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Abstract Background Populations of the Oriental White-backed Vulture (Gyps bengalensis) have declined by over 95% within the past decade. This decline is largely due to incidental consumption of the non-steroidal anti-inflammatory veterinary pharmaceutical diclofenac, commonly used to treat domestic livestock. The conservation status of other Gyps vultures in southern Asia is also of immediate concern, given the lack of knowledge regarding status of their populations and the continuing existence of taxonomic uncertainties. In this study, we assess phylogenetic relationships for all recognized species and the majority of subspecies within the genus Gyps. The continuing veterinary use of diclofenac is an unknown but potential risk to related species with similar feeding habits to Gyps bengalensis. Therefore, an accurate assessment of the phylogenetic relationships among Gyps vultures should aid in their conservation by clarifying taxonomic uncertainties, and enabling inference of their respective relatedness to susceptible G. bengalensis. Results Phylogenetic results using mitochondrial cytB, ND2 and control region sequence data indicate a recent and rapid diversification within the genus Gyps. All recognized species formed monophyletic groups with high statistical support, with the exception of the Eurasian Vulture, for which specimens identified as subspecies G. fulvus fulvescens appear closely related to the Himalayan Vulture (G. himalayensis). In all analyses, the earliest divergence separated the Oriental White-backed Vulture from other Gyps taxa, with the next diverging taxon being either the African White-backed Vulture (G. africanus), or the Himalayan Vulture. All analyses supported a sister relationship between the Eurasian Vulture (G. f. fulvus), and Rüppell's Vulture (G. rueppellii), with this clade being sister to another consisting of the two taxa of "Long-billed" Vulture (G. indicus indicus and G. i. tenuirostris), and the Cape Vulture (G. coprotheres). These molecular phylogenies strongly support the treatment of indicus and tenuirostris as separate species, as does morphological data showing that these two taxa of similar overall size differ in proportions, especially in rostral, alar, and pedal characters. In addition, grouping of bengalensis and africanus together in the genus Pseudogyps, as historically proposed, is not upheld based on mitochondrial data. Conclusion Both molecular and morphological data provide strong support for considering the "Long-billed" Vulture to be comprised of two species (G. indicus and G. tenuirostris), and further analysis is warranted to determine the taxonomic distinctiveness of G. f. fulvescens. Our phylogenetic analyses and conservative estimates suggest the diversification of Gyps taxa to be within the past 6 million years. Diclofenac susceptibility has been previously demonstrated for four Gyps species (G. indicus, G. fulvus, G. africanus, G. bengalensis), and the phylogenetic position of these species each forming a sister relationship with at least one of the remaining species, support concern that other Gyps taxa may be susceptible as well. Determining genetic and evolutionary distinctiveness for Gyps lineages is increasingly important as a breeding program is being established to prevent extinction.

Introduction: Anatomic factors that predict outcomes following basal ganglia intracranial hemorrhage (bgICH) evacuation are poorly understood. Given the compact neuroanatomic organization of the basal ganglia, we hypothesized that bgICH spatial representation could predict postoperative functional outcomes., Methods: Patients undergoing minimally invasive surgical bgICH evacuation between 2013 and 2024 at one center were retrospectively reviewed. bgICH volumes were segmented and stereotactically localized using anatomic landmarks. Heat maps that identified bgICH spatial representation across functional outcome states were generated. Differential bgICH volume overlap with each heat map was calculated after subtracting out that patient's contribution to the map. Area under the receiver operating characteristic curve (AUC) was used to evaluate the diagnostic accuracy of differential volume overlap for poor functional outcome (modified Rankin Scale score of 4-6 within 1 year of surgery) and compared with that of the intracranial hemorrhage (ICH) score with a z test., Results: Forty-five patients were included (62% men, 7% Caucasian, median age 53 years). Thirty-two patients (71%) had poor functional outcome (median follow-up 4.1 months), which was associated with increased age (P=0.032), bgICH volume (P=0.005), intraventricular hemorrhage severity (P=0.032), National Institutes of Health Stroke Scale (P=0.006), and differential volume overlap (P<0.001). Anatomically, poor outcome was associated with bgICH extension into the anterior limb of the internal capsule (P=0.004), caudate (P=0.042), and temporal lobe (P=0.006). The AUC for differential volume overlap was 0.87 (95% CI: 0.76-0.97), which was higher than chance alone (P<0.001), but statistically similar to that (0.82 (0.71-0.97)) of the ICH score (P=0.545)., Conclusion: Stereotactic bgICH localization enabled functional outcome prognostication in patients undergoing minimally invasive surgical evacuation., Competing Interests: Competing interests: VRK is a consultant for Stryker and Integra. MB received teaching honoraria, is a consultant for Cerenovus and Integra, and is a member of the advisory board for Stryker., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Significant controversy exists about the management of unruptured cerebral arteriovenous malformations (AVMs). Results from A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) suggested that intervention increases the risk of stroke/death compared with medical management. However, numerous study limitations raised concerns about the trial's generalizability., Objective: To assess the rate of stroke/death and functional outcomes in ARUBA-eligible patients from a multicenter database, the Neurovascular Quality Initiative-Quality Outcomes Database (NVQI-QOD)., Methods: We performed a retrospective analysis of prospectively collected data of ARUBA-eligible patients who underwent intervention at 18 participating centers. The primary endpoint was stroke/death from any cause. Secondary endpoints included neurologic, systemic, radiographic, and functional outcomes., Results: 173 ARUBA-eligible patients underwent intervention with median follow-up of 269 (25-722.5) days. Seventy-five patients received microsurgery±embolization, 37 received radiosurgery, and 61 received embolization. Baseline demographics, risk factors, and general AVM characteristics were similar between groups. A total of 15 (8.7%) patients experienced stroke/death with no significant difference in primary outcome between treatment modalities. Microsurgery±embolization was more likely to achieve AVM obliteration (P<0.001). Kaplan-Meier survival curves demonstrated no difference in overall death/stroke outcomes between the different treatment modalities' 5-year period (P=0.087). Additionally, when compared with the ARUBA interventional arm, our patients were significantly less likely to experience death/stroke (8.7% vs 30.7%; P<0.001) and functional impairment (mRS score ≥2 25.4% vs 46.2%; P<0.01)., Conclusion: Our results suggest that intervention for unruptured brain AVMs at comprehensive stroke centers across the United States is safe., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objective: Postoperative thrombotic complications represent a unique challenge in cranial neurosurgery as primary treatment involves therapeutic anticoagulation. The decision to initiate therapy and its timing is nuanced, as surgeons must balance the risk of catastrophic intracranial hemorrhage (ICH). With limited existing evidence to guide management, current practice patterns are subjective and inconsistent. The authors assessed their experience with early therapeutic anticoagulation (≤ 7 days postoperatively) initiation for thrombotic complications in neurosurgical patients undergoing cranial surgery to better understand the risks of catastrophic ICH., Methods: Adult patients treated with early therapeutic anticoagulation following cranial surgery were considered. Anticoagulation indications were restricted to thrombotic or thromboembolic complications. Records were retrospectively reviewed for demographics, surgical details, and anticoagulation therapy start. The primary outcome was the incidence of catastrophic ICH, defined as ICH resulting in reoperation or death within 30 days of anticoagulation initiation. As a secondary outcome, post-anticoagulation cranial imaging was reviewed for new or worsening acute blood products. Fisher's exact and Wilcoxon rank-sum tests were used to compare cohorts. Cumulative outcome analyses were performed for primary and secondary outcomes according to anticoagulation start time., Results: Seventy-one patients satisfied the inclusion criteria. Anticoagulation commenced on mean postoperative day (POD) 4.3 (SD 2.2). Catastrophic ICH was observed in 7 patients (9.9%) and was associated with earlier anticoagulation initiation (p = 0.02). Of patients with catastrophic ICH, 6 (85.7%) had intra-axial exploration during their index surgery. Patients with intra-axial exploration were more likely to experience a catastrophic ICH postoperatively compared to those with extra-axial exploration alone (OR 8.5, p = 0.04). Of the 58 patients with postoperative imaging, 15 (25.9%) experienced new or worsening blood products. Catastrophic ICH was 9 times more likely with anticoagulation initiation within 48 hours of surgery (OR 8.9, p = 0.01). The cumulative catastrophic ICH risk decreased with delay in initiation of anticoagulation, from 21.1% on POD 2 to 9.9% on POD 7. Concurrent antiplatelet medication was not associated with either outcome measure., Conclusions: The incidence of catastrophic ICH was significantly increased when anticoagulation was initiated within 48 hours of cranial surgery. Patients undergoing intra-axial exploration during their index surgery were at higher risk of a catastrophic ICH.

Deep-brain stimulation (DBS) is an effective treatment for patients suffering from otherwise therapy-resistant psychiatric disorders, including obsessive-compulsive disorder. Modulation of cortico-striatal circuits has been suggested as a mechanism of action. To gain mechanistic insight, we monitored neuronal activity in cortico-striatal regions in a mouse model for compulsive behavior, while systematically varying clinically-relevant parameters of internal-capsule DBS. DBS showed dose-dependent effects on both brain and behavior: An increasing, yet balanced, number of excited and inhibited neurons was recruited, scattered throughout cortico-striatal regions, while excessive grooming decreased. Such neuronal recruitment did not alter basic brain function such as resting-state activity, and only occurred in awake animals, indicating a dependency on network activity. In addition to these widespread effects, we observed specific involvement of the medial orbitofrontal cortex in therapeutic outcomes, which was corroborated by optogenetic stimulation. Together, our findings provide mechanistic insight into how DBS exerts its therapeutic effects on compulsive behaviors., (© 2023. Springer Nature Limited.)

Objective: In 2020, the coronavirus disease 2019 (COVID-19) pandemic exposed existing stressors in the neurosurgical care infrastructure in the United States. We aimed to detail innovative technologic solutions inspired by the pandemic-related restrictions that augmented neurosurgical education and care delivery., Methods: Several digital health and audiovisual innovations were implemented, including use of remote video technology to facilitate inpatient consultations and outpatient ambulatory virtual visits, optimize regional hospital neurosurgical coverage, expand interdisciplinary patient management conferences (i.e., tumor board), and further enhance the neurosurgical resident education program. Enterprise patient experience data were queried to evaluate patient satisfaction following the switch to virtual visits., Results: Between January 2020 and April 2021, use of virtual visits more than doubled in the Department of Neurosurgery. A survey of 10,772 patients following ambulatory visits showed that virtual visits were equal if not better in providing satisfactory patient care than in-person visits. After switching our interdisciplinary spine tumor board to a virtual meeting, we increased surgeon participation and attendance by 49.29%. Integration of remote audiovisual technology in resident didactics and clinical training improved our ability to provide comprehensive and personalized educational experiences our trainees., Conclusions: Digital health technology has improved neurosurgical care and comprehensive training at our institution. Investment in the technologic infrastructure required for these remote audiovisual services during the COVID-19 pandemic will facilitate the expansion of neurosurgical care provision for patients across the United States in the future. Governing bodies within organized neurosurgery should advocate for the continued financial and licensing support of these service on a national fiscal and policy level., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: Deep brain stimulation (DBS) is a well-established therapy for the management of patients with advanced Parkinson's disease and other movement disorders. Patients implanted with DBS require life-long management of the medical device as well as medications. Patients are often challenged to frequently visit the specialized DBS centers and such challenges are aggravated depending on geography, socioeconomic factors, and support systems. We discuss the need for digital health solutions to overcome these barriers to better and safely take care of patients, especially in the current COVID-19 pandemic., Materials and Methods: A review of the literature was conducted for technology and logistics necessary in forming a digital health program., Results: Digital health encounters can take place in both a synchronous and asynchronous manner. Factors involving patients include cognitive capacity, physical safety, physical capacity, connectivity, and technological security. Physician factors include examining the patient, system diagnostics, and adjusting stimulation or medications. Technology is focused on bridging the gap between patient and physician through integrating the DBS lead, implantable pulse generator (IPG), programmer, novel devices/applications to grade motor function, and teleconference modalities., Conclusions: For patients with Parkinson's disease, digital health has the potential to drastically change the landscape after DBS surgery. Furthermore, technology is fundamental in connectivity, diagnostic evaluation, and security in order to create stable and useful patient-focused care., (© 2020 International Neuromodulation Society.)

Background: Virtual visits (VVs) are a modality for delivering health care services remotely through videoconferencing tools. Data about patient and physician experience in using VVs are limited., Objective: The purpose of this study was to assess patient and physician experience with the use of VVs in cardiac electrophysiology., Methods: We performed a prospective survey of cardiac electrophysiology patients and physicians who participated in an outpatient VV from December 2018 to July 2019., Results: One-hundred consecutive VVs were included. Sixty-four patients elected to complete a survey. Patients rated their experience as either excellent/very good in scheduling a VV (87%), seeing their physician of choice (100%), transmitting arrhythmia data (88%), rating their physician's ability to communicate (98%), asking all questions (98%), rating the level of care received (98%), paying for the cost of a VV (67%), and rating their overall level of satisfaction (98%). Thirty-eight of 64 patients (59.4%) preferred a VV for their next visit, 12 of 64 (18.8%) preferred an in-office visit, 13 of 64 (20.3%) responded that their decision for a virtual or office visit depended on indication, and 1 of 64 (1.6%) had no preference. A total of 14 cardiac electrophysiologists participated in 100 VVs. Nine visits were not included due to technical difficulty. Physician responses to survey questions were rated as excellent/very good in the ability to communicate (92%), accessing monitoring data (95%), and overall level of satisfaction (98%)., Conclusion: In our small study population, most patients and physicians prefer VVs. Convenience, cost, and reason for follow-up were important determinants that affected both patient and physician preference., (Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Introduction: The 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., Methods: Our 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., Results: From 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., Conclusion: The 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., Competing Interests: Competing interests: MB is a consultant for Rebound Therapeutics and Stryker Neurovascular. MSH is a consultant for Cerenovus. PAR is on the Medical Advisory Board for Mehana Medical, Stryker Neurovascular, Medtronic Neurovascular, Perflow Medical, and has an Equity Position in Mehana Medical, Perflow Medical, and Bard Neurovascular. GT is a consultant for Dynamed EBSCO., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The guideline for treating unruptured brain arteriovenous malformations (ubAVMs) remains controversial. A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) reported lower risk of stroke or death with conservative management compared to interventional treatment. There were numerous limitations to the study, including short follow-up period and disproportionate number of patients treated with surgery and embolization., Objective: To evaluate whether treatment of ARUBA-eligible patients have acceptable outcomes at our institution., Methods: Retrospective analysis was performed on 673 patients with brain AVMs treated at our institution between 2001 and 2014. One hundred five patients were ARUBA eligible and included in the study. Patients were divided into the microsurgery or Gamma Knife Radiosurgery (GKS; Elekta, Stockholm, Sweden) arm depending on their final treatment. Mean follow-up period was 43 mo (range 4-136 mo). Primary outcome was stroke or death., Results: A total of 8 (7.6%) patients had a stroke or died. The overall risk of stroke or death was 11.4% (5 of 44 patients) for the microsurgery arm and 4.9% (3 of 61 patients) for the GKS arm. The annual rates of stroke or death were 2.1%, 4.0%, and 1.2% for the entire patient cohort, microsurgery arm, and GKS arm, respectively. AVM obliteration rates at the end of the follow-up period were 95.5% and 47.5% for the microsurgery and GKS arms, respectively., Conclusion: We report a lower overall risk of stroke or death in our ARUBA-eligible patients following treatment than ARUBA. Our results suggest that microsurgery and GKS may be appropriate treatments for patients with ubAVM.

Removing the geographic barriers to health care and extending care to the home has been the goal of the health-care system for decades as the introduction of new information technology capabilities has driven operational efficiencies in our daily lives. Patient demand for convenience and access continues to surge as these technologies are used for their personal lives. Coupled with the need to lower our health-care cost structure, distance health technologies are emerging as a care facilitator for our arthroplasty patients. A critical aspect of introducing distance health technologies is the requirement to define the entire episode of care. Once defined, metrics to assess success can be measured, and clinical and technical outcomes can be determined. Distance health technologies are emerging in the management of the arthroplasty episode of care through the preponderance of connectivity coupled with the adoption of mobile technologies, ushering in a new era of improved efficiency, efficacy, satisfaction, and outcomes while providing greater value for our patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background and Purpose- Endovascular therapy in an extended time window has been shown to be beneficial in selected patients. This study correlated angiographic outcomes of patients randomized to endovascular therapy with clinical and imaging outcomes in the DEFUSE 3 study (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3). Methods- Angiograms were assessed for the primary arterial occlusive lesion and the modified Thrombolysis in Cerebral Infarction (TICI) score at baseline and the final modified TICI score. Clinical outcomes were assessed using an ordinal analysis of 90-day modified Rankin Scale and a dichotomous analysis for functional independence (modified Rankin Scale score of 0-2). TICI scores were correlated with outcome, types of device used for thrombectomy, and 24-hour follow-up imaging. Results- TICI 2B-3 reperfusion was achieved in 70 of 92 patients (76%). TICI 2B-3 reperfusion showed a more favorable distribution of Rankin scores compared with TICI 0-2A; odds ratio, 2.77; 95% confidence interval, 1.17-6.56; P=0.019. Good functional outcome (90-day modified Rankin Scale score of 0-2) increased with better TICI scores ( P=0.0028). There was less disability comparing TICI 3 patients to TICI 2B patients ( P=0.037). Successful reperfusion (TICI 2B-3) was independent of the device used, the site of occlusion (internal carotid artery or M1) or adjunctive use of carotid angioplasty and stenting. Significantly less infarct growth at 24 hours was seen in TICI 3 patients compared with TICI 0-2A ( P=0.0015) and TICI 2B ( P=0.0002) patients. Conclusions- Thrombectomy in an extended time window demonstrates similar rates of TICI 2B-3 reperfusion to earlier time window studies. Successful reperfusion was independent of the device used, the site of occlusion or adjunctive use of carotid angioplasty and stenting. TICI 3 reperfusion was more likely to result in low rates of infarct growth at 24 hours and good functional outcome at 90 days. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT02586415.

Carotid-cavernous fistula was one of the first intracranial vascular lesions to be recognized. This paper focuses on the historical progression of our understanding of the condition and its symptomatology-from the initial hypothesis of ophthalmic artery aneurysm as the cause of pulsating exophthalmos to the recognition and acceptance of fistulas between the carotid arterial system and cavernous sinus as the true etiology. The authors also discuss the advancements in treatment from Benjamin Travers' early common carotid ligation and wooden compression methods to today's endovascular approaches.

Objective: To summarize the current literature regarding the initial hospital management of patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO), and to offer recommendations designed to decrease the time to endovascular treatment (EVT) for appropriately selected patients with stroke., Methods: Using guidelines for evidenced-based medicine proposed by the Stroke Council of the American Heart Association, a critical review of all available medical literature supporting best initial medical management of patients with AIS secondary to ELVO was performed. The purpose was to identify processes of care that most expeditiously determine the eligibility of a patient with an acute stroke for interventions including intravenous fibrinolysis with recombinant tissue plasminogen activator (IV tPA) and EVT using mechanical embolectomy., Results: This review identifies four elements that are required to achieve timely revascularization in ELVO. (1) In addition to non-contrast CT (NCCT) brain scan, CT angiography should be performed in all patients who meet an institutional threshold for clinical stroke severity. The use of any advanced imaging beyond NCCT should not delay the administration of IV tPA in eligible patients. (2) Activation of the neurointerventional team should occur as soon as possible, based on either confirmation of large vessel occlusion or a prespecified clinical severity threshold. (3) Additional imaging techniques, particularly those intended to physiologically select patients for EVT (CT perfusion and diffusion-perfusion mismatch imaging), may provide additional value, but should not delay EVT. (4) Routine use of general anesthesia during EVT procedures, should be avoided if possible. These workflow recommendations apply to both primary and comprehensive stroke centers and should be tailored to meet the needs of individual institutions., Conclusions: Patients with ELVO are at risk for severe neurologic morbidity and mortality. To achieve the best possible clinical outcomes stroke centers must optimize their triage strategies. Strategies that provide patients with ELVO with the fastest access to reperfusion depend upon detail-oriented process improvement., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Surgical intervention has been proposed as a means of reducing the high morbidity and mortality associated with acute intracerebral hemorrhage (ICH), but many previously reported studies have failed to show a clinically significant benefit. Newer, minimally invasive approaches have shown some promise., Objective: We report our early single-center technical experience with minimally invasive clot evacuation using the BrainPath system., Methods: Prospective data were collected on patients who underwent ICH evacuation with BrainPath at the Cleveland Clinic from August 2013 to May 2015., Results: Eighteen patients underwent BrainPath evacuation of ICH at our center. Mean ICH volume was 52.7 mL ± 22.9 mL, which decreased to 2.2 mL ± 3.6 mL postevacuation, resulting in a mean volume reduction of 95.7% ± 5.8% (range 0-14 mL, P < .001). In 65% of patients, a bleeding source was identified and treated. There were no hemorrhagic recurrences during the hospital stay. In this cohort, only 1 patient (5.6%) died in the first 30 days of follow-up. Median Glasgow Coma Score improved from 10 (interquartile range 5.75-12) preoperation to 14 (interquartile range 9-14.25) postoperation. Clinical follow-up in this cohort is ongoing., Conclusion: Evacuation of ICH using the BrainPath system is safe and technically effective. The volume of clot removed compares favorably with other published studies. Early improved clinical outcomes are suggested by improvement in Glasgow Coma Score and reduced 30-day mortality. Ongoing analysis is necessary to elucidate long-term clinical outcomes and the subsets of patients who are most likely to benefit from surgery., (Copyright © 2016 by the Congress of Neurological Surgeons)

Background: There is scant information on in-stent stenosis after flow diversion treatment of intracranial aneurysms with the Pipeline Embolization Device (PED)., Objective: To assess the incidence, severity, nature, and clinical consequences of in-stent stenosis on angiographic follow-up after treatment with the PED., Methods: 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 at <25%. In-stent stenosis represented an area of parent vessel narrowing, most often focal, graded as mild (25%-50%), moderate (50%-75%), or severe (>75%)., Results: 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., Conclusion: 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., Abbreviation: FD, flow diverter.

Background: Surfer's myelopathy is a rare, acute, atraumatic myelopathy that occurs in novice surfers., Objective: To review the literature and to present an illustrative case., Methods: Medical literature was queried for all reports of this condition, systematically abstracted, and analyzed. An illustrative case that provides the most definitive support for a vascular cause is presented. Treatment considerations based on prior cases and expert opinions are provided., Results: Sixty-four cases of surfer's myelopathy have been reported to date. This atraumatic thoracic/conus medullaris myelopathy with only a 42% neurological recovery rate almost uniformly affects young, healthy, novice surfers who have no pre-existent spinal disease. Symptoms usually start with back pain and rapidly progress to complete or incomplete myelopathy. T2 magnetic resonance images show increased signal in the central spinal cord within 24 to 72 hours. Gadolinium enhancement and diffusion-weighted imaging are not helpful. Angiography has been underused. Angiogram in our case showed the absence of a right T12 radicular artery and no artery of Adamkiewicz, which, along with clinical findings, support the vascular origin theory. Incomplete cases often improve within 24 hours of onset, whereas no improvement has been reported for American Spinal Injury Association class A cases. Several acute interventions have been tried. Steroids are most common, and patients receiving steroids improved 55% of the time with no reported adverse effects., Conclusion: Surfer's myelopathy is a clinical entity associated with complete deficit in >50% of cases. Its prognosis is almost exclusively dictated by severity at presentation/nadir. Thus, publicizing this rare but serious condition (within and outside the medical literature) may be an effective intervention.

Stroke remains the fifth leading cause of death in the United States, despite declining morbidity and mortality rates. Patients who receive timely care provided by mobile stroke treatment unit staffs have dramatically improved outcomes compared with patients who receive initial treatment in an emergency department. Portable imaging technology and wireless communication devices have contributed significantly to shorter time to treatment, which is a key factor in improved outcomes., (Copyright © 2015 Cleveland Clinic.)

Background and Importance: The publication of the COSS (Carotid Occlusion Surgery Study) trial in 2011 concluded that the addition of external carotid to internal carotid (EC-IC) bypass to a medical regimen "did not reduce the risk of ipsilateral ischemic stroke at 2 years" for patients with symptomatic internal carotid artery occlusion. This has resulted in decreasing referrals for surgical management under the guise of "evidence-based" medicine. The conclusions drawn from a study can only be as good as the selected end points. COSS did not consider important end points such as the effects of long-term cerebral ischemia or recurrent debilitating transient ischemic attacks (TIAs). However, the study is often quoted as "proof" that EC-IC bypass has no role in the treatment of these patients., Clinical Presentation: A middle-aged patient presented to a primary neurologist with left-sided weakness and 2 months of personality changes. Magnetic resonance imaging (MRI) showed small watershed infarcts in the right hemisphere. An angiogram showed right carotid occlusion. Perfusion scans confirmed hypoperfusion. The patient was managed medically. Without any further clinical stroke events, the patient progressed to complete hemispheric infarction on MRI over the next 5 months., Conclusion: The public perception of the results of large randomized clinical trials is significantly altered by their ubiquitous dissemination and broad generalization without adequate understanding of the details. Careful assessment of the methodology and end points of a trial are essential when applying the results for evidence-based medicine to individual patients. This patient would have been considered a medical "success" in COSS, but her outcome with surgical intervention will never be known., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Brain arteriovenous malformations (BAVM) are some of the most complex lesions treated by clinical neuroscientists. The recent publication of the ARUBA trial, showing higher complication rates with treatment compared with the natural history over a short period of follow-up, puts even more pressure on the physician to achieve complete BAVM eradication without complication. These lesions are often treated by multimodality therapy with some combination of endovascular embolization, radiosurgery, and microsurgical resection; however, multimodality therapy involves the additive risk of procedural complication with each procedure. While surgical resection has long been accepted as monotherapy with good cure rates, staged pre-operative endovascular embolization has facilitated microsurgical resection with lower blood loss. Endovascular embolization is more often utilized in conjunction with surgical resection, and often the portions of the AVM and feeders that are completely embolized with Onyx or glue may not be surgically resected since they have been "internally obliterated." We present a case where the AVM was preoperatively embolized with Onyx and subsequently partially surgically resected. Post-operative angiography showed complete obliteration or "cure" of the AVM with no filling of the nidus or early venous drainage. The patient presented 12 months later with seizures and imaging showed volume loss in the residual Onyx cast and recanalization of the AVM nidus. The patient subsequently underwent repeat resection with complete removal of the residual AVM and Onyx cast. To our knowledge this is the first published report of volume loss within the Onyx cast leading to recanalization of the AVM nidus. This suggests that extreme care should be taken with partial resection of the AVM nidus or with embolization for cure, as late recanalization may occur., (© The Author(s) 2015.)

Telestroke and teleneurologic intensive care units (teleneuro-ICUs) optimize the diagnosis and treatment of neurologic emergencies. Establishment of a telestroke or teleneuro-ICU program relies on investment in experienced stroke and neurocritical care personnel as well as advanced telecommunications technologies. Telemanagement of neurologic emergencies can be standardized to improve outcomes, but it is essential to have a relationship with a tertiary care facility that can use endovascular, neurosurgical, and neurocritical care advanced therapies after stabilization. The next stage in telestroke/teleneuro-ICU management involves the use of mobile stroke units to shorten the time to treatment in neurocritically ill patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background and Purpose: Intraarterial (IA) mechanical thrombectomy has an excellent recanalization rate but does not always correlate with good clinical outcomes. We aimed to investigate whether hyperdense middle cerebral artery sign (HMCAS) on preintervention nonenhanced CT (NECT) predicts IA therapy outcome for acute stroke., Methods: Data were abstracted from our Hyperacute Ischemic Stroke database. Patients with occlusion in ICA, MCA, or MCA M2 branches who underwent IA therapy were included., Results: Among 126 patients who underwent IA treatment, 64 (51%) had hyperdense M1 MCA sign (M1 HMCAS), 11 (9%) had hyperdense M2, and 51 (40%) had No HMCAS (NHMCAS).M1 HMCAS and NHMCAS group has comparable baseline stroke severity and infarct volume (P > .05); and the differences of favorable outcome (modified Rankin Score 0-2) at 30 days were not significant (21% vs. 30%, P = .259). For those with HMCAS, favorable 30-day outcome was most frequent in Distal HMCAS (39%), followed by hyperdense M2 (27%), HMCAS proximal (11%), and HMCAS full length (0%)., Conclusions: For acute ischemic stroke due to large vessel occlusion, the lack of HMCAS on NECT does not predict favorable outcome after IA therapy. Among those with HMCAS, proximal and longer HMCAS predicts unfavorable outcome., (Copyright © 2014 by the American Society of Neuroimaging.)

Background: Stable access to target lesions is foundational to endovascular therapy, be it in hemorrhagic or ischemic disease. Continued evolution in access technology has resulted in next generation catheters that afford improved trackability and proximal support., Objective: Assess safety and patterns of use at two high volume centers, and conceptualize usage patterns., Materials and Methods: A retrospective review of 608 cases in which a 'next generation' catheter was used during 2008-2010 at Cleveland Clinic (Cleveland, Ohio, USA) and throughout 2009-2010 at Emory University Hospital (Atlanta, Georgia, USA) was conducted, and the cases classified by indication. Catheter placement, distal most location, and related complications were recorded and experience summarized. We also reviewed the differences in the catheters and the rationale for catheter selection, as well as relative costs for each approach., Results: 311 Neuron 053, 166 Neuron 070, 36 distal access catheter (DAC) 3.9 F, 61 DAC 4.3 F, and 34 DAC 5.2 F catheters were deployed. Of these, 459 placements were in the anterior circulation, 130 in the posterior circulation, 11 in the external carotid artery, and eight were used intravenously. Complication rates were 9/131 (6.9%) for the DAC catheter group, 16/311 (5.1%) for the Neuron 053 group, and 14/166 (8.4%) for the Neuron 070 group (p=0.37, χ(2) test)., Conclusions: Next generation access catheters possess characteristics that blend qualities of traditional microcatheters and stiff guide catheters. There was no statistically significant difference in complication rates between the various catheter families in this small retrospective review, and the complication rates were similar to historical complication rates., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Object: The appropriate dose during stereotactic radiosurgery (SRS) of cerebral arteriovenous malformations (AVMs) remains a matter of debate. In the present study, the authors retrospectively evaluated the association of using a prescribed dose calculated utilizing the K index with the obliteration rate of cerebral AVMs after SRS., Methods: The authors performed a retrospective analysis of the Cleveland Clinic SRS database. All patients undergoing Gamma Knife radiosurgery for cerebral AVMs from 1997 to 2010 were selected. Regression techniques and Kaplan-Meier analyses were used to investigate the effect of divergence from the optimal K index dose on the rate of AVM obliteration., Results: In the study period 152 patients (mean age 43.6 years; 53.9% of treatments were performed in females) underwent 165 Gamma Knife radiosurgery treatments for AVMs. In a univariate analysis Spetzler-Martin grade (OR 0.63 [95% CI 0.42-0.93]), higher AVM score (OR 0.43 [95% CI 0.27-0.70]), larger AVM volume (OR 0.88 [95% CI 0.82-0.94]), and higher maximum diameter (OR 0.56 [95% CI 0.41-0.77]) were associated with a lower rate of AVM obliteration. Higher margin dose (OR 1.16 [95% CI 1.08-1.24]) and higher maximum dose (OR 1.08 [95% CI 1.04-1.13]) were associated with a higher obliteration rate. To further examine the effect of prescribed dose divergence from the calculated K index dose, cases were classified to groups depending on the AVM volume and dose variance from the ideal K index dose. Contingency tables and Kaplan-Meier curves were then created, and no significant differences in rates of obliteration were noted among the different groups., Conclusions: Gamma Knife radiosurgery for cerebral AVMs remains an effective and safe treatment modality. Smaller AVMs may receive doses less than the calculated K index dose without an apparent effect on obliteration rates.

Vasospasm has been a long known source of delayed morbidity and mortality in aneurysmal subarachnoid hemorrhage patients. Delayed ischemic neurologic deficits associated with vasospasm may account for as high as 50% of the deaths in patients who survive the initial period after aneurysm rupture and its treatment. The diagnosis and treatment of vasospasm has still been met with some controversy. It is clear that subarachnoid hemorrhage is best cared for in tertiary care centers with modern resources and access to cerebral angiography. Ultimately, a high degree of suspicion for vasospasm must be kept during ICU care, and any signs or symptoms must be investigated and treated immediately to avoid permanent stroke and neurologic deficit. Treatment for vasospasm can occur through both ICU intervention and endovascular administration of intra-arterial vasodilators and balloon angioplasty. The best outcomes are often attained when these methods are used in conjunction. The following article reviews the literature on cerebral vasospasm and its treatment and provides the authors' approach to treatment of these patients.

Background: The development of detachable coils is one of the most pivotal developments in neurointervention, providing a tool that could be used to treat a wide variety of hemorrhagic stroke. From the original Guglielmi detachable coil, a number of different coil designs and delivery designs have evolved. This article reviews the history of commercially available detachable coils., Methods: A timeline of detachable coils was constructed and coil design philosophies were reviewed., Results: A complete list of commercially available coils is presented in a timeline format., Conclusions: Detachable coil technology continues to evolve. Advances in construction and design have yielded products which may benefit patients in terms of safety, radiation dose reduction and cost of treatment. Continued evolution is expected, irrespective of competing disruptive technologies.

Background and Purpose: The failure of recent trials to show the effectiveness of acute endovascular stroke therapy (EST) may be because of inadequate patient selection. We implemented a protocol to perform pretreatment MRI on patients with large-vessel occlusion eligible for EST to aid in patient selection., Methods: We retrospectively identified patients with large-vessel occlusion considered for EST from January 2008 to August 2012. Patients before April 30, 2010, were selected based on computed tomography/computed tomography angiography (prehyperacute protocol), whereas patients on or after April 30, 2010, were selected based on computed tomography/computed tomography angiography and MRI (hyperacute MRI protocol). Demographic, clinical features, and outcomes were collected. Univariate and multivariate analyses were performed., Results: We identified 267 patients: 88 patients in prehyperacute MRI period and 179 in hyperacute MRI period. Fewer patients evaluated in the hyperacute MRI period received EST (85 of 88, 96.6% versus 92 of 179, 51.7%; P<0.05). The hyperacute-MRI group had a more favorable outcome of a modified Rankin scale 0 to 2 at 30 days as a group (6 of 66, 9.1% versus 33 of 140, 23.6%; P=0.01), and when taken for EST (6 of 63, 9.5% versus 17 of 71, 23.9%; P=0.03). On adjusted multivariate analysis, the EST in the hyperacute MRI period was associated with a more favorable outcome (odds ratio, 3.4; 95% confidence interval, 1.1-10.6; P=0.03) and reduced mortality rate (odds ratio, 0.16; 95% confidence interval, 0.03-0.37; P<0.001)., Conclusions: Implementation of hyperacute MRI protocol decreases the number of endovascular stroke interventions by half. Further investigation of MRI use for patient selection is warranted.

Objective: A study on factors of material costs in endovascular coil embolization has not been previously reported. The aim of this study was to assess the effect of aneurysm size and other factors on implanted coil costs., Methods: Implanted coil costs were retrospectively obtained for all 387 consecutive aneurysm coiling procedures of saccular aneurysms performed in 342 patients over 2.5 years at the Cleveland Clinic. ANOVA and least squares linear regression were utilized to examine relationships., Results: Linear regression analysis showed a significant relationship between log volume and log cost (p<0.0001). The fit relationship can be represented as normalized cost=1.6×volume(0.36). Other factors (aneurysm geometry, recurrent vs primary, vendor/coil choice, procedure dates) were not shown to be significant at the p<0.05 level., Conclusions: The costs associated with the coils implanted in an aneurysm vary in a predictable fashion as a function of aneurysm volume, suggesting that coiling costs can be modeled prior to actual embolization of a lesion and may be useful in refining the reimbursement models for endovascular aneurysm treatment.

Introduction: Surgical simulation provides a zero-risk setting in which technical skills can be obtained through repetition. The feasibility and utility of simulated diagnostic cerebral angiography among neurosurgical residents and fellows was studied using an endovascular biplane angiography simulator., Methods: Ten neurosurgical residents and four endovascular neurosurgery fellows were recruited into a standardized training protocol consisting of a didactic, demonstration and hands-on learning environment using the Simbionix simulator. Participants were instructed to catheterize the right internal carotid artery, left internal carotid artery and left vertebral artery. The task was repeated five times., Results: All participants demonstrated improvement over the five trials. Residents performed actions that were perceived as potentially dangerous (n=8) while fellows performed the procedure with superior technique. Residents performed the task with an initial total procedure and fluoroscopy time of 6.6 ± 4.3 min and 4.9 ± 3.7 min, respectively, and improved on the fifth trial to 3.4 ± 1.3 min (p=0.03) and 2.3 ± 0.78 min (p=0.004), respectively. Residents approximated the efficiency of fellows for the third and fourth trial., Conclusions: Incorporating an endovascular simulator is feasible for training purposes in a neurosurgical residency program. This study provides objective documentation of the facilitation of technical angiography skill acquisition by the use of simulation technology.

Background: Symptomatic intracranial atherosclerotic disease (ICAD) worldwide represents one of the most prevalent causes of stroke. When severe, studies show that it has a very high risk for recurrent stroke, highlighting the need for effective preventative strategies. The mainstay of treatment has been medical therapy and is of critical importance in all patients with this disease. Endovascular therapy is also a possible therapeutic option but much remains to be defined in terms of best techniques and patient selection. This guideline will serve as recommendations for diagnosis and endovascular treatment of patients with ICAD., Methods: A literature review was performed to extract published literature regarding ICAD, published from 2000 to 2011. Evidence was evaluated and classified according to American Heart Association (AHA)/American Stroke Association standard. Recommendations are made based on available evidence assessed by the Standards Committee of the Society of NeuroInterventional Surgery. The assessment was based on guidelines for evidence based medicine proposed by the American Academy of Neurology (AAN), the Stroke Council of the AHA and the University of Oxford, Centre for Evidence Based Medicine (CEBM)., Results: 59 publications were identified. The SAMMPRIS study is the only prospective, randomized, controlled trial available and is given an AHA level B designation, AAN class II and CEBM level 1b. The Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial arteries (SSYLVIA) trial was a prospective, non-randomized study with the outcome assessment made by a non-operator study neurologist, allowing an AHA level B, AAN class III and CEBM level 2. The remaining studies were uncontrolled or did not have objective outcome measurement, and are thus classified as AHA level C, AAN class IV and CEBM level 4., Conclusion: Medical management with combination aspirin and clopidogrel for 3 months and aggressive risk factor modification is the firstline therapy for patients with symptomatic ICAD. Endovascular angioplasty with or without stenting is a possible therapeutic option for selected patients with symptomatic ICAD. Further studies are necessary to define appropriate patient selection and the best therapeutic approach for various subsets of patients.

Stroke is the third leading cause of death in the United States, Canada, Europe, and Japan. According to the American Heart Association and the American Stroke Association, there are now 750,000 new strokes that occur each year, resulting in 200,000 deaths, or 1 of every 16 deaths, per year in the United States alone. Endovascular therapy for patients with acute ischemic stroke is an area of intense investigation. The American Stroke Association has given a qualified endorsement of intra-arterial thrombolysis in selected patients. Intra-arterial thrombolysis has been studied in 2 randomized trials and numerous case series. Although 2 devices have been granted FDA phase 3 approval with an indication for mechanical stroke thrombectomy, none of these thrombectomy devices has demonstrated efficacy for the improvement of patient outcomes. The purpose of the present document is to define what constitutes adequate training to perform neuroendovascular procedures in patients with acute ischemic stroke and what performance standards should be adopted to assess outcomes. These guidelines have been written and approved by multiple neuroscience societies that historically have been directly involved in the medical, surgical and endovascular care of patients with acute stroke. These organizations include the Neurovascular Coalition and its participating societies, including the Society of NeuroInterventional Surgery (SNIS), American Academy of Neurology (AAN), American Association of Neurological Surgeons/Cerebrovascular Section (AANS/CNS), and Society of Vascular & Interventional Neurology (SVIN).