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Minimally invasive surgery (MIS) for intracranial pathology minimizes surgical morbidity but can come at the cost of operator ergonomics and technical surgical success. Here, the authors present a case series to report the first use of a novel 15-mm tubular retraction system with integrated lighting and visualization capabilities for MIS access to intracranial lesions.To demonstrate feasibility and effectiveness of the 15-mm Aurora Surgiscope (Integra Lifesciences) for intracranial MIS approaches.The 15-mm Aurora Surgiscope facilitated MIS approach to gain access to intraparenchymal pathologies. The device consists of a tubular access system with integrated light source and a reusable control unit that modifies video parameters. The port was inserted along a preplanned trajectory through a mini-craniotomy. Bimanual access allowed the surgeon to comfortably dissect/resect lesional tissue using high-quality video.Four patients are presented. In cases 1 and 2, the authors evacuated acute intracerebral hemorrhages. Both had15 cc hemorrhage with improved or stable neurological examination. In case 3, the authors performed gross total resection of a cerebellar pilocytic astrocytoma. In case 4, the authors resected a mesial posterior temporal cavernoma. No perioperative/technical complications were noted.The Aurora Surgiscope system is a novel integrated tubular retraction, lighting, and visualization system that allows access to a wide variety of pathologies using a MIS approach. The Surgiscope allows the surgeon to use bimanual dexterity through a small access port while limiting the need for additional equipment such as microscope, exoscope, or endoscope.

BackgroundThe Surpass flow diverter was developed to treat intracranial aneurysms not amenable to standard treatment. Indications for use allow placement in the internal carotid artery to the terminus, including the communicating artery segment.MethodsThe Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms (SCENT) trial is an international, multicenter, prospective, non-randomized trial comparing the outcomes of Surpass flow diverter treatment with historic control designed to evaluate the effectiveness and safety of Surpass for the treatment of wide neck (≥4 mm) large or giant intracranial aneurysms ≥10 mm. The primary effectiveness endpoint is the percentage of subjects with 100% aneurysm occlusion without significant stenosis of the parent artery and without retreatment of the target aneurysm at 12 months. The primary safety endpoint is the percentage of subjects experiencing neurologic death or major ipsilateral stroke at 12 months. We report the effectiveness and safety of flow diversion in the subgroup of posterior communicating artery (PComA) aneurysms.ResultsOf the 180 patients treated, 38 harbored a PComA aneurysm. Mean aneurysm size was 12.2 mm and mean neck width was 4.8 mm. The mean number of Surpass devices used was 1.1 per procedure, with 94.7% of aneurysms treated with one flow diverter. The 12 month primary effectiveness rate was 73.7% (28/38). At 36 months, 68.4% (26/38) of aneurysms remained completely occluded. The 12 month major ipsilateral stroke or neurological death rate was 10.5%. No patients with PComA occlusion after flow diverter placement (54.5%) had clinical sequelae.ConclusionsSCENT demonstrated acceptable 12 month effectiveness of flow diversion in PComA aneurysms. Despite associated PComA occlusions in many cases, arterial occlusions were clinically silent.Trial registration numberURL: https://www.clinicaltrials.gov. Unique identifier: NCT01716117.

Background: Leakage is the number one concern for people with an ostomy. The 2019 Ostomy Life Study, a global study of more than 5000 ostomates, showed that 92% of people living with a stoma worry about leakage. Getting the right stoma appliance for each patient is key to increasing patient quality of life. Aim: The study was designed to assess the use of the Peristomal Body Profile Assessment Tool in helping choose the most appropriate stoma products for a given patient, decreasing incidents of leakage and peristomal skin complications. Methods: A multi-centre (33 sites, 147 patients) low-interventional clinical investigation was conducted in which the use of the Peristomal Body Profile Assessment Tool was evaluated as a tool to reduce incidents of leakage, increase peristomal skin health and increase patient quality of life. A focus group of randomised participating clinicians (n=16) was held to explore the audit results. Results: The assessment tool most often took between 2 and 5 minutes to complete. It supported clinicians in selecting the right appliance for each patient, avoiding leakages and preventing associated peristomal skin complications. The assessment tool helped improve the accuracy and quality of documentation in the patients' medical/nursing notes, increasing the quality and continuity of care. Participants reported that using the assessment tool helped reduce care costs by reducing the need for product changes, supporting product usage and return patient visits. Conclusion: Use of the Peristomal Body Profile Assessment Tool helped clinicians choose the most appropriate stoma appliance the first time, resulting in patients having healthier peristomal skin, fewer leakages, more confidence in their stoma appliance and a higher quality of life.

BACKGROUND Catheter-based endovascular neurointerventions require deep neuromuscular blocks during the procedure and rapid subsequent recovery of strength to facilitate neurological evaluation. We tested the primary hypothesis that sugammadex reverses deep neuromuscular blocks faster than neostigmine reverses moderate neuromuscular blocks. METHODS Patients having catheter-based cerebral neurointerventional procedures were randomized to: (1) deep rocuronium neuromuscular block with posttetanic count 1 to 2 and 4-mg/kg sugammadex as the reversal agent or (2) moderate rocuronium neuromuscular block with train-of-four (TOF) count 1 during the procedure and neuromuscular reversal with 0.07-mg/kg neostigmine to a maximum of 5 mg. Recovery of diaphragmatic function was assessed by ultrasound at baseline before the procedure and 90 minutes thereafter. The primary outcome-time to reach a TOF ratio ≥0.9 after administration of the designated reversal agent-was analyzed with a log-rank test. Secondary outcomes included time to successful tracheal extubation and the difference between postoperative and preoperative diaphragmatic contraction speed and distance. RESULTS Thirty-five patients were randomized to sugammadex and 33 to neostigmine. Baseline characteristics and surgical factors were well balanced. The median time to reach TOF ratio ≥0.9 was 3 minutes (95% confidence interval [CI], 2-3 minutes) in patients given sugammadex versus 8 minutes (95% CI, 6-10 minutes) in patients given neostigmine. Sugammadex was significantly faster by a median of 5 minutes (95% CI, 3-6 minutes; P < .001). However, times to tracheal extubation and diaphragmatic function at 90 minutes did not differ significantly. CONCLUSIONS Sugammadex reversed deep rocuronium neuromuscular blocks considerably faster than neostigmine reversed moderate neuromuscular blocks. However, times to extubation did not differ significantly, apparently because extubation was largely determined by the time required for awaking from general anesthesia and because clinicians were willing to extubate before full neuromuscular recovery. Sugammadex may nonetheless be preferable to procedures that require a deep neuromuscular block and rapid recovery.

OBJECTIVE Woven EndoBridge (WEB) intrasaccular flow disruptors and stent-assisted coiling (SAC) are viable endovascular treatment options for wide-neck bifurcation intracranial aneurysms (WNBAs). Data directly comparing these two treatment options are limited. The authors aimed to compare radiographic occlusion rates and complication profiles between patients who received WEB and those who received SAC for WNBAs. METHODS Retrospective review of a prospectively maintained cerebrovascular procedural database was performed at a single academic medical center between 2017 and 2021. Patients were included if they underwent WEB embolization or SAC of an unruptured WNBA. SAC patients were propensity matched to WEB-embolized patients on the basis of aneurysm morphology. Complete and adequate (complete occlusion or residual neck remnant) occlusion rates at last angiographic follow-up, as well as periprocedural complications, were compared between the two groups. A cost comparison was performed for a typical 5-mm WNBA treated with WEB versus SAC by using manufacturer-suggested retail prices. RESULTS Thirty-five WEB and 70 SAC patients were included. Aneurysm width, neck size, and dome-to-neck ratio were comparable between groups. Follow-up duration was significantly longer in the SAC group (median [interquartile range] 545 [202–834] days vs 228 [177–494] days, p < 0.001, Mann-Whitney U-test). Complete (66% of WEB patients vs 69% of SAC patients) and adequate (94% WEB vs 91% SAC) occlusion rates were similar between groups at the last available angiographic follow-up (p = 0.744, chi-square test). Complete occlusion rates were comparable on Cox regression analysis after correction for follow-up duration (hazard ratio 1.5, 95% CI 0.8–3.1). Average time to residual aneurysm or neck formation was not statistically different between treatment groups (613 days for SAC patients vs 347 days for WEB patients, p = 0.225, log-rank test). Periprocedural complications trended higher in the SAC group (0% WEB vs 9% SAC, p = 0.175, Fisher exact test), although this finding was not significant. The equipment costs for a typical SAC case were estimated at $18,950, whereas the costs for a typical WEB device case were estimated at $18,630. CONCLUSIONS Midterm complete and adequate occlusion rates were similar between patients treated with WEB and those treated with SAC. Given these comparable outcomes, there may be equipoise in treatment options for WNBAs.

Flow diversion has revolutionized endovascular treatment for cerebral aneurysms. The Surpass Streamline flow diverter (SSFD) has shown promise for expanding flow diversion device options for aneurysm treatment. SSFD differs from earlier stents by maintaining high porosity with increased pore density to ensure appropriate flow disruption. Given the delivery system's increased dimension options and potential greater flow-diverting properties, SSFD is poised to extend the anatomic and pathologic reaches of flow diversion therapy.Data pertaining to SSFD-treated aneurysms were gathered retrospectively between 2019 and 2020, including aneurysm location, size, symptoms, complications, and occlusions rates at follow-up. Size was categorized as small (10 mm), large (10-25 mm), and giant (25 mm) according to SCENT (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms) criteria. Aneurysm occlusion on follow-up imaging was characterized by Simple Measurement of Aneurysm Residual after Treatment (SMART) grading with adequate occlusion defined as grades 3 and 4. Imaging was performed at time of treatment and 6-month and 1-year follow-up.There were 42 aneurysms treated with SSFD throughout the cerebrovascular system: 3 cervical, 4 posterior, and 35 intracranial anterior circulation. Complete occlusion rates at 6 months and 1 year were 48% and 57% with adequate occlusion achieved in 89.6% and 85.7%, respectively. Rates of complete occlusion were higher for small (69%) compared with large (38%) aneurysms.Our data suggest comparable complete occlusion rates compared with SCENT (66.1% vs. 57% in our center) and adequate occlusion rates. Similar occlusion rates to prior studies despite broadened inclusion criteria and diversity of treated aneurysms demonstrate favorable generalizability of flow-diverting technology to a wide array of aneurysmal pathology.

This meeting abstract was removed due to the OA licensing requirements of this journal. The full abstract is listed here : https://www.svin.org/files/SVIN_2021_Abstracts_for_Web.pdf

Background Intracerebral hemorrhage (ICH) is associated with a significant mortality of up to 50%, with almost all survivors suffering from debilitating functional compromise. In most cases, open craniotomy has failed to yield significant survival benefit. However, emerging evidence suggests that minimally invasive surgery (MIS) may yield clinically significant improvements in patient survival and quality of life in cases where open craniotomy has not shown benefit. Case presentation We report the first documented usage of a side-cutting-aspiration device via an endoscopic approach for the evacuation of a 56cc hematoma, which was a technical modification on previous MIS techniques. The patient is a 50-yr-old female who was transferred emergently to our center with a National Institutes of Health Stroke Scale score of 27 and found to have a large hematoma involving her left basal ganglia. A minimally-invasive approach was elected due to evidence on the risks and suboptimal outcomes of open craniotomy in ICH evacuation. Neuronavigation was used to plan the surgical trajectory for ICH access. Evacuation took place in three main steps: 1) beginning at the center of the clot to remove bulk; 2) mobilizing clots from parenchymal walls to a safe zone via aspiration, followed by clot homogenization; and 3) re-expansion of the cavity via continuous irrigation to allow visualization of further clots. A final inspection was performed to ensure removal of all clots that could be safely removed. The dual functionalities of the device, namely, suction only and suction plus side-cutting functions, enabled key maneuvers, such as clot homogenization and controlled aspiration strength, to be safely performed. A near-total evacuation of the hematoma was achieved without damage to surrounding parenchyma. The patient experienced a rapid clinical course from comatose to discharge-ready in 5 d. At 30-d follow-up, the patient had residual expressive aphasia and was able to ambulate with the assistance of a quad cane. There are no radiographical signs of recurrent hemorrhage or parenchymal injury. Clinical follow-up with this patient is ongoing. Conclusion This is the first ICH evacuation with a side-cutting-aspiration device via an endoscopic approach. In our patient, this technique proved to be safe and efficacious, suggesting that this technique may be a promising addition to the armamentarium of MIS for ICH evacuation.

BACKGROUND Prospective evidence to support mechanical thrombectomy (MT) for mild ischemic stroke with large vessel occlusion (LVO) is lacking. There is uncertainty about using an invasive procedure in patients with mild symptoms. OBJECTIVE To evaluate the safety and feasibility of MT in patients with mild symptoms and LVO. METHODS Our single-arm prospective pilot study recruited patients with LVO and initial National Institute of Health Stroke Scale (NIHSS)

IntroductionThe low-profile Neuroform Atlas stent received FDA Humanitarian Device Exemption status (HDE) in January 2018 for stent-assisted coil embolization of wide-necked saccular aneurysms. We review and report our results with the Atlas stent in our institution within the first year after its HDE approval.MethodsOur retrospective chart review identified patients treated with the Atlas stent. We analyzed the patient demographics, aneurysm characteristics, stent parameters and configuration, complications, angiographic, and clinical outcomes at discharge.ResultsFrom January to December 2018, 76 Atlas stents were deployed in 58 patients (average 1.3 stents/patient). Median patient age was 63.5 (IQR 56–71) years. Fifty-six (96.6%) patients had elective embolization of unruptured aneurysms, while two (3.4%) patients underwent embolization of a ruptured aneurysm within 2 weeks of subarachnoid hemorrhage. Forty (69.0%) patients were treated with a single stent, 15 (25.9%) with a Y-stent, and three (5.2%) with X-stent configuration. All stent deployments were technically successful. Most stents (82.9%) were the smallest 3 mm diameter devices. Procedural complications included transient stent-associated thrombosis in three (5.2%) patients and aneurysm rupture in one (1.7%). None had distal embolization, associated cerebral infarction, or permanent neurological deficits. Immediate Raymond–Roy 1 occlusion was achieved in 41 (70.7%) patients. Median hospital length of stay for elective aneurysm embolization was 1 day. Excellent outcomes with median National Institute of Health Stroke Scale score 0 (IQR 0–0) and modified Rankin Score 0 (IQR 0–1) were seen for elective patients at discharge.ConclusionThe Neuroform Atlas stent provided a reliable technical and safety profile for the treatment of intracranial wide-neck aneurysms. Further experience is needed to determine long-term durability and safety of this device.

BackgroundTo report the 3-year safety and effectiveness of the Surpass Streamline flow diverter in the SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms).MethodsThe Surpass Streamline flow diverter device was evaluated in a multicenter, prospective, single-arm, non-randomized interventional trial including patients with uncoilable or previously treated but failed aneurysms of the intracranial internal carotid artery. 3-year outcomes were tabulated with descriptive statistics and compared with 1-year outcomes.ResultsOf 180 patients in the modified intent-to-treat (mITT) cohort, 36-month clinical and angiographic follow-up was available in 134 and 117 cases, respectively. Effectiveness endpoint of complete aneurysm occlusion without clinically significant stenosis or retreatment was met in 71.8% (79/110, 95% CI 62.4% to 80.0%) of cases. Safety composite endpoint was 12.2% (22/180) over the 3-year period, with two major safety events (ipsilateral ischemic strokes) occurring between 12–36 months. Complete aneurysm occlusion was noted in 77.8% (91/117), and 99.1% (116/117) of the patients demonstrated adequate aneurysm occlusion (complete occlusion or neck residual). There were four cases (2.2%) of aneurysm rupture, all occurring within the first month of the index procedure. Target aneurysm retreatment rate was 2.8% (5/180).ConclusionThe present findings support the long-term safety and effectiveness of the Surpass Streamline flow diverter device.Trial registrationNCT01716117.

IntroductionSince the publication of the ARUBA trial, interventional management of cerebral arteriovenous malformations has become an area of debate. Treatment practices may have changed based on data from this recent trial which suggested that the risk of AVM treatment is greater than medical management in unruptured AVMs. To assess the ‘real world’ experience with interventional AVM outcomes, we compared outcomes of ARUBA eligible patients from the NVQI-QOD registry database to the ARUBA trial results.MethodsIn an IRB approved study, the NVQI-QOD AVM registry database was queried for treated patients between 2017 to present with the following inclusion criteria: age > 18 years, baseline mRS> 1, unruptured AVMs. 174/364 patients were ARUBA eligible and were included in the analysis. Patients were divided into embolization alone, microsurgery with or without embolization, and gamma knife radiation therapy with or without embolization. Primary outcomes of ischemic/hemorrhagic stroke or death were analyzed with a mean follow up time of 5.8 months (range 1 to 128 months).ResultsA total of 14 (8.0%) of patients that underwent any type of intervention suffered stroke or mortality. The risk of stroke or death was 6.8% (5 of 74) for microsurgery, 5.4% (2 of 37) for gamma knife, and 10.9% (7 of 64) for embolization alone. Annual stroke or death rates for all treatments were 7.5% (13 of 174) at one year and 0.57% (1 of 174) at 2 years.ConclusionARUBA eligible patients from the NVQI-QOD registry demonstrate a significantly lower risk of stroke or death with intervention of 8.0% (N=174) compared to the 30.7% (N=114) ARUBA trial interventional risk, and is nearly equivalent to the ARUBA trial medical management risk of 10.1% (N=109) over 33 months.DisclosuresN. Moore: 1;C;SNIS Joe Niekro Research Grant. R. Abdalla: None. T. Patterson: None. Y. Moazeni: None. P. Rasmussen: 2;C;Blockade Medical, Covidien/Medtronic, Stryker Neurovascular, Perflow Medical. 4;C;Perflow Medical. G. Toth: None. M. Bain: 2;C;Stryker Neurovascular. S. Ansari: None. S. Hussain: 2;C;Pulsar Inc.

Background Intracranial hemorrhage (ICH) results in devastating neurological injury as a result of both mass effect and the pro-inflammatory response to erythrolysis. Minimally invasive surgical techniques for hematoma evacuation are promising for improving functional outcome. The NICO BrainPath 13.5 mm tubular retractor system has been used as a minimally invasive approach to subcortical intracranial hemorrhages. Here we report the first ever use of the novel 11 mm BrainPath retractor system to evacuate a subcortical intracerebral hematoma. Case Description: 52 year-old man presented to our hospital with expanding left basal ganglia hemorrhage and declining neurological exam. The patient underwent minimally invasive NICO (Indianapolis, IN) BrainPath evacuation using an 11 mm tubular retractor system. Near total evacuation was successfully achieved. The patient did well postoperatively, with a favorable 90-day functional outcome. Conclusion In this case, using an 11 mm NICO (Indianapolis, IN) BrainPath system for basal ganglia ICH provided early, near-total hematoma evacuation and favorable functional outcome at 90-day check-in. Here, we demonstrate the technical feasibility of utilizing an 11 mm BrainPath tubular retractor instead of the traditional 13.5 mm system for evacuating ICH. It is the hope that the smaller 11 mm access port more closely matches endoscopic evacuation access techniques and could potentially mitigate the impact of a MIS approach on surrounding parenchyma while still achieving optimal evacuation.

Like all DNA viruses, human cytomegalovirus (HCMV) infection is known to result in profound effects on host cell cycle. Infection of fibroblasts with HCMV is known to induce an advance in cell cycle through the G(0)-G(1) phase and then a subsequent arrest of cell cycle in early S-phase, presumably resulting in a cellular environment optimum for high levels of viral DNA replication whilst precluding replication of cellular DNA. Although the exact mechanisms used to arrest cell cycle by HCMV are unclear, they likely involve a number of viral gene products and evidence points to the ability of the virus to prevent licensing of cellular DNA synthesis. One viral protein known to profoundly alter cell cycle is the viral immediate early 86 (IE86) protein--an established function of which is to initially drive cells into early S phase but then inhibit cellular DNA synthesis. Here we show that, although IE86 interacts with the cellular licensing factor Cdt1, it does not inhibit licensing of cellular origins. Instead, IE86-mediated inhibition of cellular DNA synthesis requires mini-chromosome-maintenance 3 (MCM3) associated protein (MCM3AP), which can cause subsequent inhibition of initiation of cellular DNA synthesis in a licensing-independent manner.

Mechanical thrombectomy has become standard of care for patients with ischemic strokes with large vessel occlusion (LVO). Fortunately, new device technology for mechanical thrombectomy and better selection methods have led to more effective treatment and better outcomes from this devastating condition. Patients with large clot burden (mega clots) or continuous thrombus reaccumulation are among the most difficult types of clots to treat in the setting of LVO, often resulting in unsuccessful recanalization and poor patient outcome. In this chapter, we seek to share methods of mega clot management found successful in our clinical practice.

As capabilities for endovascular treatment of intracranial vascular pathologies continue to expand, the need for access to the distal internal carotid artery with rigid support catheter systems continues to increase. One of the dominant factors limiting this access is patient anatomy, specifically vessel tortuosity. Increased tortuosity of the carotid siphon is a frequently encountered anatomic variant and may complicate endovascular procedures in adults and children.1,2 Failed attempts to navigate the carotid siphon with a distal access catheter carry a risk of vessel injury and treatment failure. For this reason, techniques that aid in supporting safe advancement of a distal access catheter across a tortuous carotid siphon are essential.3,4 In this video, we demonstrate 2 ways in which this may be accomplished. The first technique uses a larger diameter microcatheter, such as the AXS Offset catheter (Stryker, Kalamazoo, Michigan), to increase support for the distal access catheter, while the second uses a buddy wire technique to accomplish this increased support. Both of these techniques can help increase the safety of navigating a tortuous carotid siphon and increase the likelihood of successful treatment. The procedures shown were performed with the informed consent of the patients.

Introduction The Sofia Plus aspiration catheter (Microvention; Tustin, CA) is a recently introduced 0.070-inch inner diameter catheter designed to provide distal intracranial access and engage thrombus to facilitate thrombectomy for acute ischemic stroke. Methods This single-center retrospective study assessed technical outcomes of mechanical thrombectomy using the Sofia Plus aspiration catheter. Utilizing a prospective database of all acute stroke interventions at our institution, cases utilizing SOFIA Plus on the first pass were identified. Patient characteristics, procedural details, and radiographic outcomes were analyzed. Results Sofia Plus was utilized as a first pass aspiration catheter in 138 cases. Patients presented with a median NIHSS of 17 (IQR 10–22), ASPECT of 10 (IQR 8–10), and had target occlusions involving the ICA (n=30), M1 (n=73), M2 (n=22), or basilar artery (n=13). The aspiration catheter was used for first-pass direct aspiration alone in 86 patients (62%), and in conjunction with a stent retriever in 52 patients (38%). A recanalization grade of TICI 2b or better was achieved in 118 patients (86%), which was accomplished with a single pass in 88 (64%). Median time from groin puncture to recanalization was 44 minutes (IQR 30–68). Comparison of direct aspiration alone versus with stent retrievers demonstrated no difference in recanalization grade (p=0.64) or rates of first-pass recanalization (p=0.28), but direct aspiration was associated with faster recanalization (41 vs 53 minutes, p=0.02). There were two cases of vessel perforation (both involving stent retrievers), and two additional patients had symptomatic ICH on follow-up CT. Conclusions Our experience demonstrates that the SOFIA Plus aspiration can facilitate safe and effective revascularization for acute ischemic stroke, either using a direct aspiration technique or in conjunction with a stent-retriever. However, reperfusion was achieved faster with direct aspiration alone. Disclosures A. Witek: None. T. Patterson: None. L. Sheikhi: None. M. Bain: 2; C; Medtronic PLC, Stryker Corp. M. Hussain: 2; C; Johnson & Johnson. G. Toth: None.

Introduction Cerebral arteriovenous malformation (AVM) rupture risk is thought to be approximately 3% peryear, but varies with high risk anatomic features. Recent studies have raised the question about whether treatment is indicated for unruptured AVMs. The important decisions about treatment versus conservative management is largely based on a collection of outcome studies that may not match a patient’s particular AVM. The ultimate purpose of this research is to create a predictive computational model for a patient’s specific AVM anatomy to give them a lifetime risk of rupture profile. Our hypothesis is that the flow and pressure patterns within the nidus of the AVM can be determined by creating a 3D printed model of a simple AVM with internal imbedded pressure and flow sensors. This information can then be incorporated into a fluid structure interaction model of a simple arteriovenous malformation. Methods In an IRB approved study, unruptured Spetzler Martin Grade I and II AVMS were evaluated to select an AVM that demonstrated a relatively de-compact nidus and simple inflow and outflow vessels with cerebral angiography imaging with at least 4 frames/second anterior-posterior and lateral runs. This AVM was then processed in Matlab as well as manually segmented to create a 3D printing stereolithography file. The AVM was then printed in the Cleveland Clinic 3D printing laboratory with hollow lumens within the vessels and was fitted with inline flow probes within the inflow, outflow and nidus vessels and pressure transducers. This AVM was then inserted into a flow circuit connected to a cardiac cycle pump. The pump was then run with fluid that mirrors the viscosity of blood and cycled for 10 repetitions to verify stability of the pressure and flow readings at each 10 mmHg increment of output pressure between 100 mmHg to 260 mmHg. The model was then imaged in a cerebral angiography machine and connected to a pressure injector to compare transit time between the flow model and the previously obtained cerebral angiogram data from the patient. Results We successfully built and measured flow and pressure from a 3D printed replica of a simple brain AVM incorporated into a cardiac cycle fluid circuit. This data is currently being compared to cerebral angiography transit rates to validate the data and fit the projected flow and pressure measurements to clinically obtained data. The data additionally is being incorporated into inflow and outflow parameters in the ANSYS fluid structure interaction model of the same simple AVM to compare predicted pressure and flow through the simulation compared to the 3D printed AVM measurements. Conclusions We have made progress in the multistep task of building a fluid structure interaction model of a simple AVM by measuring flow rate and pressure measurements in an anatomically correct 3D printed model of a simple AVM. This data allows for more accurate simulation and for further evaluation of whether flow and pressure characteristics can be simplified for a compact AVM nidus with the goal of developing a predictive model of the natural history of AVM rupture. Disclosures N. Moore: 1; C; Joe Niekro/SNIS Research Grant. R. Klatte: None. A. Erdemir: None. T. Masaryk: None. N. Parkar: None. M. Bain: None. M. Hussain: None.

Supplemental Digital Content is available in the text., Background and Purpose: Stent-assisted coil embolization using the new generation Neuroform Atlas Stent System has shown promising safety and efficacy. The primary study results of the anterior circulation aneurysm cohort of the treatment of wide-neck, saccular, intracranial, aneurysms with the Neuroform Atlas Stent System (ATLAS trial [Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System]) are presented. Methods: ATLAS IDE trial (Investigational Device Exemption) is a prospective, multicenter, single-arm, open-label study of wide-neck (neck ≥4 mm or dome-to-neck ratio 50%) at the target location. The primary safety end point was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary end points was performed by an independent Imaging Core Laboratory and the Clinical Events Committee. Results: A total of 182 patients with wide-neck anterior circulation aneurysms at 25 US centers were enrolled. The mean age was 60.3±11.4 years, 73.1% (133/182) women, and 80.8% (147/182) white. Mean aneurysm size was 6.1±2.2 mm, mean neck width was 4.1±1.2 mm, and mean dome-to-neck ratio was 1.2±0.3. The most frequent aneurysm locations were the anterior communicating artery (64/182, 35.2%), internal carotid artery ophthalmic artery segment (29/182, 15.9%), and middle cerebral artery bifurcation (27/182, 14.8%). Stents were placed in the anticipated anatomic location in all patients. The study met both primary safety and efficacy end points. The composite primary efficacy end point of complete aneurysm occlusion (Raymond-Roy 1) without parent artery stenosis or aneurysm retreatment was achieved in 84.7% (95% CI, 78.6%–90.9%) of patients. Overall, 4.4% (8/182, 95% CI, 1.9%–8.5%) of patients experienced a primary safety end point of major ipsilateral stroke or neurological death. Conclusions: In the ATLAS IDE anterior circulation aneurysm cohort premarket approval study, the Neuroform Atlas stent with adjunctive coiling met the primary end points and demonstrated high rates of long-term complete aneurysm occlusion at 12 months, with 100% technical success and

Background Clinical trials of extracranial-intracranial (EC-IC) bypass surgery studied patients in subacute and chronic stage after ischemic event. Objective To investigate the short-term outcomes of EC-IC bypass in progressive acute ischemic stroke or recent transient ischemic attacks. Methods The study was a retrospective review at a single tertiary referral center from 2008 to 2015. Inclusion criteria consisted of EC-IC bypass within 1 yr of last ischemic symptoms ipsilateral to atherosclerotic occlusion of internal carotid or middle cerebral artery. Early bypass group who underwent surgery within 7 d of last ischemic symptoms were compared to late bypass group who underwent surgery >7 d from last ischemic symptom. The primary endpoint was perioperative ischemic or hemorrhagic stroke or intracranial hemorrhage within 7 d of surgery. Results Of 126 patients who underwent EC-IC bypass during the period, 81 patients met inclusion criteria, 69 (85%) persons had carotid artery occlusion, 7 (9%) had proximal MCA occlusion, and 5 (6%) had both. Early surgery had a 31% (9/29) perioperative stroke rate compared to 11.5% (6/52) of patients undergoing late bypass (P = .04). Of patients with acute stroke within 7 d of surgery, 41% (7/17) had perioperative stroke within 7 d (P = .07). Six of nine patients (67%) with blood pressure dependent fluctuation of neurologic symptoms had perioperative stroke (P = .049). Conclusion EC-IC bypass in setting of acute symptomatic stroke within 1 wk may confer higher risk of perioperative stroke. Patients undergoing expedited or urgent bypass for unstable or fluctuating stroke symptoms might be at highest risk for perioperative stroke.

Robert J. White is probably best known as the first neurosurgeon to perform successful "cephalic exchange" on monkeys in 1971. However, he was also a pioneer in the field of neurosurgery and contributed tremendously to the field of neuroanesthesia and bioethics. White received medical training at the University of Minnesota, Harvard University, Peter Bent Brigham Hospital, and Mayo Clinic before becoming the first Chief of Neurosurgery at Metrohealth Hospital in Cleveland, Ohio. He made significant strides in the field of spinal cord cooling and hypothermia. White and his team was also the first to successfully isolate the monkey brain with retention of biological activity. In 2004 and 2006, White and colleagues were nominated for the Nobel Prize in Physiology and Medicine, with Harvey Cushing and Wilder Penfield being the only other 2 neurosurgeons ever to be nominated for the award. Aside from his career as a neurosurgeon, he was also an advisor to 2 popes and an advocate for animal research. By the end of his career, White performed over 10 000 brain operations and published over 1000 articles, which has pushed the frontiers of neurosurgical research.

Acute carotid terminus occlusion (CTO) is responsible for up to 5% of acute ischemic strokes secondary to emergent large vessel occlusion (ELVO) and up to 20% of acute internal carotid artery (ICA) occlusions.1 The term "CTO" has also been used to describe occlusions in the supra-clinoid segment or at the bifurcation of the ICA. Compared to other ELVOs, patients with CTO present with higher stroke severity and larger infarct volume, likely to be a result of disruption of direct Circle of Willis collaterals across the anterior communicating artery (AComA) and posterior communicating artery (PComA).2,3 Similary, CTO is usually associated with worse prognosis compared to other ELVOs in general. With regard to response to treatment, previous studies have reported significantly lower recanalization rates with intravenous alteplase with CTO compared to M1 segment occlusion. With regard to the safety and efficacy of mechanical thrombectomy, prior reports provide conflicting results with some reporting lower successful recanalization rates with CTO compared to M1 occlusion, and others reporting similar results. In our experience, we have found that successful recanalization of CTO can be achieved with a similar approach to M1 occlusions utilizing a direct aspiration first pass technique (ADAPT).3,4 Herein, we present a case of CTO for which we performed mechanical thrombectomy using ADAPT. This procedure was an emergent standard of care procedure for which a consent was not required and so not obtained.

Background Anterior inferior cerebellar artery (AICA) aneurysms are rare lesions whose treatment can involve microsurgical and/or endovascular techniques. Such treatment can be challenging and may carry a significant risk of neurological morbidity. Objective To demonstrate a case involving a complex AICA aneurysm that was treated with a unique microsurgical approach involving trapping the aneurysm and performing in Situ bypass from the posterior inferior cerebellar artery (PICA) to the distal AICA. The nuances of AICA aneurysms and revascularization strategies are discussed. Methods The aneurysm and the distal segments of AICA and PICA were exposed with a retrosigmoid and far lateral approach. A side-to-side anastomosis was performed between the adjacent caudal loops of PICA and AICA. The AICA aneurysm was then treated by trapping the aneurysm-bearing segment of the parent vessel between 2 clips. Results A postoperative angiogram demonstrated a patent PICA-AICA bypass and complete occlusion of the AICA aneurysm. There were no complications, and the patient made an excellent recovery. Conclusion The combination of parent vessel sacrifice and bypass remains an excellent option for certain difficult-to-treat aneurysms. This case involving PICA-AICA bypass to treat an AICA aneurysm serves as an example of the neurosurgeon's ability to develop unique solutions that take advantage of individual anatomy.

Blood blister-like aneurysms (BBA) are small, friable, broad-based aneurysms that represent high risk for rerupture. Treatment of BBA is challenging, and may include surgical wrapping, clipping, multiple overlapping stents, and/or coiling. Flow diversion is a rapidly evolving treatment strategy for intracranial aneurysms, but the evidence for its use in cases of BBA is scarce. A retrospective review of flow-diverter-treated, ruptured BBA cases at our tertiary care institution was undertaken. Clinical, imaging, procedural, and mid-term follow-up data on the patients were collected. Eight patients underwent flow-diverter stent treatment for ruptured BBA. Median age at time of treatment was 49 years (interquartile range [IQR] 42–57) with five females (62.5%). The most common location of the BBA was the supraclinoid segment of the internal carotid artery. The median Hunt-Hess score was 2 (IQR 1.7–3.2). All patients were treated with dual anti-platelet therapy. Good clinical outcomes (modified Rankin score 0–2) were seen in 6/7 (85.7%) patients with available follow-up at 1 year. Complete occlusion of the aneurysm on latest angiogram (7) or MRI (1) was seen in 6/8 (75%) patients (at a median of 8 months). No patient had rerupture, retreatment, or recurrence of the aneurysm. Flow-diverter stents may be a feasible treatment option for BBAs. They offer high occlusion and low retreatment rates with good mid-term outcomes, but the long-term efficacy remains unknown. Also, dual anti-platelet therapy in the acute ruptured setting can be challenging.

Introduction Intracranial vertebral dissecting pseudoaneurysms are a rare, but increasingly recognized, cause of subarachnoid hemorrhage and ischemic stroke. The risks of aneurysm re-rupture and associated morbidity are high. The use of flow diverter stents for the treatment of these aneurysms has not been well studied. Objective To report our data and provide a summarized review of literature using flow diverter stents for the treatment of intracranial vertebral artery dissecting pseudoaneurysms. Methods We performed a retrospective analysis of flow diverter stents used for the treatment of intracranial vertebral artery dissecting pseudoaneurysms. Clinical, imaging, procedural, and follow-up data were collected. Results We identified eight vertebral dissecting pseudoaneurysms in seven patients (5 (71.4%) female; median age 47 years (IQR 46–52)) who had undergone treatment with flow diverter stents. In 4/7 patients (57.1%) the aneurysm had ruptured; however, only one was treated in the acute phase. Median size of the largest diameter of the aneurysm was 6.3 mm (IQR 4.2–8.8), and 7/8 aneurysms (87.5%) were treated with a single flow diverter device. Three aneurysms were concurrently coiled. Angiographic complete occlusion was seen in 6/8 (75%) aneurysms at a median follow-up of 14 months (IQR 7.7–20.2). Two patients had periprocedural strokes with transient neurologic deficits. All patients had a good clinical outcome (modified Rankin Scale score ≤2). There were no re-treatments or aneurysm ruptures during the follow-up period. Conclusions Our experience suggests that flow diverter stent treatment of intracranial vertebral artery dissecting pseudoaneurysms is safe, and associated with good occlusion rates and favorable clinical outcomes.

Introduction Reversible cerebral vasoconstriction syndrome (RCVS) can occur spontaneously or may be a secondary response. RCVS is rarely reported in literature following carotid revascularization and thought to be a possible result of chronic cerebral hypoperfusion with disturbance of cerebral autoregulation. There is no standard treatment for this condition. Here we report occurrence and management of cerebral vasoconstriction following unique combined neurosurgical and endovascular carotid revascularization for symptomatic carotid occlusion. Methods We review a patient’s clinical and imaging characteristics following carotid artery revascularization. Results A female patient in her 70 s with history of hypertension, controlled type 2 diabetes mellitus, and current smoker presented with recurrent episodes of transient left sided limb shaking. She was found to have a right internal carotid artery (ICA) occlusion at the cervical origin with a non-flow limiting 40% stenosis of the left ICA associated with an acute infarct in the right frontal white matter. A diagnostic cerebral angiogram confirmed the occlusion of the right ICA with limited and delayed retrograde filling from the vertebrobasilar system via the right posterior communicating artery and smaller collateral contribution via right external carotid to ophthalmic artery. Notably, there was no anterior communicating artery for contralateral cross-filling. She had several outpatient visits and hospital admissions for hypotensive episodes associated with recurrent stereotypic symptoms. Repeat imaging demonstrated overall small stroke burden and no hemorrhage. Upon careful discussion and review of possible options, a combined neurosurgical-endovascular carotid revascularization was performed with endarterectomy of an occlusive plaque involving the distal common carotid to the proximal ICA, and direct mechanical thrombectomy with aspiration and stentriever of the cervical ICA to the terminus. Additional angioplasty and stenting of proximal petrous ICA segment was performed via femoral access after closure of the surgical site. She clinically was doing well until 5 days post-operatively, when she developed recurrent symptoms. Imaging showed small new ischemic strokes without hemorrhage. Continuous video-EEG monitoring was negative for seizures. Transcranial doppler monitoring over the next few days demonstrated worsening velocities, with a repeat angiogram confirming severe focal segmental irregularities isolated to the right anterior territory. The surgical and stenting site remained widely patent. Her vasospasm was successfully treated with intra-arterial verapamil with improvement in vessel caliber and clinical symptoms. Conclusions Post carotid revascularization cerebral vasoconstriction may be an unusual cause of clinical worsening after revascularization for chronic carotid stenosis or occlusion. Intra-arterial treatment with verapamil can be a safe and effective mode of therapy. Disclosures L. Sheikhi: None. J. Tsai: None. M. Bain: 2; C; Stryker. 4; C; Rebound Therapeutics. G. Toth: None.

Background: Lumbar spine surgery with or without intraoperative dural tear (DT) may contribute to postoperative subdural hematomas and/or cerebellar intracranial hemorrhages (ICHs). Here, we present two patients, one with and one without an intraoperative DT occurring during lumbar surgery, both of whom developed acute postoperative supratentorial ICHs. Case Description: Two patients developed supratentorial lobar ICH following lumbar decompressions and fusion. The first patient, without an intraoperative DT, developed multiple ICHs involving the left cerebellum and left temporal lobe. The second patient, following an L4-5 decompression/instrumented fusion involving a DT, postoperatively developed a large right frontal ICH. Conclusion: Here, two patients undergoing lumbar spine surgery with/without DT subsequently developed significant ICH.

Introduction: Mycotic aneurysms are a serious complication of infective endocarditis with increased risk of intracranial hemorrhage. Patients undergoing open heart surgery for valve repair or replacement are exposed to anticoagulants, increasing the risk of aneurysm bleeding. These patients may require endovascular or surgical aneurysm treatment prior to heart surgery, but data on this approach are scarce. Methods: Retrospective review of consecutive patients with infectious endocarditis and mycotic aneurysms treated endovascularly with Trufill n-butyl cyanoacrylate (n-BCA) at the Cleveland Clinic between January 2013 and December 2015. Results: Nine patients underwent endovascular treatment of mycotic aneurysms with n-BCA (mean age of 39 years). On imaging, 4 patients had intracerebral hemorrhage, 2 had multiple embolic infarcts, and the rest had no imaging findings. Twelve mycotic aneurysms were detected (3 patients with 2 aneurysms). Seven aneurysms were in the M4 middle cerebral artery segment, 4 in the posterior cerebral artery distribution, and 1 in the callosomarginal branch. n-BCA was diluted in ethiodized oil (1:1 to 1:2). Embolization was achieved in a single rapid injection with immediate microcatheter removal. Complete aneurysm exclusion was achieved in all cases without complications. All patients underwent open heart surgery and endovascular embolization within a short interval, 2 with both procedures on the same day. There were no new hemorrhages after aneurysm embolization. Conclusions: Endovascular embolization of infectious intracranial aneurysms with liquid embolics can be performed successfully in critically ill patients requiring immediate open heart surgery and anticoagulation. Early embolization prior to and within a short interval from open heart surgery is feasible.

There is scant information on in-stent stenosis after flow diversion treatment of intracranial aneurysms with the Pipeline Embolization Device (PED).To assess the incidence, severity, nature, and clinical consequences of in-stent stenosis on angiographic follow-up after treatment with the PED.A retrospective study of patients who underwent aneurysm treatment with the PED was conducted. In-stent stenosis was assessed on subsequent follow-up angiography. Intimal hyperplasia was defined as a uniform growth process beyond the limits of the metallic mesh at25%. In-stent stenosis represented an area of parent vessel narrowing, most often focal, graded as mild (25%-50%), moderate (50%-75%), or severe (75%).Between June 2011 and April 2015, 80 patients were treated with the PED. Angiographic follow-up was available for 51 patients (representing 76% of available or 64% of all patients). Mean follow-up was 12.5 months. In-stent stenosis was detected in 5 patients (9.8%) at a median of 6 months. Stenosis was mild in 4 of 5 (80%) and moderate in 1 of 5 (20%) patients. There were no cases of severe stenosis. No stenosis caused flow limitation, clinical symptoms, or required re-treatment. Additional follow-up angiography was available in 2 of 5 stenosis patients showing marked improvement. Sixteen patients (31%) had intimal hyperplasia, and 28 patients (55%) had no stenosis. Asymptomatic stent occlusion occurred in 2 patients (4%) related to medication noncompliance.Treatment with the PED was associated with a 9.8% rate of in-stent stenosis, detected on first angiographic follow-up, at a median of 6 months. None were symptomatic or required re-treatment, and they showed significant improvement on follow-up.FD, flow diverter.

Spontaneous intracerebral hemorrhage (ICH) is the most common type of hemorrhagic stroke, ≈4 times more common than subarachnoid hemorrhage and accounting for 15% of all strokes.1 ICH is associated with higher rates of morbidity and mortality than all stroke subtypes. Overall, mortality rates for ICH are estimated to be as high as 40% to 50%, with the vast majority of survivors disabled at 6 months. When ICH is associated with intraventricular hemorrhage (IVH), outcomes are even worse, with estimated rates of mortality between 50% and 80%.1 Current standards recommend that patients with cerebellar hemorrhages measuring >3 cm with associated neurological deterioration or significant mass effect be managed with emergency surgical decompression. Similarly, patients with supratentorial hemorrhage and impending herniation are frequently taken for surgical decompression with or without hematoma evacuation. ICH patients who do not fall into either of these 2 categories are, in the vast majority of cases, managed medically.2 With the exception of aggressive blood pressure normalization, no medical therapy has been shown to improve outcomes or reduce mortality in patients with ICH.2 In the absence of clinical evidence to guide therapy, many aspects of medical management are based on local practice patterns with significant variations between institutions. Spontaneous supratentorial ICH may be divided into 2 general categories based on anatomic location—deep (involving the deep gray matter nuclei) or lobar. Deep hemorrhages are generally caused by hypertension, whereas lobar hemorrhages are most often caused by either hypertension or amyloid angiopathy.3 Either type of hemorrhage may be caused or exacerbated by an inherent or pharmacologically induced coagulopathy.1 Brain injury caused by spontaneous ICH is believed to be a biphasic process. The initial hemorrhage dissects through the brain parenchyma, creating a direct traumatic injury to the regional neurons. Although some neurons are irreversibly injured …