successful recanalization (p < 0.001), and a lower percentage of good outcome (p = 0.009). In multivariate analysis, patients randomized to the Merci group (OR 3.99, 95% CI 1.58, 10.10) and age >80 years (OR 3.51, 95% CI 1.06, 11.64) were predictors of rescue therapy. Conclusions: Merci treatment group and age were predictors of rescue therapy, while a trend toward an increased need of rescue therapy was observed with hypertension and proximal clot location. Rescue therapy was associated with fewer good outcomes. These findings may reflect targets for improvement in endovascular therapy.

Background: Idiopathic intracranial hypertension (IIH) is a disorder characterized by signs and symptoms of increased intracranial pressure without structural cause seen on conventional imaging. Hallmark treatment after failed medical management has been CSF shunting or optic nerve fenestration with the objective of preserving vision. Recently, there have been multiple case reports and case series on dural sinus stenting for this disorder. Objective: We aim to review all published cases and case series of dural sinus stenting for IIH, with analysis of patients' presenting symptoms, objective findings (CSF pressures, papilledema, pressure gradients across dural sinuses), follow-up of objective findings, and complications. Methods: A Medline search was performed to identify studies meeting prespecified criteria of a case report or case series of patients treated with dural sinus stent placement for IIH. The papers were reviewed and data were extracted. Results: A total of 22 studies were identified, of which 19 studies (including a total of 207 patients) met the criteria and were included in the analysis. Only three major complications related to the procedure were identified. Headaches resolved or improved in 81% of patients. Papilledema improved in 90% of cases (172 of 189 patients). Sinus pressure decreased from an average of 30.3 to 15 mm Hg. Sinus pressure gradient decreased from 18.5 mm Hg (n = 185) to 3.2 mm Hg (n = 172). Stenting had an overall symptom improvement rate of 87%. Conclusion: Although all published case reports and case series are nonrandomized, the low complication and high symptom improvement rate make dural sinus stenting for IIH a potential alternative surgical treatment. Standardized patient selection and randomization trials or registry are warranted.

Background: Intracranial atherosclerotic disease (ICAD) is a common cause of stroke with a poor natural history despite medical therapy. Few studies have investigated endovascular therapies for the treatment of symptomatic ICAD in distal intracranial arteries. Here, we present the feasibility and safety of balloon angioplasty with and without stenting in patients with medically refractory small-artery symptomatic ICAD. Methods: Personal logs were reviewed to identify patients who were treated for small-artery ICAD (stenosis >50%) using angioplasty and/or stenting. Small cerebral arteries were defined by a diameter of ≤2 mm or any branch distal to a large intracranial vessel (i.e. distal to the internal carotid artery, M1, A1, or vertebrobasilar trunk). Patient characteristics, clinical manifestations, treatment, hospital course, and follow-up data were collected and analyzed. Results: Ten patients (12 arteries) were treated with either primary balloon angioplasty (58.3%) or angioplasty with stenting (41.6%) with a 100% technical success rate. Mean pretreatment stenosis was 79.9%, while mean posttreatment stenosis was 19.0%. There were no major periprocedural complications, including symptomatic intracranial hemorrhage or mortality; 3 cases were complicated by groin hematoma. Patients were followed for a mean total of 18.6 months with only 1 symptomatic restenosis which was retreated successfully. All patients had good functional outcome with a modified Rankin Scale of either 0 (80%) or 1 (20%) on follow-up. Conclusion: In our case series, treatment of symptomatic small-artery ICAD with angioplasty and/or stenting was safe and effective. These interventions should be considered as an alternative treatment for ICAD patients refractory to medical therapy.

Background: Small aneurysms located at the anterior communicating artery carry significant procedural challenges due to a complex anatomy. Recent advances in endovascular technologies have expanded the use of coil embolization for small aneurysm treatment. However, limited reports describe their safety and efficacy profiles in very small anterior communicating artery aneurysms. Objective: We sought to review and report the immediate and long-term clinical as well as radiographic outcomes of consecutive patients with ruptured very small anterior communicating artery aneurysms treated with current endovascular coil embolization techniques. Methods: A prospectively maintained single-institution neuroendovascular database was accessed to identify consecutive cases of very small (Results: A total of 20 patients with ruptured very small (Conclusion: This report describes the largest series of consecutive endovascular treatments of ruptured very small anterior communicating artery aneurysms. These findings suggest that coil embolization of very small aneurysms in this location can be performed with acceptable rates of complications and recanalization.

Standard measurement criteria for vertebral artery origin (VAO) stenosis have not yet been established. We propose such criteria and report on interrater agreement using two measurement methods in a series of patients referred for endovascular therapy. Three experienced angiography raters independently reviewed magnified cerebral angiograms. The formula [1 - (Ds/Dn)] × 100 was used, where Ds is the diameter of the most stenotic portion of the lesion and Dn is normal vessel diameter. The first measurement method allows unrestricted use of the V1 segment for measurement of normal diameter. In the second method, normal diameter is measured in the first portion of the V2 segment with exclusion of any region of poststenotic dilatation. Ten consecutive patients with VAO stenosis were reviewed. The mean degree of stenosis was 71.9% (standard deviation, ± 10.7%) with the first method and 66.9% ± 10.6% with the second method. Average interrater agreement was 80% with the first method and 87% with the second method. The intraclass correlation coefficient (ICC) demonstrated greater interrater agreement when the tortuous proximal V1 segment was excluded in normal diameter measurement (ICC = 0.7750) compared with the unrestricted use of the V1 segment for normal diameter (ICC = 0.7256). The kappa statistic was the best among the 3 raters with 10% variance when the tortuous V1 segment was excluded, at 0.73 (overall agreement, 87%). Our findings indicate that excluding the tortuous V1 portion when measuring normal diameter improves interrater agreement and simplifies the measurement of high-grade VAO stenosis.

Objective: To estimate the needed workforce of trained neurointerventionalists (NIs) to perform endovascular therapy (ET) for eligible patients with acute ischemic stroke (AIS). Method: Population and ischemic stroke incidence data were extracted with use of US Census and Centers for Disease Control and Prevention 2009 estimates. The annual “demand” is defined as the proportion of AIS patients who would meet inclusion criteria and clinical standards for ET. The “supply” is defined as the number of trained NIs and NIs in training. The “workforce” is the number of NIs needed to meet the demand (the number of eligible AIS patients) within an accessible geographic diameter. Data on NIs and NI fellowships were collected (Society of Neurointerventional Surgery [SNIS], Society of Vascular & Interventional Neurology [SVIN], Concentric Medical, and Penumbra Inc.). Results: The estimated number of NIs is close to 800, practicing within a 50-mile radius of major metropolitan areas in the United States, covering more than 95% of the US population. Approximately 40 NI fellows are graduating yearly from US training programs. In 5 years and 10 years, the number of NIs may reach 1,000 and 1,200, respectively. Currently, there are approximately 14,000 thrombectomy procedures performed in the United States each year. However, the percentage of AIS patients who may be eligible for ET in our estimation is 4% to 14%, or about 25,000 to 95,000 patients. This means that cases will occur at a rate of 26 to 97 per year in 5 years, or 22 to 81 per year in 10 years, for each NI. Providing 24/7 AIS coverage requires 2 to 3 NIs per medical center, adding to the challenge of providing manpower without diluting experience in areas of lower population density. Conclusion: The current and projected number of NIs would adequately supply the future need if the proportion of patients requiring AIS endovascular therapy increases. However, 2 to 3 NIs per comprehensive stroke center would be needed to provide 24/7 AIS therapy with a sufficient number of cases per NI. A tertiary stroke center model similar to the trauma model may provide the manpower solution without compromising the quality of care.

Background: Recanalization and angiographic reperfusion are key elements to successful endovascular and interventional acute ischemic stroke (AIS) therapy. Intravenous recombinant tissue plasminogen activator (rt-PA), the only established revascularization therapy approved by the US Food & Drug Administration for AIS, may be less effective for large artery occlusion. Thus, there is enthusiasm for endovascular revascularization therapies, which likely provide higher recanalization rates, and trials are ongoing to determine clinical efficacy and compare various methods. It is anticipated that clinical efficacy will be well correlated with revascularization of viable tissue in a timely manner. Method: Reporting, interpretation, and comparison of the various revascularization grading methods require agreement on measurement criteria, reproducibility, ease of use, and correlation with clinical outcome. These parameters were reviewed by performing a Medline literature search from 1965 to 2011. This review critically evaluates current revascularization grading systems. Results and Conclusion: The most commonly used revascularization grading methods in AIS interventional therapy trials are the thrombolysis in cerebral ischemia (TICI, pronounced “tissy”) and thrombolysis in myocardial ischemia (TIMI) scores. Until further technical and imaging advances can incorporate real-time reliable perfusion studies in the angio-suite to delineate regional perfusion more accurately, the TICI grading system is the best defined and most widely used scheme. Other grading systems may be used for research and correlation purposes. A new scale that combines primary site occlusion, lesion location, and perfusion should be explored in the future.

Over the past decade, endovascular therapy has emerged as a promising therapeutic approach for select patients with acute ischemic stroke. However, the morbidity, mortality, and complication rates in intra-arterial recanalization trials are higher than in the National Institute of Neurological Disorders and Stroke trial of IV tissue plasminogen activator. This review discusses common complications associated with endovascular therapy for acute ischemic stroke, avoidance of complications, and management of some of the common complications.

Digital subtraction angiography (DSA) is the gold standard imaging for detection of in-stent restenosis (ISR) but there is limited literature on optimal non-invasive surveillance imaging. In this study, the ability of CT angiography (CTA) and MR angiography (MRA) compared with DSA in recognizing ISR was assessed.A single center database of patients treated with stent implantation for ICAD was accessed. All patients who underwent follow-up imaging with DSA paired with either MRA or CTA within 30 days were included. Two angiography readers and two non-invasive imaging readers measured restenosis with a submillimeter digital caliper. ISR was categorized as: none/minimal, mild (50%), moderate (≥50-70%) or severe (≥70%). Analysis was performed with weighted κ statistics.17 cases of individual stents that underwent surveillance imaging with paired DSA and CTA and five stents with paired DSA and MRA were identified. Of those undergoing DSA and CTA, inter-reader agreement produced κ=0.68 (95% CI 0.40 to 0.95) for DSA and κ=0.75 (95% CI 0.55 to 0.95) for CTA. Agreement across CTA and DSA was κ=0.36 (95% CI 0.26 to 0.52). Of those undergoing DSA and MRA, inter-reader agreement produced κ=0.71 (95% CI 0.27 to 1.00) for DSA and κ=1.00 (95% CI 1.00 to 1.00) for MRA. Agreement across MRA and DSA was κ=0.34 (95% CI 0.18 to 0.51).Good inter-reader agreement exists within DSA, CTA and MRA. However, when comparing non-invasive imaging (CTA and MRA) with DSA, only fair agreement exists. These data suggest that CTA and MRA are not comparable to DSA for evaluation of ISR.

Atrial fibrillation (AF) is a major risk factor for recurrent ischemic stroke. We aimed to compare the detection rate of AF using continuous cardiac telemetry (CCT) versus Holter monitoring in hospitalized patients with ischemic stroke or transient ischemic attack (TIA). Between June 2007 and December 2008, 133 patients were admitted to an academic institution for ischemic stroke or TIA and underwent concurrent inpatient CCT and Holter monitoring. Rates of AF detection by CCT and Holter monitoring were compared using the McNemar paired proportion test. Among the 133 patients, 8 (6.0%) were diagnosed with new-onset AF. On average, Holter monitoring was performed for 29.8 hours, and CCT was performed for 73.6 hours. The overall rate of AF detection was higher for Holter monitoring compared with CCT (6.0%; 95% confidence interval [CI], 2.9-11.6 vs 0; 95% CI, 0-3.4; P = .008). Holter detection of AF was even higher in specific subgroups (those with an embolic infarct pattern, those age >65 years, and those with coronary artery disease). Holter monitoring detected AF in 6% of hospitalized ischemic stroke and TIA patients, with higher proportions in high-risk subgroups. Compared with CCT, Holter monitoring is significantly more likely to detect arrhythmias.

Background Pericallosal artery aneurysms at the bifurcation represent a special endovascular technical challenge given their distal location, commonly wide-neck morphology, small parent vessel diameter and potentially high recurrence rate after coiling given the bifurcation location. Y-configuration stent-assisted coil embolization techniques have been reported for the treatment of wide-neck aneurysms located at other vascular bifurcations and only rarely with A2 bifurcation aneurysms. Methods A neurointerventional database was reviewed for identification of all cases of A2 bifurcation aneurysms that were treated with Y-stent configuration. The authors report clinical, technical and outcome data on four patients with pericallosal aneurysms who were treated with a Y-configuration stent-assisted coil embolization technique. Results A Y-configuration stent placement in the anterior cerebral artery/A2 bifurcation was successfully achieved in all four patients without significant technical difficulties. One patient presented with a previously ruptured and partially treated aneurysm and three patients with incidentally found aneurysms. All four patients had a Y-configuration stent placement in one setting. The Y-configuration allowed for complete occlusion of all four aneurysms with no recurrence or arterial occlusion on mean angiographic follow-up of 13.5 months (6–28). Conclusion Treating wide-neck pericallosal artery aneurysms at the bifurcation with Y-configuration stent placement is feasible and effective. This technique may be considered as a therapeutic option for wide-neck aneurysms that pose a difficult technical challenge.

BACKGROUND One method used to treat atherosclerotic carotid disease is carotid artery stenting (CAS). A rarely encountered limitation of this technique is stent migration. Here, we present a rare case of carotid stent downward migration found on follow-up imaging 8 months post operation. METHOD/RESULT A 70-year-old man presented with aphasia and right-sided weakness secondary to high-grade (99%) proximal left internal carotid artery (ICA) stenosis that was treated with CAS. Stent apposition distally was achieved as well as proximally at the carotid bulb without crossing the bifurcation and without going distally beyond the ICA angulation to avoid kinking. Eight months follow-up computerized axial angiogram showed downward migration of the stent into the common carotid with restenosis distal to the stent. A 6—8 × 40 mm stent was deployed and the stenosed area restented with good results to overlap with the older stent and landed distal to the ICA angulation. CONCLUSION Interventionalists should be aware of the rare possibility of migrating downward “watermelon-seeding” of carotid stents. This report may generate the hypothesis that the stent watermelon-seeding effect may be related to proximal placement of a short stent below the ICA angulation and at the carotid bulb in severely stenotic lesion. J Neuroimaging 2011;21:395-398.

Background and purpose Limited data exist to guide patient selection for preventive treatment of unruptured cerebral aneurysms. Cerebral aneurysms have been associated with circle of Willis anomalies but whether this association is also related to aneurysm rupture is not known. The occurrence of cerebral aneurysm rupture when a circle of Willis anomaly was present or absent was compared. Methods Patients admitted over a 2 year period with a diagnosis of a cerebral aneurysm and an anterior communicating artery (ACoA) or posterior communicating artery (PCoA) aneurysm were included in the analysis. Brain vascular imaging was reviewed for aneurysm size, morphology and presence of circle of Willis anomaly. Relevant medical history and demographics were obtained from the medical records. Results Of the 113 patients with ACoA or PCoA aneurysms, 85 (75.2%) cases were ruptured. There were 49 (43.4%) PCoA aneurysms and 64 (56.6%) ACoA aneurysms. Mean aneurysm size was 5.65 mm (SD 3.31). A circle of Willis anomaly was identified in 46 (40.7%) of all patients. Circle of Willis anomalies were present in 38 (46.9%) ruptured aneurysm cases and eight (29.6%) unruptured aneurysm cases. Multivariate analysis revealed a higher risk of aneurysm rupture when a circle of Willis anomaly was present (p=0.0245, OR 3.72 (CI 1.18 to 11.66)). Conclusions This series shows that circle of Willis anomalies are more commonly found in ruptured as opposed to unruptured cerebral aneurysms of the anterior and posterior communicating arteries. The presence of a circle of Willis anomaly may be an important characteristic for selecting patients for preventive aneurysm treatment.

Antithrombotic therapy plays a key role in secondary ischemic stroke prevention. A multitude of antithrombotic agents exist with varying pharmacologic, efficacy, and safety profiles. In this review, the authors discuss the mechanisms of antithrombotic therapy, summarize the data on commonly used agents, and introduce emerging antithrombotic medications.

Background: Induced hypothermia is a promising neuroprotective treatment for acute ischemic stroke. Data from both global and focal ischemia animal models have been encouraging. However, only a few small clinical studies have investigated its use in humans. Objective: To review the background, possible mechanisms of action, and the preclinical and clinical data supporting the neuroprotective role of induced hypothermia following acute ischemic stroke. Methods: A literature search was performed using the PubMed database. Only papers in English were reviewed. Results/conclusions: Induced hypothermia is effective as a neuroprotectant in animal models of acute ischemic stroke. Its multimodal mechanism of action makes it a very attractive method of neuroprotection. Although human studies suggest it is safe and feasible, larger randomized controlled trials are necessary to address clinical efficacy and to refine the methods and parameters of induced hypothermia protocols.

Devic’s disease is often considered as a variant of multiple sclerosis (MS). However, evidence suggests that Devic’s disease may be distinct from MS. Devic’s disease can coexist with connective tissue diseases, particularly Sjögren’s disease, but this association is rare with MS. Diagnosis of Sjögren’s disease in patients with neurological symptoms is often difficult. During early stages of Sjögren’s disease, patients may not fulfill all criteria for Sjögren’s disease. A high percentage of patients with Sjögren’s disease have inflammatory infiltrates in minor salivary glands, and this may be a reliable indicator of early or subclinical disease. We show high prevalence (80%) of salivary gland inflammation in Devic’s disease and longitudinally extensive transverse myelitis (LETM). We diagnosed 16 patients with Devic’s disease, and 2 of these satisfied criteria for Sjögren’s disease as did 2 of 9 patients with LETM. Anti-SSA/B titers were infrequently elevated. Although most did not satisfy criteria for Sjögren’s disease. 9 of 12 Devic’s disease patients and 7 of 8 LETM patients had severe salivary gland inflammation. Thus: (1) patients with Devic’s disease or with LETM who have positive labial biopsies but do not satisfy criteria for Sjögren’s disease could have subclinical Sjögren’s diseases. Alternatively, (2) as patients with Devic’s disease have elevated titers of several autoantibodies, so there may exist a set of antibodies that react with antigens in minor salivary glands and cause inflammation. Minor salivary gland biopsy is more sensitive than anti-SSA/B serology in providing histological evidence for possible Sjögren’s disease with CNS lesions.

Arteriovenous malformations of the brain can carry considerable morbidity and mortality in the setting of rupture. The complex angioarchitecture and hemodynamic alteration requires careful consideration in diagnostic and management approaches. In this review, the authors define the pathophysiology, outline diagnostic methods, and highlight current management approaches.

Background Carotid artery dissection is an important cause of stroke in young patients. Selection criteria for endovascular repair have not been well defined and limited data exist on long-term outcomes of stent reconstruction. Objective To report the immediate and long-term clinical and radiographic outcomes of patients treated with stent placement for progressively worsening symptomatic carotid arterial dissection despite antithrombotic therapy. Methods A single institution neuro-endovascular database was accessed to identify consecutive cases in which carotid artery dissection was treated with endovascular repair between 2006 and 2012. Clinical, demographic, radiographic, and procedural data were obtained through chart review. Results A total of 22 patients were identified and included 27 carotid artery dissection repairs with stent implantation. The mean age was 43 years (±8.7) with 13 patients being women. Traumatic dissections were seen in 9 (40.9%) patients and spontaneous dissections in 13 (59.1%) patients. All patients were symptomatic and were started on antithrombotic therapy on diagnosis. Most common indications for treatment included recurrent ischemia despite antithrombotic therapy in 15 (55.5%) arteries and enlarging dissecting aneurysm in 4 (14.8%) arteries. Mean degree of stenosis was 79.1%. Mean number of stents used was 1.88 (range 1–4). There was 1 (4.5%) asymptomatic peri-procedural thromboembolic event. Median clinical follow-up was 14 months (range 3–40) and median imaging follow-up was 14 months (range 3–38). There was 1 (4.5%) case of recurrent transient ischemic attack. There was no death, significant restenosis or stroke in the territory of the treated vessel during the duration of the follow-up. Conclusions Endovascular stent reconstruction for the treatment of selected patients with progressively worsening carotid dissection despite medical management is feasible with acceptable immediate and long-term clinical and radiographic outcomes. To be able to draw more robust conclusions, further evaluation with larger number of patients and longer follow-up is needed.

Outcomes from endovascular therapy for acute stroke are time dependent. Delays in the administration of this therapy have not been extensively studied and no performance benchmarks have been established. There are limited data on the complex factors that can affect these delays. In this review, we discuss the existing literature on the delays involved in endovascular therapy and have presented them as prehospital and inhospital factors. Some of these factors are common to intravenous thrombolysis; in addition, there are some that are unique to endovascular therapy. These include the awareness of the first responders, emergency medical services, interhospital transfer and triage systems, activation of the endovascular team, complex imaging decisions, and intraprocedural delays. A thorough understanding of these delays can help identify areas of improvement which may affect clinical outcomes.

Introduction Aneurysmal subarachnoid hemorrhage (SAH) is a rare but devastating form of stroke. Endovascular therapy has been criticized for its higher rate of recanalization and retreatment. The safety and predictors of retreatment are unknown. We report the clinical outcomes, imaging outcomes and predictors for aneurysm retreatment after initial endovascular embolization. Method We identified patients who underwent endovascular retreatment from July 2005 through November 2011. Aneurysm and patient data were collected. Periprocedural complications were reported as intraoperative perforation (IOP) or thromboembolic event (TEE). Aneurysm and patient characteristics were compared between aneurysms requiring retreatment and those not requiring retreatment to evaluate aneurysm retreatment predictors. Results A total of 111/871 (13%) aneurysms underwent retreatment. Two (0.2%) were retreated for recurrent acute SAH, 82 (74%) aneurysms were located in the anterior circulation, 47 (42%) required stent and 5 (5%) required balloon assist during retreatment. There were a total of 5 (5%) IOP and 6 (5%) TEE from which 2 (2%) and 1 (1%) were symptomatic, respectively. Overall symptomatic events rate were 2.7%. Patients were followed up for an average of 15±14 months. Seven (0.8%) aneurysms required a second retreatment without any recurrent SAH. Multivariable analysis revealed an OR for aneurysms requiring retreatment of 2.965 for aneurysms presenting as aneurysmal SAH, 1.791 for aneurysms in the posterior circulation and 1.053 for aneurysms with large dome size. Conclusions Aneurysm retreatment is a safe option without a significant increase in morbidity or mortality. SAH, posterior circulation aneurysms and larger aneurysm dome size are predictors of aneurysms requiring retreatment.

Background: Wide-neck bifurcation cerebral aneurysms pose technical challenges in endovascular therapy. Intersecting stents are used with increasing frequency. Periprocedural, clinical, and mid-term angiographic outcomes of this approach are not well known. We report clinical and angiographic outcomes in our use of the X- and Y-configuration techniques. Methods: We reviewed a retrospectively collected database to identify all aneurysm cases in which an X- or Y-configuration stent technique was used. Demographic, periprocedural and mid-term clinical and imaging data were collected. Outcomes included rate of thromboembolic events (TEE), intraoperative perforations (IOP), mortality, aneurysm residual at the time of the procedure and recurrence observed at follow-up. Results: Among 807 cerebral aneurysms, we identified 52 aneurysms in 50 patients treated with X- or Y-configuration stent implantation. Mean age was 58 years (SD = 10) with 34 (65%) women. Aneurysm locations were basilar artery (n = 20), MCA (n = 13), ACA (n = 16), and ICA (n = 3). Mean aneurysm maximum diameter was 7.0 mm (SD 2.9) and the mean neck size was 4.5 mm (SD = 1.7). Fifty cases (96%) involved “Y” configuration, and two cases (4%) used an “X” configuration. Aneurysm catheterization technique was trans-stent in all cases (vs jailing). Interstices catheterization required a wire or catheter change in 13 (25%) cases. Immediate results revealed complete occlusion in 45 (86.5%), residual aneurysm in 3 (5.7%), and residual neck in 4 (7.7%). There were no mortalities, and 7 (13.5%) TEEs, of which 2 (4%) were symptomatic. There were 2 (4%) asymptomatic IOPs. Imaging follow-up was available for 40 (77%) cases, with mean interval from index procedure of 5.7 months. This mid-term outcome showed complete obliteration in 28 (70%) cases, residual neck in 8 (20%), and residual aneurysm in 4 (10%). Conclusions: These results suggest that placement of intersecting stents in X- and Y-configurations for coil embolization of wide-neck bifurcation cerebral aneurysms is feasible and can be performed with acceptable procedural safety and good rates of aneurysm occlusion.

Introduction: In the Solitaire With the Intention For Thrombectomy (SWIFT) trial, rescue therapy was used when the Solitaire or Merci device was unable to restore vessel patency. Markers for non-recanalization in acute stroke have been reported for IV tPA, however similar predictors are not known for endovascular therapy. We sought to identify predictors and outcomes associated with rescue therapy in the SWIFT trial. Methods: Rescue therapy was defined per SWIFT study protocol, and included the use of an alternative device, agent, or maneuver following failure to recanalize with 3 retrieval attempts using the initial device. Clinical, angiographic, and demographic data was reviewed. Statistical analysis was performed using t-test or Wilcoxon methods and multivariate logistic regression analyses. Results: Among a total of 144 patients enrolled (31 roll-in phase Solitaire patients, and 113 randomized patients, 58 Solitaire, 55 Merci), 43 (29.9%) required rescue therapy. Baseline demographics for patients with and without rescue therapy were no different. Rescue therapy was used in a higher percentage of patients randomized to Merci than Solitaire (43% vs 21%, p = 0.009). Patients with rescue therapy experienced longer time to recanalization (p < 0.001), a lower percentage of successful recanalization (p < 0.001), and a lower percentage of good outcome (p = 0.009). In multivariate analysis, predictors of rescue therapy were those patients randomized to the Merci group (OR 3.99, 95% CI 1.58, 10.10) and patients over age 80 years (OR 3.51, 95% CI 1.06, 11.64). Non-significant trends toward an increased need for rescue therapy were observed in patients with hypertension (p = 0.09), and occlusions of the carotid terminus and M1 MCA compared with other locations (p = 0.10). No association was observed with rescue therapy and afib (p = 0.47) or IV tPA failure (p = 0.49), and rescue therapy was not associated with symptomatic ICH (p = 0.43). Conclusions: Predictors of rescue therapy included Merci treatment group and age, while trend toward an increased need of rescue therapy was observed with hypertension and proximal clot location. Rescue therapy was associated with fewer good outcomes. These findings may reflect targets for improvement in endovascular therapy.

Methods: We retrospectively reviewed clinical data on patients admitted at a single institution for possible stroke between 2004 and 2007, and selected subjects who underwent angiography of the neck. We classified subjects as having vertebral artery origin stenosis (VAOS) by ‘moderate’ to ‘severe’ (≥50%) occlusion. Age, sex, and race-matched control subjects were selected from our study population as having no evidence of VAOS on angiography. Long-term follow-up data was collected and death certificates were searched for comparison among cases and controls. A Kaplan-Meier curve was plotted based on time to event (stroke or death). Results: The proportion of subjects that were found to have VAOS was 58 per 358 cases, or 16.2%. Four subjects were excluded because of stenting, so a total of 54 cases and 54 matched controls were included for long-term follow-up analysis. In our study population, we calculated the relative risk of having a stroke or dying in patients with VAOS to be 6.0 times that of patients without VAOS ( p p Conclusions: Patients with vertebral artery origin stenosis are at a significantly higher risk of having a stroke or dying. Subsequent prospective, multicenter studies are needed to validate our results.

The effect of oversized intracranial stent implantation, and potential excessive neointimal hyperplasia from the chronic outward radial force, has not been reported. We sought to compare the angiographic narrowing associated with implantation of oversized stents.We reviewed an aneurysm database and identified patients treated with stent-assisted embolization involving a vessel size transition. Demographics and lesion characteristics were extracted. The relationship between lumen diameter and stent oversizing was compared.Twenty vessels were identified in 18 patients, providing 80 paired data points. Mean follow-up time was 8 months (SD 6). The average oversizing in the smaller diameter parent vessel landing-zone was 1.75 mm. Mean change in lumen size from pre-stent implantation was not significantly different for any of the four sites. There was a significant difference in change of lumen size at the stent tines when compared with the respective mid-stent segment for both the proximal (P = 0.02) and distal (P = 0.0004) landing zones.A small significant lumen loss occurs at stent tines when compared to midstent struts. However, there is no overall significant stenosis from highly oversized stents. Persistent luminal gain from the oversized stent radial force likely predominates over any neointimal hyperplasia.

Guidelines have been established for the management of acute ischemic stroke; however, specific recommendations for endovascular revascularization therapy are lacking. Burgeoning investigation of endovascular revascularization therapies for acute ischemic stroke, rapid device development, and a diverse training background of the providers performing the procedures underscore the need for practice recommendations. This review provides a concise summary of the Society of Vascular and Interventional Neurology endovascular acute ischemic stroke roundtable meeting. This document was developed to review current clinical efficacy of pharmacologic and mechanical revascularization therapy, selection criteria, periprocedure management, and endovascular time metrics and to highlight current practice patterns. It therefore provides an outline for the future development of multisociety guidelines and recommendations to improve patient selection, procedural management, and organizational strategies for revascularization therapies in acute ischemic stroke.

Endovascular revascularization therapy is a promising method for treating patients with AIS; however, many challenges remain. The findings from the SVIN roundtable meeting highlight several important points regarding the present state of endovascular therapy and the future direction of the field. Patient selection is essential for the success of endovascular therapy in acute stroke.1 The spectrum of dramatic benefit and failure in endovascular therapy for AIS underscores the importance of identifying markers for those who will be helped and those who will be harmed. Simple rapid imaging such as noncontrast head CT remains fundamental to patient evaluation. However, further study is needed in advanced imaging such as perfusion studies, in order to liberate stroke triage from the constraint of time and reach more patients.2 Furthermore, the triage system for stroke networks, requirements of providing institutions, and guidelines for those trained in neurointerventional procedures need to be better defined.3,4 Stroke intervention techniques vary among neurointerventionalists, which emphasizes the need to identify the optimal revascularization approach. This might include a single or multimodal use of mechanical devices, thrombolytic agents and doses, and adjunctive therapies. Perioperative management also varies, and not all factors that might change outcome are known. The variability in triaging patients, in the neurointerventional technical approach, and in periprocedural management is an indication of the urgent need for consensus, standardization, and additional research to provide evidence to support particular approaches for particular patient populations. The armamentarium available to neurointerventionalists continues to expand, but the optimal design for a revascularization device remains unknown and demands continued innovation. As the young field of endovascular revascularization therapy continues to evolve and patient selection is better defined, education of health care providers and awareness among those in the community will become essential to carry the success of endovascular therapy in the battle against AIS. In these interesting polling questions, participants of the SVIN roundtable meeting addressed each aspect of the care of patients with ischemic stroke as it pertains to endovascular therapy, and their answers may be of interest to readers, policymakers, and researchers alike. However, because of space limitations, only certain polling questions and responses were included in this report, which may limit the ability to understand the full complexity of the system of care for AIS. Moreover, some new areas of clinical care and research may not have been addressed by the polling questions or the roundtable topics. A clinical continuum network of care with a spokes-and-hub model (whether ship-and-drip or retrieve-and-ship to a tertiary stroke center) and research network needs were not brought up in this polling report. We would like to underscore that the current polling report reflects the opinions of the attendees of the SVIN roundtable but is limited in lacking supportive data and sampling errors. Polling different attendees might have produced different responses.

BACKGROUND: Idiopathic intracranial hypertension (IIH) remains a poorly understood and therapeutically challenging disease. Enthusiasm has emerged for endovascular therapy with stent reconstruction of dural sinus narrowing; however, a complete understanding of the hydrodynamic dysequilibrium is lacking. OBJECTIVE: To review and characterize catheter manometry findings including pulsatility changes within the venous sinuses in IIH. METHODS: Cases of venous sinus stent implantation for IIH were retrospectively reviewed. RESULTS: Three cases of venous sinus stent implantation for treatment of IIH are reported. All cases demonstrated severe narrowing (.70%) within the transverse sinus and a high pressure gradient across the lesion (.30 mm Hg). Stent implantation resulted in pulsatility attenuation, correction of pressure gradient, and improvement of flow. CONCLUSION: We report the finding of high venous sinus pulsatility attenuation after stent implantation for dural sinus narrowing and propose the hypothesis that this finding is a marker of advanced dural sinus incompetence. This characteristic may be useful in identifying patients who would benefit from endovascular stent remodeling.

In the wake of the Interventional Management of Stroke (IMS) III independent data safety monitoring board's recommendation on 18 April 2012 to place the IMS III trial on hold due to prespecified planned interim analysis showing the very low likelihood of finding a significant difference between the two treatment arms, one might properly wonder, “What is next”? Restoration of blood flow after acute ischemic stroke (AIS) is associated with improved outcome and reduced mortality.1 2 Death and disability from AIS remains staggering despite the approval of intravenous thrombolysis with tissue plasminogen activator (IV-rtPA) over 15 years ago. The small population that benefits from IV-rtPA is, in part, limited to those patients treated within a narrow time window. Although cerebrovascular imaging is not consistently performed prior to administration of IV-rTPA, there is some evidence that the infusion is most effective in those patients who have small or distal vessel occlusions.3 The likelihood of recanalization with IV-rtPA declines considerably in occlusions of larger vessels such as the proximal middle cerebral artery and terminal internal carotid artery,3 and underscores the need for good AIS revascularization therapy (RT). The IMS I trial suggested that combination therapy with IV-rtPA and an intra-arterial (IA) approach was safe and may be clinically useful in AIS treatment.4 This was further supported by the IMS II trial, a single-arm pilot study showing preliminary estimates of efficacy and safety of combination IV and IA therapy.5 The IMS III trial subsequently became the pioneering phase III randomized multicenter open-label clinical trial that was designed to assess if the combined IV-rtPA and IA approach is superior to IV rt-PA alone when initiated within 3 h of AIS onset (http://clinicaltrials.gov/ct2/show/NCT00359424).6 The randomization scheme was to enrol two-thirds in the combined arm and one-third in the IV-rtPA alone arm. …

Pharmacologic and mechanical endovascular acute ischemic stroke therapy aims to recanalize occluded cerebral vessels to achieve improved clinical outcome. Several limitations to achieving this goal have been identified; one of the least discussed challenges in the literature is reocclusion. The intraprocedure and periprocedural roles of anticoagulation and antiplatelet agents in preventing reocclusion are unclear. In this review, the role of antiplatelet and anticoagulation agents as an adjunctive to acute ischemic stroke endovascular revascularization therapy is discussed.

Introduction: Aneurysmal subarachnoid hemorrhage (SAH) is a rare but devastating form of stroke. Currently surgical clipping and endovascular embolization are the two therapeutic options for treatment of intracerebral aneurysm. The reported complication rate associated with the initial endovascular treatment is about 2-40%. However, outcome and complications after target aneurysmal retreatment (TAR) is unknown. Our objective is to report clinical and imaging outcomes for TAR. Design/Methods: We identified patients who underwent TAR from a hospital neurointerventional database. We collected data on demographics, peri-procedural complications, clinical and imaging outcomes at the discharge and last follow-up. Peri-procedural complications were reported as intra operative perforation (IOP), thromboembolic event (TEE), both were considered symptomatic if patient develop new neurological deficit lasting for increase in NIHSS . Length of hospital stay, modified Ranking Scale (mRS), discharge disposition, recurrent SAH, re-treatment of the same aneurysm, and mortality were measured at discharge and follow up appointments. Complete data was available for 115/155 (74%) cases. Results: There were total of 155/1169 (13.3%) cases underwent TAR with mean age of 55 ( 3), 98 (63%) were females, and 118 (76%) were Caucasians. One hundred four (67%), had aneurysm located in the anterior circulation, 4/116 (3%) underwent TAR for recurrent acute SAH, 72/116 (62%) required stent and 10/116 (9%) required balloon assist. There were total of 5/115 (4%) IOP, and 8/115 (7%) TEE from which 2/115 (2%), and 1/115 (1%) were symptomatic respectively for a total of 3/115 (2.6%) patients. 117/151 (77%) had complete immediate obliteration of the aneurysm after TAR. Ninety five patients (83%) had mean length of hospital stay with 143/151 (95%) patients discharged home. At discharge 99/114 (87%) patients, had mRS with 0% mortality. Total of 90/155 (58%) patients had average follow up of 14 months with 8/90 (9%) requiring a 2 nd TAR and 1/90 (1%) requiring 3 rd TAR for recanalization. There was no re-rupture after the 1 st TAR for the duration of follow-up period of 14 ( in total of 90 patients). Conclusions: In our study the rate of symptomatic events following TAR after initial endovascular therapy is 3/115 (2.6%) with 77% obliteration rate and 0% re-repture rate. TAR after an initial endovascular treatment is safe with an acceptable rate of complications and may be effective, suggested by lower rate of re-rupture.