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Several collateral venous pathways exist to assist in cranial venous drainage in addition to the internal jugular veins. The important extrajugular networks (EJN) are often readily identified on diagnostic cerebral angiography. However, the angiographic pattern of venous drainage through collateral EJN has not been previously compared among patients with and without idiopathic intracranial hypertension (IIH).To quantify EJN on cerebral angiography among patients both with and without IIH and to determine whether there is a different EJN venous drainage pattern in patients with IIH.Retrospective imaging review of 100 cerebral angiograms (50 IIH and 50 non-IIH patients) and medical records from a single academic medical center was performed by 2 independent experienced neuroendovascular surgeons. Points were assigned to EJN flow from 0 to 6 using an increasing scale (with each patient's dominant internal jugular vein standardized to 5 points to serve as the internal reference). Angiography of each patient included 11 separately graded extrajugular networks for internal carotid and vertebral artery injections.Patients in the IIH group had statistically significant greater flow in several of the extrajugular networks. Therefore, they preferentially drained through EJN compared with the non-IIH group. Right transverse-sigmoid system was most often dominant in both groups, yet there was a significantly greater prevalence of codominant sinus pattern on posterior circulation angiograms.Patients with IIH have greater utilization of EJN compared with patients without IIH. Whether this is merely an epiphenomenon or possesses actual cause-effect relationships needs to be determined with further studies.

BACKGROUND Facilitation of venous outflow from the brain is largely believed to be responsible for the beneficial effect of head elevation on intracranial pressure (ICP). However, the impact on cerebral perfusion pressure can be deleterious. Although the adverse effect of obstructing venous outflow in the setting of intracranial hypertension is well documented, the converse (improvement with augmented drainage) has not been demonstrated. Our hypothesis is that the effect of active augmentation of cerebral venous outflow on ICP, although unknown, could be potentially beneficial under conditions of intracranial hypertension. METHODS Published literature was perused to ascertain known relationships between head elevation, ICP, cerebral perfusion pressure, and the cerebral venous system. RESULTS Head elevation benefits ICP control in intracranial hypertension from improved venous outflow via various networks and craniospinal cerebrospinal fluid displacement; but patients on the severe spectrum have a high likelihood of experiencing cerebral perfusion pressure decline especially beyond 30°. In addition, the interaction between autoregulation, compliance, head elevation, ICP pulse amplitude, cerebral perfusion pressure, and ICP becomes increasingly dyssynchronous in the severely affected brain. Although the detrimental effects of obstructing venous drainage are well documented, the possibility of augmenting venous outflow by withdrawal of sagittal sinus blood has not been described previously. CONCLUSION There could exist a potential role for targeted sagittal sinus venous aspiration in favorably influencing control of increased ICP conditions, without significant risk to cerebral perfusion.

Introduction Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA. Methods A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0–2). Secondary endpoints included complications and radiographic occlusion at follow-up. Results A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access. Conclusion Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.

Acute occlusion of the posterior sagittal sinus may lead to dramatic increase in intracranial pressure (ICP), refractory to standard treatment. Hybrid vascular bypass of cranial venous outflow into the internal jugular vein (IJV) has seldom been described for this in recent neurosurgical literature. To describe creation of a novel vascular bypass shunt from the superior sagittal sinus (SSS) to internal jugular vein (IJV) utilizing a covered stent-Dacron graft construct for control of refractory ICP. We illustrate a patient with refractory ICP increases after acute sinus ligation that was performed to halt torrential bleeding from intraoperative injury. A temporary shunt was created that successfully controlled ICP. From the promising results of the temporary shunt, we utilized a prosthetic hybrid bypass graft to function as a shunt from the sagittal sinus to IJV. Yet the associated anticoagulation led to complications and a poor outcome. Rapid and sustained ICP reduction can be expected after sagittal sinus-to-jugular bypass shunt placement in acute sinus occlusion. Details of the surgical technique are described. Heparin anticoagulation, while imperative, is also associated with worrisome complications. Acute occlusion of posterior third of sagittal sinus carries a very malignant clinical course. Intractable intracranial hypertension from acute sinus occlusion may be effectively treated with a SSS-IJV bypass shunt. A covered stent construct provides an effective vascular bypass conduit. However, the anticoagulation risk can lead to fatal outcomes. The neurosurgeon must always strive for primary repair of an injured sinus.

BackgroundRadial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates.MethodsAn international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature.ResultsOne hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%).ConclusionsUETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.

Background Endovascular therapy is a viable alternative to surgical clipping for the treatment of intracranial aneurysms; however, aneurysms arising at bifurcations remain a challenge. The purpose of this technical report is to share the nuances of treating aneurysms with the PulseRider (PR), including device selection and positioning strategy, from authors who are highly experienced in its use. Methods We offer a comprehensive guide for neuroendovascular surgeons less experienced with PR applications to include design, general coil embolization technique, principles of deployment and detachment, positioning options, and geometric challenges and their solutions. Results In our experience, the PR is well suited for addressing the challenges of treating bifurcation aneurysms. Conclusions PR use is intuitive and straightforward for use in bifurcation aneurysms with ideal favorable. PR can also be safely and effectively used to address a much broader and more challenging range of geometries.

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

Reduction in the mortality and disability resulting from acute ischemic stroke translates into restoration of blood flow to ischemic penumbra or tissue-at-risk. Reopening occluded large intracranial arteries is currently possible by timely institution of endovascular mechanical thrombectomy. In this topic, we discuss the physiologic basis of thrombectomy, technical steps and future directions in a concise yet eminently readable manner.

Background The middle meningeal artery (MMA) is an important conduit for the endovascular treatment of skull base and intracranial pathologies including, recently, subdural hematomas. A key aspect of such procedures is to perform a thorough diagnostic angiogram to detect anomalous arterial origins and “dangerous” anastomoses with branches of the internal carotid arteries. Although the most common anomaly related to the MMA is an abnormal origin from the ophthalmic artery, anomalous origin from the posterior circulation is rare. Moreover, its recognition requires a concerted effort at performing a vertebral artery angiogram irrespective of the location of the pathology (e.g., in subdural hematoma). Case Description We describe a case of anomalous origin of MMA from the basilar artery as a lateral pontine artery branch that was detected in a patient with recurrent subdural hematoma who presented for endovascular MMA embolization. Conclusions The embryologic origin of the entity is briefly discussed, along with suggestions for managing such an anomaly during endovascular embolization.

Ischemic stroke is the leading cause of disability and the fourth-leading cause of mortality in the United States. Intracranial atherosclerotic disease (ICAD) is one of the major causes of ischemic stroke in the general population. The pathophysiology is not yet fully understood and, therefore, the optimal treatment modality has yet to be defined. The results of the two most recent large-scale randomized trials (VISSIT and SAMMPRIS) favored maximal medical therapy as a first-line treatment. However, the failure rate of medical therapy is about 12% at 1 year and increases to as high as 22% at 2 years. Furthermore, first generation devices were used in SAMMPRIS with a high reported periprocedural stroke rate. All these factors have led to a renewed interest in endovascular approaches to ICAD, specifically with the development of newer techniques and devices. In addition, even though the current data support medical management for this disease, there is a subset of patients who seem to benefit from angioplasty and stenting. Proper selection criteria must be met, however. Because of the complexity of the pathophysiology, the ever-improving endovascular options, and the high failure rate of current treatment paradigms, further studies are required to advance our understanding of ICAD. Only then will we be able to select the optimal treatment for each subset of patients.

The large size of guide catheters in the traditional triaxial configuration can prove limiting during transradial vertebrobasilar thrombectomy. This is especially important for the direct aspiration technique because of the large aspiration catheters that can reach an inner diameter of 0.072 in. A strategy that strikes a balance between stable proximal vessel support and distal navigation for aspiration is conceptually attractive.To describe a series of transradial posterior circulation thrombectomy procedures in which the aspiration catheter served a dual role of guide support and clot aspiration in a coaxial configuration, thus obviating a larger guide catheter.Patients selected in the series underwent radial artery access and direct over-the-wire navigation of the aspiration catheter into the vertebral artery. With coaxial microcatheter navigation, the aspiration catheter reached distal enough to ingest the clot successfully. Along with clinical and angiographic data, imaging features such as angle of vertebral artery origin were calculated.Five patients underwent a stand-alone aspiration catheter technique for basilar artery occlusion through transradial access. All procedures resulted in thrombolysis in cerebral infarction 3 recanalization. The mean time to basilar artery recanalization was 10 minutes. No access site complications or vertebral artery dissection were noted. The mean subclavian artery-vertebral origin angle was 84.06° (range 78.2-90.2°).For patients selected properly based on vascular anatomy and a careful technique, a large bore aspiration catheter can fulfil a stand-alone dual-role, thus obviating the need for a guide catheter. This can potentially improve the technical feasibility and success of transradial vertebrobasilar thrombectomy.

BACKGROUND Dural reconstruction to achieve expansion duraplasty is important in suboccipital decompression for Chiari malformation type 1 (CM1). Although various dural substitutes are available, including synthetic collagen matrix grafts and dural xenografts, they have the potential to induce an inflammatory response. In this case series, the authors present their experience and discuss the incidence and possible mechanism of aseptic meningitis after the use of bovine collagen matrix graft as a dural substitute in patients with CM1 after suboccipital decompression. OBSERVATIONS Three consecutive adult female patients who underwent suboccipital decompression at a single institution by a single neurosurgeon were retrospectively reviewed. They all presented with signs of aseptic meningitis in a delayed fashion, responded well to steroid administration, but had recurrence of their symptoms. Bovine collagen dural substitutes are resorbed in a process that induces an inflammatory response manifesting with signs of aseptic meningitis and is only alleviated with removal of the dural substitute. LESSONS DuraMatrix Suturable, a dural xenograft derived from bovine dermis, though a viable choice for dural repair, is a potential cause of chemical meningitis after duraplasty in Chiari decompression surgery. In patients presenting with delayed and persistent aseptic meningitis after intervention, removal of this dural substitute led to improved symptomatology.

The Penumbra SMART COIL System includes a novel generation of embolic coils composed of complex and WAVE shape properties with varying levels of softness.To assess safety and efficacy of the SMART COIL System through a 1-year follow-up in patients with small intracranial aneurysms.This subset analysis of the SMART Registry, a prospective, multicenter study, includes patients with small intracranial aneurysms (≤4 mm) treated with the SMART COIL System. Registry end points include retreatment rates through 1 year, procedural device-related serious adverse events, and adequate occlusion postprocedure.Of 905 enrolled patients with aneurysms, 172 (19.0%) had small (≤4 mm) aneurysms (75.6% female; mean age 57.2 ± 13.4 years). 30.8% (53/172) of small aneurysms were ruptured, of which 50.9% (27/53) had Hunt and Hess ≥3. 79.5% (132/166) were wide-necked. Stent-assisted coiling and balloon-assisted coiling were performed in 37.2% (64/172) and 22.1% (38/172) of patients, respectively. The mean packing density for very small aneurysms was 44.9 (SD 25.23). Raymond Class I and Class II were achieved in 89.5% (154/172) postprocedure and 97.2% (137/141) at 1 year. The retreatment rate through 1 year was 5.6% (8/142), and the recanalization rate was 7.1% (10/141). The periprocedural device-related serious adverse event rate was 2.9% (5/172). Intraprocedural aneurysm rupture occurred in 0.8% of patients.This analysis suggests that the SMART COIL System is safe and efficacious in small aneurysms with satisfactory occlusion rates and low rates of rupture or rerupture. At 1 year, patients had low retreatment rates and good clinical outcomes.

Introduction The transradial approach (TRA) is being employed to a greater degree in neuroendovascular procedures. Multicenter studies examining TRA versus transfemoral approach (TFA) across all neuroendovascular procedures have demonstrated lower rates of both minor and major complications using TRA. Previous studies have described TRA for flow diversion using the Pipeline embolization device (ev3/Chestnut Medical, Menlo Park, California) with good result. The Surpass Evolve device (SED; Stryker Neurovascular, Kalamazoo, Michigan, USA) is a new 64-wire flow diverting stent that obtained FDA approval in 2020. In this study we present a single center experience of patient who underwent TRA for placement of Surpass Evolve flow diversion for treatment of cerebral aneurysms. Methods We performed a retrospective review of patient who underwent TRA for SED placement for treatment of aneurysm between August 2020 to February 2021. Patient demographic, procedural techniques, clinical and angiographic data were recorded. Results 15 patients underwent SED placement for treatment of aneurysm (age 46.6, 62.5% female). 81% of patients had hypertension, 43% had hyperlipidemia, and 75% were current or former smokers. 3 (20%) patients presented with ruptured aneurysms. 7 (47%) patients had underwent previous aneurysm treatment. 5 patients (33%) had recurrence of their previously treatment aneurysm. 1 patient was converted to TFA after attempted TRA due to vasospasm. The following aneurysms were treated: anterior communicating artery aneurysm in 3 patients, ophthalmic artery aneurysm in 3 patients, anterior choroidal artery aneurysm in 3 patients, superior hypophyseal artery aneurysm in 3 patients, vertebral artery aneurysm in 2 patients, posterior communicating artery aneurysm in 1 patient, cervical carotid artery aneurysm in 1 patient, and a fusiform cavernous carotid aneurysm in 1 patient. The right radial artery was used in all cases. Mean radial artery diameter was 2.64 mm. A 5/6 French slendersheath was utilized in all cases. Coaxial system was used in all cases. Mean smallest parent vessel diameter measured 3.52mm, and mean largest parent vessel diameter measured 4.06 mm. Placement of the TFA flow diversion device was successful in all cases. Balloon angioplasty was used in 5 (33%) patients to achieve wall apposition. No patients had access site complications. There were no procedural or postoperative neurological complications. 1 patient had proximal shelfing of SED. The patient required retreatment with good outcome using an atlas stent. Conclusions TRA is a safe and feasible approach for flow diversion using the Surpass Evolve device. Rates of access site complications is favorable. Overall rate of conversion to TFA is low. Our early experience suggests frontline TRA is feasible for the utilization of Surpass Evolve flow diverting device. Disclosures Z. Hubbard: None. B. Saway: None. K. Zilinskas: None. G. Porto: None. S. Al Kasab: None. M. Sattur: None. A. Spiotta: None.

Background The adoption of endovascular techniques for treatment of pericallosal artery aneurysms (PAAs) has been comparatively gradual due to anatomic and technological factors. We conducted a retrospective cohort study to evaluate the outcomes of PAA treatment with coiling and flow diversion at our institution. Methods This was a retrospective study of patients treated endovascularly for PAAs from December 2007 to January 2019. Results In total, 33 patients with 34 aneurysms were included (25 aneurysms ruptured, 9 unruptured or recurrent). Of the ruptured group, 22 were coiled (88%) and rest treated with flow diversion. Initial angiographic follow up rate was 72%, at median of 159 days. Overall recurrence rate was 40% (10/25) at median of 376 days, all among coiled aneurysms. 6 recurrent aneurysms were retreated with further coiling (2) and flow diversion (4). Of the unruptured/recurrent group, 5 were coiled (55%) and remainder treated with flow diversion. Angiographic follow-up rate was 100% at median of 267 days. Recurrence rate was 22% (2/9), both in coiled aneurysms. Overall, 27 aneurysms were coiled, 9 treated with flow diversion and 3 with “partial” flow diversion. All aneurysms treated with pipeline flow diversion achieved 100% occlusion. No re-rupture or new rupture was observed. Good clinical outcome (modified Rankin Scale 0–2) was seen in 79% of patients. Conclusions Our study demonstrates that endovascular coiling for PAAs is associated with a definite rate of recurrence, which has to be monitored with timely angiography. We also demonstrate the excellent effectiveness of flow diversion for PAAs with either presentation.

Cavernous carotid aneurysms (CCAs) are usually considered benign as the natural history of the condition is often asymptomatic; however, CCAs can reach giant proportions and become symptomatic, thus requiring treatment. The introduction of flow diverters has revolutionized management of this condition. However, the parent artery geometry in giant lesions may prove exceedingly difficult to navigate and deploy stents satisfactorily. In such cases, indirect surgical treatment such as proximal occlusion of internal carotid artery (ICA) should be employed. Preoperative balloon test occlusion is indicated before permanent occlusion to identify patients who demonstrate hemispheric ischemia (for possible bypass), but it requires understanding of important operative complications and technical nuances. Endovascular parent artery sacrifice is an effective modality to achieve proximal occlusion. Here, we describe the step-wise management approach in a 53-year-old female with a giant, left CCA presenting with headache and cavernous sinus syndrome who was ultimately successfully treated with endovascular coiling and ICA occlusion. The management of complex lesions such as giant skull base aneurysms requires a sound understanding of vascular anatomy, tools available for evaluation, and physiological interpretation of diagnostic and therapeutic modalities to obtain excellent clinical results and patient satisfaction.

International audience; Abstract BACKGROUND Randomized controlled trials evaluating mechanical thrombectomy (MT) for acute ischemic stroke predominantly studied anterior circulation patients. Both procedural and clinical predictors of outcome in posterior circulation patients have not been evaluated in large cohort studies. OBJECTIVE To investigate technical and clinical predictors of functional independence after posterior circulation MT while comparing different frontline thrombectomy techniques. METHODS In a retrospective multicenter international study of 3045 patients undergoing MT for stroke between 06/2014 and 12/2018, 345 patients had posterior circulation strokes. MT was performed using aspiration, stent retriever, or combined approach. Functional outcomes were assessed using the 90-d modified Rankin score dichotomized into good (0-2) and poor outcomes (3-6). RESULTS We included 2700 patients with anterior circulation and 345 patients with posterior circulation strokes. Posterior patients (age: 60 ± 14, 46% females) presented with mainly basilar occlusion (80%) and were treated using contact aspiration or ADAPT (39%), stent retriever (31%) or combined approach (19%). Compared to anterior strokes, posterior strokes had delayed treatment (500 vs 340 min, P

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.

Basilar artery occlusions (BAOs) are devastating ischemic strokes that account for 1% of all strokes with high morbidity and mortality; however, neuroendovascular techniques such as ADAPT have recently revolutionized the clinical outcomes of these patients.1-3 Common underlying pathology in patients with BAO include intracranial atherosclerotic disease (ICAD) as well as thromboembolic origin.4 Basilar artery ICAD in a setting of acute stroke portends a poor prognosis and post-thrombectomy residual critical flow limiting stenosis treatment options, including balloon angioplasty with or without stent placement.5-7 We present a video illustration of neuroendovascular technique and challenges encountered when managing this pathology. Image at 5:42 reprinted with permission from Alawieh et al, Lessons learned over more than 500 stroke thrombectomies using ADAPT with increasing aspiration catheter size, Neurosurgery, 86(1), 2020, pp. 61-70, with permission from the Congress of Neurological Surgeons.1.

Acute occlusion of the posterior sagittal sinus may lead to dramatic increase in intracranial pressure (ICP), refractory to standard treatment. Hybrid vascular bypass of cranial venous outflow into the internal jugular vein (IJV) has seldom been described for this in recent neurosurgical literature.To describe creation of a novel vascular bypass shunt from the superior sagittal sinus (SSS) to internal jugular vein (IJV) utilizing a covered stent-Dacron graft construct for control of refractory ICP.We illustrate a patient with refractory ICP increases after acute sinus ligation that was performed to halt torrential bleeding from intraoperative injury. A temporary shunt was created that successfully controlled ICP. From the promising results of the temporary shunt, we utilized a prosthetic hybrid bypass graft to function as a shunt from the sagittal sinus to IJV. Yet the associated anticoagulation led to complications and a poor outcome.Rapid and sustained ICP reduction can be expected after sagittal sinus-to-jugular bypass shunt placement in acute sinus occlusion. Details of the surgical technique are described. Heparin anticoagulation, while imperative, is also associated with worrisome complications.Acute occlusion of posterior third of sagittal sinus carries a very malignant clinical course. Intractable intracranial hypertension from acute sinus occlusion may be effectively treated with a SSS-IJV bypass shunt. A covered stent construct provides an effective vascular bypass conduit. However, the anticoagulation risk can lead to fatal outcomes. The neurosurgeon must always strive for primary repair of an injured sinus.

Background Traditionally, neuroangiography for diagnosis and therapy has been achieved via the transfemoral route. Femoral access, however, has been associated with catastrophic complications. Although transradial access (TRA) has been adopted late by the field of neuroendovascular surgery, several groups have recently demonstrated a dramatically safe and rapid learning curve with a radial-first approach. However, there is a need for a detailed illustrative approach on the transradial technique. Objective To provide a detailed description of the operative technique with step-by-step illustrations derived from our single center series of 506 cases, as an early adopter. Methods A step-by-step illustrated approach to our technique of transradial angiography is provided, based on our clinical experience of an early radial-first approach. Prospective review of patients undergoing transradial angiography and interventions from April 1 to November 30, 2019, at our institution was performed. We included all cases that received radial-first arterial access for diagnostic and interventional neuroangiography. Efficacy, complications, catheter use, and radiation metrics of TRA for the entire cohort were noted. The radial approach was described in 4 stages beginning from the wrist (Stage I) and ending with distal access to target vessel of interest (Stage IV). Results A total of 506 patients underwent TRA over the 7-mo period. Procedural success was achieved in 92.3% of patients (93.7% for diagnostic and 88.5% for interventional). Crossover to the femoral route occurred in 33 (6.5%) cases (25 diagnostic and 8 interventional). The majority occurred in Stage I. No major complications were noted. Conclusion Our preferred technique for the transradial approach provides excellent safety and efficacy in performing diagnostic and interventional neuroangiography. The illustrated technical steps are expected to provide guidance for early adopters of TRA.

BACKGROUND. Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage. METHODS. MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0–3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number . FINDINGS. Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0–3 at 365 days (adjusted risk difference 4% [95% CI –4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012). INTERPRETATION. For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons.

Background and importance Aneurysms of the ophthalmic artery (OA) within the orbit and optic canal are extremely rare. Given the peripheral location of these aneurysms and the fact that most are fusiform, parent artery occlusion is preferred for symptomatic aneurysms. However, the impact of OA occlusion on vision is not always innocuous. Balloon occlusion testing (BOT) of the OA has the potential to gauge the possibility of visual compromise, in addition to assessing collaterals. While BOT has been assessed for carotid artery occlusion, its role in OA occlusion has not been well defined. Clinical presentation We describe a patient with a 6-mm intracanalicular OA aneurysm who was treated with endovascular coil embolization of the aneurysm and occlusion of the parent artery. We performed a 30-min balloon occlusion test, in which we verified intact visual and neurological function. Collateral vascularity was confirmed. Complete occlusion was achieved and the patient recovered with intact visual and neurological function. We provide a review of literature pertaining to parent artery occlusion of OA aneurysms that occur within optic canal and orbit. A brief note on anatomy of OA and collaterals is provided. Conclusion Endovascular parent artery occlusion is an effective treatment for OA aneurysms that occur in optic canal and orbit. Assessment of effect of occlusion on vision is important. BOT can assess this and provide valuable information. Recovery or preservation of visual function is highly dependent on preoperative visual status.

Wide-necked bifurcation aneurysms pose technical and anatomical challenges to endovascular treatment, which make the simpler assisted (balloon or single stent) coiling techniques less effective.1 Consequently, unique endovascular solutions to treat such aneurysms have been devised.2,3 One such device is PulseRider (Cerenovus, New Brunswick, New Jersey), which is designed to provide neck support for a coil mass while protecting the bifurcation.3 The device comprises a body or stem that is deployed in the parent artery and a saddle component that sits at the aneurysm neck to keep the coil mass away from the bifurcation. There are several technical nuances involved in successful use of the device during positioning, deployment, and detachment.3 We present a surgical video detailing the steps of PulseRider-assisted coiling of unruptured basilar bifurcation (or basilar apex) aneurysms. The first case highlights index treatment at diagnosis and the second showcases treatment of a recurrent basilar apex aneurysm. Both patients provided informed consent to the procedure. We also briefly discuss the rationale for treating basilar apex aneurysms.4,5.

Malignant large artery stroke is associated with high mortality of 70% to 80% with best medical management. Decompressive craniectomy (DC) is a highly effective tool in reducing mortality. Convincing evidence has accumulated from several randomized trials, in addition to multiple retrospective studies, that demonstrate not only survival benefit but also improved functional outcome with DC in appropriately selected patients. This article explores in detail the evidence for DC, nuances regarding patient selection, and applicability of DC for supratentorial intracerebral hemorrhage and posterior fossa ischemic and hemorrhagic stroke.

Background Neuroendovascular intervention has become a key treatment option for acute ischemic stroke. The Sofia (6F) PLUS catheter was designed for neurovascular access for diagnostic or therapeutic interventions. Objective To report the first series describing use of the Sofia PLUS intermediate/distal access reperfusion catheter in the treatment of acute ischemic stroke. Methods In this retrospective study, 41 stroke cases were identified in which the catheter was utilized for thrombolysis/thrombectomy. Mean preprocedure National Institutes of Health Stroke Scale score was 16.5 ± 5.2 (range 4-29). Occluded vessels included the M1 segment, M2 segment, internal carotid artery terminus, cervical internal carotid artery, and basilar artery. Results Successful positioning of the Sofia PLUS catheter near the occlusion site was achieved in 38 (92.7%) of 41 cases in which thrombectomy or thrombolysis was attempted using intraarterial tissue plasminogen activator, a direct aspiration first-pass technique, and/or stent retrieval. A postprocedure thrombolysis in cerebral infarction (TICI) score of 2b/3 was achieved in 37 of 41 cases. Of 15 cases where the Sofia PLUS was used for a direct aspiration first-pass technique, TICI 2b/3 was achieved in 11 (73.3%). In one case where intra-arterial tissue plasminogen activator was used as the only treatment modality, TICI 2a was achieved. No device-related or catheter-related complications were observed. The mean 7-d-postprocedure National Institutes of Health Stroke Scale score among the 39 survivors was 8.5 ± 7.3 (range 0-23). Conclusion Initial results with use of the Sofia (6F) PLUS for endovascular treatment of acute ischemic stroke have been encouraging. Experience with a larger series is warranted to further evaluate the safety and efficacy of this device and compare it with other reperfusion catheters.

Despite advances in imaging methods, neurosurgical techniques, adjuvant radiation, radiosurgery, and chemotherapy, neurocritical care of the patient with neuraxial tumors is an important component of care. Treatment of these tumors may include management of refractory (often focal) seizures and treatment of mass effect and shift from associated edema. This chapter outlines the important pathophysiologic concepts behind the clinical presentation, neurosurgical management, and perioperative intensive care of patients who have these tumors.

Background Endovascular treatment of cerebral aneurysms in the posterior circulation poses a challenge because of the higher rate of wide-necked aneurysms and presentation with rupture. In this study, we compare the baseline characteristics and outcomes of patients with posterior circulation aneurysms treated with novel second-generation coils in the SMART registry. Methods SMART is a phase 4, multicenter, prospective, registry that enrolled patients with anterior and posterior circulation cerebral aneurysms (both ruptured and unruptured) who underwent endovascular treatment using Penumbra SMART™ Coils. Collected data included baseline clinical and angiographic characteristics at presentation. Primary and secondary end points were immediate angiographic occlusion, periprocedural complications, recanalization and retreatment rates and mortality at 1-year follow up. We compared the above variables between anterior and posterior circulation aneurysms. Results Of a total of 906 patients treated in the SMART registry, 173 (19.1%) had posterior circulation aneurysms. In comparison to patients with anterior circulation aneurysms, patients with aneurysms in the posterior circulation were older (mean age 61.7 vs. 59.3 years, P 0.017) and more likely to present with rupture (38.7% vs. 30.3%, P 0.032). Posterior circulation aneurysms were more likely to be wide-necked (defined as an aneurysm with a dome-to-neck ratio less than 2.0 and/or a neck length of 4 mm or more). No significant difference was found in the rate of successful embolization at initial procedure (Raymond Class I), serious device-related adverse effects within 24 hours, one-year recanalization and one-year retreatment between both groups (table 1). Conclusions Despite being associated with higher rates of rupture and wide-necked geometry, patients with posterior circulation aneurysms experienced immediate and one-year angiographic occlusion rates that were not significantly different from anterior circulation aneurysms. Device-related peri-procedural complications were also not significantly higher than the latter. Disclosures E. Almallouhi: None. M. Sattur: None. M. Anadani: None. S. Al kasab: None. A. Spiotta: 2; C; Penumbra, Cerenovus, Minnetronix.

Background/Objective Endovascular aneurysm embolization is effective and safe. However, the angiographic recurrence continues to be an issue after endovascular embolization. In this study, we aimed to report the rate of recurrence at 1-year follow up angiography and to investigate the predictors of recurrence. Methods We used the SMART registry to identify subgroup of patients who underwent endovascular embolization with SMART coils and had one year follow up angiography. The primary outcome of this study was angiography recurrence at 1 year. We used stepwise regression analysis to identify the predictors of recurrence. Results A total of 466 patients were included of whom 78 (16%) had recurrence at 1 year follow up angiography. Mean age was 60 years and 74% were female. 112 (24%) of treated aneurysms were ruptured and 125 (27%) were ≥4 mm in size. On Multivariate analysis, Immediate post procedure Raymond II and III (vs Raymond I), neck size ≥4 (vs. Conclusion In this study we identified the predictors of aneurysm recurrence after endovascular embolization with SMART coils. Disclosures M. Anadani: None. M. Sattur: None. E. Almallouhi: None. S. Al kasab: None. A. Spiotta: None.

Traditionally, microsurgical clipping has been the mainstay of treatment for pericallosal artery aneurysms (PAAs). However, this has changed in recent years with advancements in endovascular surgical techniques. We conducted a retrospective cohort study of pericallosal artery aneurysms that underwent endovascular treatment with coiling and flow diversion at our institution. 33 patients with 34 aneurysms were included (25 aneurysms ruptured, 9 unruptured or recurrent). Of the ruptured group, 22 were coiled (88%) and rest treated with flow diversion. Initial angiographic follow up rate was 72% at median of 159 days. Overall recurrence rate was 40% (10/25) at median of 376 days, all among coiled aneurysms. 6 recurrent aneurysms were retreated with further coiling (2) and flow diversion (4). Of the unruptured/recurrent group, 5 were coiled (55%) and remainder treated with flow diversion. Initial angiographic follow up rate was 100% at median of 267 days. Recurrence rate was 22% (2/9), both in coiled aneurysms. Overall, 27 aneurysms were treated with coiling, 9 with flow diversion and 3 with ‘partial’ flow diversion. All aneurysms treated with pipeline flow diversion achieved 100% occlusion. No re-rupture or new rupture was noted in our series. Good clinical outcome (modified Rankin scale, mRS 0–2) was seen in 79% of patients. Our study demonstrates that endovascular coiling for PAAs is associated with a definite rate of recurrence, which has to be monitored with timely angiography. We also demonstrate the excellent effectiveness of flow diversion for PAAs with either presentation. Disclosures M. Sattur: None. Y. Li: None. E. Almallouhi: None. J. Lena: 2; C; Penumbra Inc., Alameda, California. A. Spiotta: 2; C; Penumbra Inc., Alameda, California.

Background/Objective Although endovascular coiling with SMART coils has been proven to be safe and effective. The rate and predictors of complete occlusion are not well understood. This study aimed to investigate the predictors of complete occlusion with endovascular coiling using SMART coils. Methods A resorptive analysis of all patients treated with SMART coils at 20 endovascular capable centers. The primary outcome of this study was complete occlusion at the end of procedure defined as Raymond class I. Predictors of complete occlusion were identified using stepwise regression analysis. Results A total of 907 patients were included in the study of whom 363 (40%) achieved complete occlusion at the end of procedure. History of smoking, location of occlusion, packing density, aneurysm size, wide neck aneurysm, neck size (≥4 vs. Conclusion This study identified the rate and predictors of complete occlusion using SMART coils. Disclosures M. Anadani: None. M. Sattur: None. E. Almallouhi: None. S. Al Kasab: None. A. Spiotta: None.

Background Previous studies have suggested that anterior communicating artery (ACoA) microaneurysms ( Methods We reviewed the prospective, multicenter SMART registry to identify patients with unruptured ACoA aneurysm who were treated with endovascular embolization using the SMART coils. We aimed to report the angiographic outcome and peri-procedural complications of endovascular embolization of ACoA aneurysm according to the aneurysm size ( Results Out of 906 patients included in the SMART registry, 146 (16.1%) patients had unruptured ACoA aneurysms (age 60.8 ±11.9 yr and 61.6% were females). Of those ACoA, 43 were Conclusions Endovascular treatment of unruptured ACoA microaneurysms is associated with similar successful embolization and complication rates compared to larger size ACoA aneurysms. Disclosures E. Almallouhi: None. M. Sattur: None. S. Al kasab: None. M. Anadani: None. A. Spiotta: 2; C; Penumbra, Cerenovus, Minnetronix.

Background Flow diversion is a viable treatment modality for the embolization of proximal intracranial carotid artery aneurysms (cavernous, superior hypophyseal, ophthalmic). In this study, we evaluated the outcomes of patients with internal carotid artery (ICA) aneurysms who were treated with using novel second generation coils in the SMART registry. Methods We reviewed the multicenter, prospective SMART registry that enrolled patients who underwent endovascular treatment using Penumbra SMART™ Coils. Study endpoints include peri-procedural device-related serious adverse events, the occlusion status immediately post procedure as well as a follow-up angiogram after one year. We included only patients who underwent coiling for intracranial carotid aneurysms in this analysis. Results Out of 906 patients included in the SMART registry, 131 (14.5%) patients were treated for cavernous, ophthalmic, or superior hypophyseal artery aneurysms (age 56.7 ±12.7 yr, 88.5% were females, and 7.6% were ruptured). Most of the aneurysms were wide-necked (defined as an aneurysm with a dome-to-neck ratio less than 2.0 and/or a neck length of 4 mm or more) (86 patients, 65.6%). Sixty patients (45.8%) underwent stent-assisted coiling and 21 patients (16%) underwent balloon-assisted coiling. Device related serious adverse effects were noticed in one patient (0.8%) and periprocedural mortality occurred in one patient (0.8%). Immediate Raymond class I was achieved in 37 patients (28.2%) and one-year Raymond class I was achieved in 56/79 patients (70.9%). One-year recanalization occurred in 8 patients (6.1%). Conclusions In this large, contemporary multicenter registry of patients, coil embolization using the SAMRT coils offers a reasonably safe and effective treatment of intracranial ICA aneurysms, as demonstrated by the high rates of complete one-year aneurysm occlusion and the low rate of recanalization and complications. Disclosures E. Almallouhi: None. M. Anadani: None. S. Al kasab: None. M. Sattur: None. A. Spiotta: 2; C; Penumbra, Cerenovus, Minnetronix.

Background Over the past decade, coil embolization of intracranial aneurysm has proved to be both safe and effective. A major concern coil embolization is the recurrence of aneurysm requiring re-treatment. Low coil packing leading to coil compaction has been associated with a higher risk of aneurysm recurrence. In this study, we evaluate packing density, aneurysm recurrence and complication rates associated with different endovascular techniques. Methods The prospectively collected data from the SMART registry was interrogated. Only patients with unruptured aneurysms were included in these analyses. Patients were divided into four groups according on the endovascular treatment modality used: group 1 (primary coiling), group 2 (balloon assisted coiling), group 3 (stent assisted coiling), and group 4 (balloon and stent assisted coiling). Baseline characteristics, aneurysm features, packing density, complication and recurrence rates were compared between the groups. Results Total of 607 patients were included in this study. Of those, 240 were in group 1, 68 in group 2, 287 in group 3, and 22 in group 4. Median age was 61 (IQR, 53–69), and 75% were females (table 1). There was no difference in aneurysm size, or duration of coil deployment. Wide neck aneurysms were more prevalent in groups 3 and 4 compared to groups 1 and 2 (group 3; 72.8%, group 4; 81.8%, group 1; 57.9%, and group 2; 61.8%, P=0.008). While there was no difference in packing density between the groups at initial treatment, at 1-year, complete occlusion (RR class 1) was achieved at a higher rate in groups 3 and 4 (75%) compared to 1 (62.6%) and group 2 (42.6%) P Conclusions In patients with unruptured intracranial aneurysms, the use of primary coiling and balloon assisted coiling was associated with similar packing density to stent or stent plus balloon assisted coiling, though with lower rates of aneurysm obliteration at 1 year. Combined stent and balloon assisted coiling was associated with higher rates of immediate complications. Further prospective studies are warranted to confirm our findings. Disclosures S. Al Kasab: None. E. Almallouhi: None. M. Anadani: None. M. Sattur: None. A. Spiotta: None.

BackgroundThe transradial approach as a frontline approach is a novel technique in neuroendovascular procedures. In this study we aim to present our early experience with full transition to transradial access as the first-line approach for neuroendovascular procedures.MethodsWe prospectively collected data on the first 100 consecutive patients who underwent a diagnostic or interventional neuroendovascular procedure using the transradial approach at our institution between March 22 and April 30, 2019. Baseline characteristics were collected in addition to the type of procedure, access site, catheters and wires used, complications, and whether there was crossover to transfemoral access.ResultsTransradial access was attempted in 121 cases and 91 cases were completed successfully (72 diagnostic procedures and 19 interventional procedures). Mean (SD) age was 56.8 (14.7) years, 54.9% (50/91) underwent the procedure in the outpatient setting, and 60.4% (55/91) were women. Seven patients had minor immediate complications related to the radial access. Interventional procedures successfully performed included aneurysm embolization (ruptured (n=3) and unruptured (n=8)), tumor embolization (n=2), cervical internal carotid artery stenting (n=2), balloon occlusion test (n=1), vertebral artery sacrifice (n=1), and arteriovenous malformation embolization (n=2).ConclusionIn this early experience, full transition to the transradial approach as the frontline approach is feasible with a low complication rate for both diagnostic and interventional neuroendovascular procedures.

BACKGROUND AND PURPOSE: Selection of the correct flow-diverter size is critical for cerebral aneurysm treatment success, but it remains challenging due to the interplay of device size, anatomy, and deployment. Current convention does not address these challenges well. The goals of this pilot study were to determine whether computational modeling improves flow-diverter sizing over current convention and to validate simulated deployments. MATERIALS AND METHODS: Seven experienced neurosurgeons and interventional neuroradiologists used computational modeling to prospectively plan 19 clinical interventions. In each patient case, physicians simulated 2–4 flow-diverter sizes that were under consideration based on preprocedural imaging. In addition, physicians identified a preferred device size using the current convention. A questionnaire on the impact of computational modeling on the procedure was completed immediately after treatment. Rotational angiography image data were acquired after treatment and compared with flow-diverter simulations to validate the output of the software platform. RESULTS: According to questionnaire responses, physicians found the simulations useful for treatment planning, and they increased their confidence in device selection in 94.7% of cases. After viewing the simulations results, physicians selected a device size that was different from the original conventionally planned device size in 63.2% of cases. The average absolute difference between clinical and simulated flow-diverter lengths was 2.1 mm. In 57% of cases, average simulated flow-diverter diameters were within the measurement uncertainty of clinical flow-diverter diameters. CONCLUSIONS: Physicians found computational modeling to be an impactful and useful tool for flow-diverter treatment planning. Validation results showed good agreement between simulated and clinical flow-diverter diameters and lengths.

BACKGROUND: MRI-based modeling of tumor cell density (TCD) can significantly improve targeted treatment of Glioblastoma (GBM). Unfortunately, interpatient variability limits the predictive ability of many modeling approaches. We present a Transfer Learning (TL) method that generates individualized patient models, grounded in the wealth of population data, while also detecting and adjusting for interpatient variabilities based on each patient’s own histologic data. METHODS: We recruited primary GBM patients undergoing image-guided biopsies and preoperative imaging including contrast-enhanced MRI (CE-MRI), Dynamic-Susceptibility-Contrast (DSC)-MRI, and Diffusion Tensor Imaging (DTI). We calculated relative cerebral blood volume (rCBV) from DSC-MRI and mean diffusivity (MD) and fractional anisotropy (FA) from DTI. Following image coregistration, we assessed TCD for each biopsy and identified corresponding localized MRI measurements. We then explored a range of univariate and multivariate predictive models of TCD based on MRI measurements in a generalized one-model-fits-all (OMFA) approach. We then implemented both univariate and multivariate individualized TL predictive models, which harness the available population level data but allow for individual variability in their predictions. Finally, we compared Pearson correlation coefficients and mean absolute error between the individualized TL versus generalized OMFA models. RESULTS: TCD significantly correlated with rCBV (r=0.33,p