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Endovascular thrombectomy (EVT) is efficacious in patients with large vessel occlusion stroke (LVO). We explored whether internal carotid (ICA) tortuosity increases the technical difficulty of EVT thereby lowering the chances of successful recanalization and favorable outcomes. Consecutive patients with LVO and patent ICAs who underwent EVT were included. Carotid tortuosity was determined on pre-EVT CTA and classified by raters blinded to outcomes into: type 1—straight ICA trunk and type 2—severe tortuosity potentially impeding adequate catheter placement. Thrombolysis in cerebral infarction (TICI) 2b-3 was considered successful recanalization, and 90-day-modified Rankin Scale ≤ 2 was considered favorable functional outcome. Among 302 patients (mean age 70 ± 15, median NIHSS 17), 53% had type 1, and 47% type 2 tortuosity. Overall, 85% had successful recanalization. Patients with type 2 tortuosity were significantly older (p

Background The artery of Wollschlaeger and Wollschlaeger is a tentorial branch of the superior cerebellar artery that is usually not visualized on conventional cerebral angiography, unless it is pathologically enlarged. It can be recruited as part of the blood supply to tentorial dural arteriovenous fistulas (AVFs), although this occurs infrequently. Case Description Here we report the clinico-radiologic evaluation and treatment of a 48-year-old man referred to our institution for hitherto workup negative progressive, relapsing quadriparesis. This represents the first reported case of cervical myelopathy caused by venous congestion from a type V dural AVF supplied by the artery of Wollschlaeger and Wollschlaeger. Conclusions The anatomic discrepancy between the symptomatic spinal cord lesion and the etiologic intracranial fistula frequently results in delayed care in cases of myelopathy due to intracranial dural AVFs. Familiarity with these disorders and of their pathophysiologic mechanisms is important to avoid unnecessary diagnostic delays.

Background and Purpose: Endovascular therapy for acute ischemic stroke has revolutionized clinical care for stroke patients with large vessel occlusion (LVO), but treatment remains time sensitive. At our stroke center, up to half of the door-to-groin time is accounted for after the patient arrives in the neuro-interventional radiology (NIR) suite. Here we apply the concept of a highly visible timer in the NIR suite to quantify the impact on endovascular treatment time in stroke patients with LVO. Methods: This was a single-center prospective pseudo-randomized study conducted over a 32-week period (September 14, 2020 through April 25, 2021). Pseudo-randomization was achieved by turning the timer on and off in 2-week intervals. The primary outcome and secondary outcomes were reduction in IR to groin time and 90-day mRS, respectively. We also performed a stratified analysis based on anesthesia status for the procedure along with a multivariate regression to evaluate the effect of the intervention on treatment time while accounting for endotracheal intubation. Results: During the 32-week study period, 97 mechanical thrombectomies were performed. The timer was ON and OFF for 38 and 59 cases, respectively. The timer resulted in a reduction in IR-to-groin time (27.7 mins vs 32.6 mins; p=0.02). Endotracheal intubation (80% of overall cohort) was associated with a longer NIR-to-groin time (33 mins vs 23 mins; p Conclusions: A highly visible timer in the NIR suite achieved a meaningful, albeit modest, reduction in endovascular treatment time for stroke patients with LVO. A larger study would be necessary to measure a potential impact on long-term functional outcome, and a multi-center study may be necessary to confirm generalizability. However, based on these results, the lack of risk, and low cost, it is reasonable for stroke centers to consider using a highly visible timer in the NIR suite to improve stroke treatment times.

INTRODUCTION: Mechanical thrombectomy is revolutionizing treatment of acute stroke due to large vessel occlusion (LVO). Unfortunately, use of the modified Thrombolysis in Cerebral Infarction score (mTICI) to characterize recanalization of the cerebral vasculature does not address microvascular perfusion of the distal parenchyma, nor provide more than a vascular “snapshot”. Thus, little is known about tissue-level hemodynamic consequences of LVO recanalization. Diffuse correlation spectroscopy (DCS) and diffuse optical spectroscopy (DOS) are promising methods for continuous, non-invasive, contrast-free transcranial monitoring of cerebral microvasculature. METHODS: Here we use a combined DCS/DOS system to monitor frontal lobe hemodynamic changes during endovascular treatment of two patients with ischemic stroke due to cervical internal carotid artery (ICA) occlusions. RESULTS AND DISCUSSION: The monitoring instrument identified a recanalization-induced increase in ipsilateral cerebral blood flow (CBF) with little or no concurrent change in contralateral CBF and extracerebral blood flow. The results suggest that diffuse optical monitoring is sensitive to intracerebral hemodynamics in patients with cervical ICA occlusion and can measure microvascular responses to mechanical thrombectomy.

The artery of Davidoff and Schechter (ADS) is the only meningeal branch of the posterior cerebral artery (PCA), supplying the medial tentorial margin and posterior portions of the falx. Given its small size, it is rarely identified on angiographic studies, unless enlarged in pathologies such as dural arteriovenous fistulas (DAVFs) or vascularized masses. This artery was first described by Wollschlaeger and Wollschlaeger in 1965, and to date, only a few reports have described its significance. The objective of this study is to report our experience with the ADS in dural fistulas from 2 tertiary medical centers and to emphasize the importance of recognizing this artery during angiographic examination of vascular tentorial and posterior fossa lesions. To our knowledge, this report demonstrates the largest angiographic case series published to date, recognizing a total of 7 patients with ADS arising secondary to a posterior fossa or tentorial DAVF and one of the largest reported series of DAVFs supplied by the ADS treated by endovascular and surgical techniques. Our cases validate the importance of prompt identification of the ADS for the diagnosis as well as endovascular treatment of vascular malformations in the posterior fossa and tentorial region.

Objective Puig types 2 through 4 venous malformations (VMs) are challenging to treat with sclerotherapy given their robust systemic outflow. Endovenous balloon occlusion offers a means of temporarily occluding systemic venous outflow to allow for more complete sclerotherapy. This study reviews our experience of implementing this technique in patients with Puig advanced (types 2 through 4) VMs. Methods An IRB approved review of treated venous malformations from 2013–2016 revealed 10 patients fitting inclusion criteria. Patient demographics, pre-procedural imaging, intra-procedural technical parameters, and post-procedural follow-up outcomes were recorded. All patients underwent temporary balloon occlusion of a systemic or major draining vein during sclerotherapy. Embolic agents included n-butyl cyanoacrylate glue, sodium tetradecyl sulfate foam, and coils. Standard 5 French angioplasty balloons ranged from 4 to 8 mm diameter and 2 to 8 cm length depending on vessel requiring occlusion. All patients underwent minimum 3-year follow-up questionnaire administration re-assessing resolution of lesion symptomology and post-procedural quality of life (QoL) measures. Results Of the 10 VMs treated, 2 were Type 2, 6 were Type 3, and 2 were Type 4. More than one sclerotherapy session was required in 7/10 patients (mean: 2, range: 1–4). Most common sites of VM systemic drainage included subclavian, popliteal, internal/external jugular, and basilic veins. All patients had no indication for further sclerotherapy following adjunctive balloon occlusion. No non-target embolization or immediate post-procedural complications occurred. Follow-up questionnaires (mean interval: 3 years 6 months, range: 3 years–3 years 11 months) confirmed the persistence of embolization effects, improved QoL, and no additional sclerotherapy sessions for all patients in the cohort. Conclusions Endovenous balloon occlusion as an adjunct to sclerotherapy can be considered when treating patients with types 2–4 venous malformations. This technique lowers the risk of non-target systemic venous embolization, allowing for operator-driven deeper intralesional sclerosant penetration and subsequently maintained treatment efficacy.

Cervical carotid artery dissections (CAD) usually produce ischemic symptoms as a result of thromboembolic phenomena, but hemodynamic insufficiency from flow-limiting stenosis can cause symptoms in a few patients [1]. CAD of the distal cervical and petrous ICA can be challenging to treat, particularly in the presence of vessel kinking or marked tortuosity of the distal cervical ICAs. The carotid stent systems used for atherosclerotic disease at the proximal ICA or carotid bulb are typically too stiff and large to safely track into a tortuous distal carotid artery, and the low radial force of the Pipeline flow diverter may occasionally result in inadequate flow restoration and even stent collapse in flow-limiting carotid dissections with large intramural thrombus burden [2,3]. In this paper, via 2 illustrative cases, we detail our experience with the latest iteration of the Neuroform stent system, the Neuroform Atlas (Stryker Neurovascular, Freemont, CA), for treatment of symptomatic flow-limiting distal cervical ICA dissections, with an emphasis on the advantages of the updated stent design.

Purpose Supported by longstanding Class I evidence from the cardiology literature showing the safety of transradial artery access for coronary angiography (Choe et al., 2016), an increasing number of neurointerventionalists have adopted the transradial approach for diagnostic cerebral angiography (Almallouhi et al., 2020). A recent study specifically showed the noninferiority of transradial arterial access compared with the transfemoral approach for cerebral angiography (Stone et al., 2020). As the transradial approach becomes more widely adopted, a few important caveats have become apparent that may preclude safe transradial arterial access (namely variant anatomy, vasospasm, or radial artery occlusion). In such cases, a transfemoral or transulnar approach may be the most feasible route for arterial access. The purpose of study was to document the feasibility and safety of ulnar artery access for both diagnostic cerebral angiography and neurointerventional cases. Materials and Methods A retrospective review of a local institutional database at a high-volume neurovascular center was performed. Consecutive diagnostic and interventional neurovascular cases completed solely via ulnar artery access over a 12-month period were reviewed and analyzed. Data including type of case (diagnostic or interventional), reason for choosing ulnar artery access, technical success for ulnar artery cannulation, successful case completion, and complications were recorded. Results The ulnar artery was accessed for 12 distinct cases in 11 patients over a 12-month period. The mean age was 52.5 years ± 16 years, and 8 total were female. Of these 12 procedures, 8 were diagnostic cerebral angiograms and 4 were neurovascular interventions. The intervention cases included pipeline flow diversion of an unruptured paraclinoid aneurysm, Pulserider stenting and coiling of an unruptured basilar tip aneurysm, coil embolization of a ruptured posterior communicating artery, and pre-operative embolization of a left cerebellopontine angle tumor. All 8 diagnostic angiograms were performed using 5 Fr sheaths and all 4 interventions required 6 Fr sheaths. The right ulnar artery was accessed in 9 out of 12 cases (75%). In all 12 cases, the ulnar artery was chosen for cannulation after ultrasound examination of the ipsilateral radial artery proved unfavorable for the procedure in question. The reasons for choosing the ulnar artery over the ipsilateral radial artery were the following: radial artery spasm (1 case), inability to pass the wire (1 case), and the remainder due to a dominant ulnar artery (ulnar artery diameter > ipsilateral radial artery diameter). All procedures were successfully completed without a need for conversion to femoral arterial access. All sites of ulnar artery access were closed via an inflatable band closure device. There were no forearm hematomas, hand ischemia, or arm nerve damage in any of the 12 cases. Conclusion Transradial arterial access has been shown to have a lower rate of access site complications when compared with the femoral approach. Our experience suggests that transulnar artery access may also be a feasible and safe alternative for diagnostic cerebral angiography and neurovascular intervention. Disclosures R. Mattay: None. M. Cox: None. P. Ramchand: None. N. Sedora-Roman: None. B. Pukenas: None. D. Kung: None. R. Hurst: None. O. Choudhri: None.

Endovascular thrombectomy (EVT) is efficacious in patients with large vessel occlusion stroke (LVO). We explored whether internal carotid (ICA) tortuosity increases the technical difficulty of EVT thereby lowering the chances of successful recanalization and favorable outcomes.Consecutive patients with LVO and patent ICAs who underwent EVT were included. Carotid tortuosity was determined on pre-EVT CTA and classified by raters blinded to outcomes into: type 1-straight ICA trunk and type 2-severe tortuosity potentially impeding adequate catheter placement. Thrombolysis in cerebral infarction (TICI) 2b-3 was considered successful recanalization, and 90-day-modified Rankin Scale ≤ 2 was considered favorable functional outcome.Among 302 patients (mean age 70 ± 15, median NIHSS 17), 53% had type 1, and 47% type 2 tortuosity. Overall, 85% had successful recanalization. Patients with type 2 tortuosity were significantly older (p 0.0001) and less frequently achieved successful recanalization (80% vs. 90%; p = 0.019) but had similar outcomes compared with those without tortuosity. On regression analysis, marked tortuosity was associated with lower chances of successful recanalization (OR 0.43 95% CI 0.20-0.92) but had no effect on clinical outcomes.Carotid tortuosity does not appear to impact the likelihood of favorable functional outcome but may influence recanalization.

Aims The purpose of our study was to analyze utilization trends and physician specialty distribution in spinal catheter angiography and magnetic resonance angiography in the Medicare fee-for-service population. Methods Data from the CMS Physician/Supplier Procedure Summary Master Files for 2004 to 2016 were used for this study. The Current Procedural Terminology version 4 codes for spinal magnetic resonance angiography (72159) and spinal catheter angiography (75705) were used to analyze the volumes of these procedures. Using Medicare’s 108 specialty code, we compared procedure volumes among physician specialties. Data analysis was performed using SAS version 9.3 for Windows. Results The volume of spinal catheter angiography performed was 4758 in 2004, peaked at 6869 in 2012, and dropped to 6656 in 2016. Overall, the volume of spinal catheter angiography increased by 40% from 2004 to 2016. Radiologists performed the majority of these procedures (3736 or 56.1%) in 2016, followed by neurosurgeons (2456 or 36.9%), and neurologists (346 or 5.2%). The spinal magnetic resonance angiography volume fluctuated between 0 and 1 from 2004 to 2009, then precipitously increased to 40 in 2010, peaked at 133 in 2011, and declined to 81 in 2016. The volume of spinal magnetic resonance angiography procedures increased by 8000% from 2004 to 2016, with radiologists performing the majority of them. Conclusion Our results show that spinal catheter angiography volumes continue to rise in the Medicare fee-for-service population, and are largely performed by radiologists, neurosurgeons, and neurologists. Although spinal magnetic resonance angiography volumes have started to increase, they comprise only a small fraction of studies performed for vascular evaluation of the spine.

Since the initial reports surfaced of a novel Coronavirus causing illness and loss of life in Wuhan, China, COVID-19 has rapidly spread across the globe infecting millions and leaving hundreds of thousands dead. As hospitals cope with the influx of COVID-19 patients, new challenges have arisen as healthcare systems care for COVID-19 patients while still providing essential emergency care for patients with acute strokes and acute myocardial infarction. Adding to this complex scenario are new reports that COVID-19 patients are at increased risk of thromboembolic complications including strokes. In this paper, we detail our experience caring for acute stroke patients, and provide some insight into neurointerventional workflow modifications that have helped us adapt to the COVID-19 era., Highlights: • COVID-19 continues its relentless march through the United States and the globe, presenting unique challenges for healthcare providers as they treat other emergent conditions while minimizing the risk of COVID-19 exposure and infection. • Acute stroke is especially challenging during the COVID-19 due to time constraints required for effective mechanical thrombectomy to improve neurologic outcomes and survival in patients whose COVID infection status is unknown. • The institutional protocol for mechanical thrombectomy described in this article may help inform models at other centers as they prepare for their respective COVID peaks

Background Subclavian steal phenomenon can cause retrograde flow in the vertebral artery as a result of ipsilateral occlusion of the subclavian artery. This phenomenon has various clinical presentations, such as claudication of the affected extremity or intermittent vertebrobasilar ischemia. Aneurysm formation in the spinal cord circulation is exceptionally rare but may occur secondary to collateral formation in subclavian steal syndrome. Case Description The case presented herein is a 53-year-old male who presented with headache and severe neck pain. Imaging studies revealed that the patient had subarachnoid hemorrhage in the perimedullary and cervicomedullary cisterns and extending to C3-C7 ventrally. Computed tomography angiography reconstruction demonstrated an aneurysmally dilated vessel dorsal to the C6 vertebral body within the spinal canal. Catheter-based angiography of the right subclavian artery demonstrated retrograde flow within the left vertebral artery and confirmed proximal left subclavian artery occlusion, findings diagnostic of subclavian steal. Further, a branch of the right thyrocervical trunk supplied a retrocorporeal artery collateral to the left vertebral artery, which also contributed to the anterior spinal artery. Conclusions After endovascular coiling of the aneurysm, the patient had no neurologic deficits or postoperative complications. Postoperative angiography revealed complete obliteration with no residual aneurysm. Imaging further demonstrated patency of the radiculomedullary (anterior spinal) artery.

Endovascular therapy is now the first-line treatment for acute ischemic stroke secondary to large vessel occlusions. As an important part of the neurovascular triad (radiology, neurology, and neurosurgery), nurses within the specialty of radiology play in important role in emergency revascularization. However, the role of nursing in acute stroke extends beyond timely recanalization, well into the convalescent phase. The purpose of our study was to explore the other important aspects of clinical care performed by diagnostic and interventional radiology nurses in acute stroke. After Institutional Review Board approval, imaging and clinical records of 100 consecutive patients presenting to a tertiary-care center with acute stroke and a large vessel occlusion were reviewed. Hospitalization records were examined for the type and number of interventional radiology-related non-neurovascular procedures performed in this patient population. Non-neurovascular interventional radiology-related procedures were performed in over 40% of patients, most commonly gastrostomy tube placement, IVC filter placement, and peripherally inserted central catheter placement. 28 gastrostomy tubes, 10 IVC filters, and 10 peripherally inserted central catheter lines were placed. The average age of IVC filter placement was 60 years, with a range of 45 to 81 years. Radiology nurses have an important role to play in the management of acute stroke patients, even after patients have undergone revascularization. Educating clinical colleagues and patients about radiology nursing-related services in acute stroke can advance the field of radiology nursing and other advanced practitioners while improving the care of the large number of patients afflicted by acute stroke.

Acute basilar artery occlusion (BAO) secondary to emergent large vessel occlusion (ELVO) has an extremely poor natural history, with a reported mortality rate up to 95%. Mechanical thrombectomy in the setting of ELVO is generally performed via a transfemoral approach. However, radial access is increasingly being utilized as an alternative. We report our initial multi-institutional experience using primary radial access in the treatment of acute BAO in nine consecutive cases. Technical success defined as a TICI score of 2B or 3 was achieved in 89% of cases. Average puncture to revascularization time was 35.8 minutes. There were no complications related to radial artery catheterization. We contend radial access should potentially be considered as the first-line approach given inherent advantages over femoral access for mechanical thrombectomy for BAO.

Background: Endovascular thrombectomy (EVT) is effective in patients with large vessel occlusion (LVO) stroke. We hypothesized that a tortuous internal carotid (ICA) may increase the technical difficulty of EVT and prevent optimal positioning of aspiration catheters thereby lowering the chances of successful recanalization and likelihood of favorable outcome. Patients and Methods: Consecutive patients with LVO and patent cervical ICAs who underwent EVT at 2 academic centers were included. Demographics, clinical and radiological factors, time metrics, occurrence of symptomatic intracranial hemorrhage (sICH), functional outcome and survival data were collected. ICA tortuosity was determined on pre-EVT sagittal maximal intensity projection images and classified into three categories: type 1 - straight ICA trunk, type 2 - moderate degree of tortuosity not judged to impair distal catheter placement and type 3 - severe tortuosity preventing optimal aspiration catheter placement. Thrombolysis in cerebral infarction (TICI) 2b-3 was considered successful recanalization and modified Rankin Scale (mRS)≤2 90days post stroke was considered favorable outcome. Results: The study included 313 patients (mean age 69±15, median NIHSS 17), and 53% had type 1, 33% type 2 and 14% type 3 ICA tortuosity. Severe tortuosity was significantly less common in patients with atrial fibrillation (p=0.032) but no other factors were associated with the degree of tortuosity. Overall, 85% had successful recanalization and 47% had favorable outcomes. The chances of favorable outcome at 90days were independent of the degree of observed tortuosity (53% type1, 32% type2 and 49% type3 respectively, p=0.94). Similarly, mortality rates, chances of succesful recanalization and sICH rates did not differ between the tortuosity groups. Clustering patients with moderate and severe tortuosity into one group showed that those with marked tortuosity were significantly older (74±12 vs. 65±16; p Conclusions: Carotid tortuosity does not impact functional outcome but may influence recanalization rates.

BackgroundHemodynamic alterations post-embolization of intracranial arteriovenous malformations (AVMs) may cause delayed edema/hemorrhage in brain parenchyma adjacent to the lesion.ObjectiveTo quantify and compare cerebral perfusion changes in the peri-AVM territory pre- and post-embolization using color-coded quantitative digital subtraction angiography (q-DSA).MethodsPediatric intracranial AVM embolization procedures performed over a 5 year period were included. DSA images of all patients were retrospectively assessed using syngo iFlow. Regions of interest (ROI) were selected on anteroposterior and lateral q-DSA views: three in the peri-AVM region; two in parenchyma distant from the AVM. Time-to-peak (TTP) contrast enhancement of ROIs and ∆TTP (TTP at the selected ROI minus TTP at either the ipsilateral internal carotid/vertebral artery) were measured.Result19 pediatric patients with 19 AVMs (9 males/10 females, mean age 12 years) underwent intracranial AVM embolization: 15/19 AVMs were supplied by the anterior circulation and 4/19 by the posterior circulation. Blood flow was significantly slower post-embolization in the draining vein (19/19) (pConclusionThis study demonstrates more rapid perfusion in the peri-nidal brain parenchyma post-embolization of the AVM, which supports the theory that increased perfusion in normal tissue surrounding the AVM after embolization may underlie some post-procedural complications.

Because treatments for cerebral arterial spasm-a delayed consequence of subarachnoid hemorrhage (SAH)-are clinically inconsistent, we describe here a new method for reversal of arterial spasm, possibly extensible to nitric oxide (NO)-sensitive microvasculature.We subjected dogs to the intracisternal double-hemorrhage model of SAH (autologous blood injection on days 1 and 3) and began endovascular treatment of the spasmed basilar artery (BA) on Day 4. A conical-tip fused silica optical fiber was introduced via a microcatheter (inserted femorally) into the proximal vicinity of the spasmed BA. After local saline flushing of blood, an ultraviolet (UV) pulsed laser beam (355 nm Nd:YAG) was focused into the optical fiber and converted into a concentric ring beam, which facilitated endovascular irradiation for 30 s at intensities of 12-20 W/cmOn Day 4 the BAs had constricted by 21 ± 11%. After UV laser irradiation on Day 4, the constricted BAs dilated to 93 ± 15% of their normal diameters within minutes, and the dilation (91 ± 12%) persisted on Day 5. Most BA segments recovered to their respective baselines after UV irradiation, even when the UV beam was located considerably proximal to the BA origin. At days 4 and 5, the percent BA dilation normalized to Day 4 pre-treatment decreased linearly (by scatter plot, p 0.02) over a range of about 60 mm from the UV irradiation site.We conjecture that the vasodilator nitric oxide, produced at high local concentration from its vascular storage forms (chiefly nitrites) by UV laser-induced photoscission, stimulates a wave of arterial dilation, possibly by longitudinal propagation of transnitrosation reactions in the arterial wall, which reverses cerebral vasospasm semi-locally and thus avoids the deleterious effects of systemic treatment.

Background: Because treatments for cerebral arterial spasm—a delayed consequence of subarachnoid hemorrhage (SAH)—are clinically inconsistent, we describe here a new method for reversal of arterial spasm, possibly extensible to nitric oxide (NO)-sensitive microvasculature.

Purpose There is now class 1a evidence for the efficacy of mechanical thrombectomy in patients with acute ischemic stroke and a large vessel occlusion (LVO).1 2 Failure to recanalize portends a poor prognosis for the patient with a decreased chance for a good function outcome (modified Rankin Score of 2 or less). The purpose of our study was to evaluate the incidence and causes of persistent occlusion of intracranial large vessel occlusion following mechanical thrombectomy at our high-volume comprehensive stroke center, with the goal of providing some insight into potential ways to increase recanalization rates in future patients. Methods After institutional board approval, a prospectively maintained institutional thrombectomy database for acute ischemic stroke was queried from 2015 to present. Patients with documented large vessel occlusion in the intracranial circulation and failure to recanalize after attempted mechanical thrombectomy were included for analysis. Patient characteristics including age, sex, co-morbidities, baseline NIHSS score, and baseline ASPECTS, were recorded. Rates of symptomatic hemorrhage, final ASPECTS, need for decompressive hemicraniectomy, and outcomes at 90 days (modified Rankin Scale) were also included. The statistical package R was used for analysis. Results 24 out of 368 patients with LVO and acute ischemic stroke had persistent TICI 0 occlusions after attempted mechanical thrombectomy. 15 patients were male. Mean age of patients with persistent TICI 0 was 68.8 years (range 44 to 94 years). A combination of stent-retrievers and direct aspiration (solumbra) was used for mechanical thrombectomy in all cases were the lesion was accessible. The most common reason for persistent TICI 0 was failure to recanalize despite adequate stent apposition and aspiration, which occurred in 18 out of 24 cases, or 75% of cases. Inability to pass a microwire through the site of occlusion was the second most common reason for persistent TICI 0, which occurred in 5 out of 24 of cases (21%). Inability to select the proximal great vessels due to extreme tortuosity only occurred in one case. 11 out of the 24 patients with persistent TICI 0 occlusions died within 90 days of attempted thrombectomy. Conclusions The rate of TICI 0 mechanical thrombectomy was extremely low in our series, accounting for only 7% of thrombectomy cases at our high-volume stroke center. Failure to recanalize the site of large vessel occlusion was the most common reason for persistent TICI 0 after attempted mechanical thrombectomy in our large series, occurring in 75% of persistent TICI 0 cases. In our series, persistent TICI 0 after mechanical thrombectomy had a high mortality rate, nearly 50%. References Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372(1):11–20. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015;372(11):1019–30. Disclosures R. Mattay: None. M. Cox: None. M. McCabe: None. J. Schmitt: None. D. Kung: None. O. Choudhri: None. B. Pukenas: 2; C; Regenxbio, Prevail Therapeutics. R. Hurst: None.

Purpose Loss of the T2 vertebral artery flow void can be an ominous sign in patients with trauma. However, the significance of an absent vertebral artery flow void is less clear when discovered incidentally in patients without trauma or acute neurological symptoms. The purpose of this study was to review retrospectively the results of additional imaging and clinical evaluation in atraumatic patients without acute neurological symptoms found to have an incidentally discovered absent vertebral artery flow void on magnetic resonance imaging. Materials and methods An imaging database was reviewed for absent vertebral artery flow voids in atraumatic cervical spine magnetic resonance images. Imaging and long-term clinical follow-up were recorded. Results Fifty-four patients were included in the study. All patients had clinical follow-up and 22 patients (40% of cases) had vascular imaging follow-up. Nine patients had a hypoplastic but patent vertebral artery on follow-up vascular imaging, and no further action was taken. Ten patients had evidence of stenosis or occlusion of the vertebral artery on follow-up imaging, none with acute neurological symptoms or new symptoms/subsequent change in management during follow-up. Three additional patients had vertebral artery dissections on follow-up imaging, but all of them had acute neurological symptoms at the time of imaging and acute infarcts on current or subsequent magnetic resonance imaging. The other 32 patients had clinical follow-up and remained asymptomatic throughout the study period, without change in management. Conclusion In the absence of trauma or acute neurological symptoms an absent vertebral artery flow void has a low likelihood of altering patient management.

Developmental venous anomalies (DVAs) are the most common cerebral vascular malformations and are usually found incidentally on neuroimaging studies. Despite the benign nature of DVAs, occasionally, they can be symptomatic. The objective of this article is to review the spectrum of imaging findings of DVAs on conventional and advanced imaging studies. In addition, neuroimaging findings of symptomatic DVAs as well as imaging mimicks will also be described to assist in the approach to differential diagnosis.

Temporomandibular joint (TMJ) arthroscopy is considered a safe, minimally invasive procedure for the treatment of certain TMJ derangements. However, as TMJ arthroscopy is being popularized, more complications are being reported. Though exceedingly rare, arteriovenous fistula (AVF) can occur. We describe a case of superficial temporal artery (STA) fistula formation successfully treated with coil embolization.

The purposes of this study were to document recent trends in stroke intervention at a tertiary-care facility with a comprehensive stroke center and to analyze current procedure volumes and the employment of specialty providers in neurointerventional radiology (NIR).Institutional trends in the volume of mechanical thrombectomy were analyzed on the basis of the number of patients who underwent mechanical thrombectomy from 2013 to 2017. To evaluate the current status of mechanical thrombectomy volumes in the United States, the number of patients in the Medicare fee-for-service database who underwent mechanical thrombectomy in 2016 was assessed. The specialty backgrounds of the various providers who performed mechanical thrombectomy were analyzed. Procedure volumes for intracranial stenting, embolization, and vertebral augmentation procedures were assessed.From 2013 to 2017, the total numbers of mechanical thrombectomy procedures for acute ischemic stroke were 19 in 2013 and 111 in 2017. The total volume of mechanical thrombectomy procedures in the Medicare fee-for-service population in 2016 was 7479. For intracranial endovascular procedures, 20,850 were performed in the U.S. Medicare population in 2015 and 22,511 in 2016. Radiologists performed 45% of procedures in 2016; neurosurgeons, 41%; and neurologists, 11%. When the total numbers of percutaneous brain and spine procedures were combined, radiologists performed 41%; neurosurgeons, 23%; and neurologists, 3%. In 2016, there were a total of 220 active NIR staff at the NIR programs with rotating residents or fellows. In these programs, 49% of staff members were neuroradiologists, 41% were neurosurgeons, and 10% were neurologists. Of the 72 NIR departments with confirmed rotating fellows or residents, 14 had only neuroradiologists on staff, six had only neurosurgeons, and one had only neurologists.Increasing radiology resident interest and participation in NIR should ensure a steady influx of radiologists into the field, continuing the strong tradition of radiology participation, leadership, and innovation in NIR.

Providing a fast and accurate diagnosis of acute large-vessel occlusion on computed tomography angiograms (CTAs) is essential for timely intervention and good stroke outcomes. However, the detection and appropriate management of incidental findings are also important parts of any clinical radiology practice and can greatly affect patient care. The intricate anatomy covered by CTAs of the head and neck coupled with the time pressures of acute stroke diagnosis creates an environment in which unrelated, important findings can potentially be missed. The purpose of our study was to document clinically actionable incidental findings on CTA in 225 patients undergoing acute stroke intervention. After institutional review board approval, a retrospective six-year review of CTAs of the head and neck in patients undergoing acute stroke intervention was performed for actionable incidental vascular and nonvascular findings. A total of 225 patients undergoing acute stroke intervention with documented intracranial large-vessel occlusion on CTAs were consecutively enrolled in the study. Incidental vascular findings were identified in 17 of 225 patients (7.5%, 95% confidence interval 5% to 12%). Previously unreported aneurysms ranging from 2 mm to 10 mm in size represented 18 of 19 vascular findings in these patients. Incidental nonvascular findings were identified in 32 patients (14%, 95% confidence interval 5% to 12%). These included malpositioned support lines and tubes; pneumothorax; interstitial lung disease; newly diagnosed metastatic disease; nasopharyngeal, parotid, and pituitary masses; and cervical spine compression fractures. CTAs of the head and neck in patients undergoing acute stroke intervention contain a relatively high frequency of vascular and nonvascular incidental findings requiring further follow-up, and therefore should be evaluated carefully and systematically.

Introduction Duplication of the vertebral artery (VA) is a rare vascular variant, with less than 50 reported cases in the literature. Case series We present four cases of VA duplication and discuss the imaging findings, which highlight the rarely seen VA duplication. Discussion VA duplication is generally considered to be an incidental finding. The VA is formed from the fusion of the longitudinal anastomoses that link the cervical intersegmental arteries, during the 32–40-day stage. The duplication of the VA is a clinically relevant finding for planning of head and neck surgery and neuro-interventional procedures.

Purpose In recent years, improving technology, safety and efficacy of percutaneous endovascular neuro-interventions (ENIs), has generated interest among various specialty groups in catheter-based therapies. We previously demonstrated that the neurovascular triad (radiology, neurosurgery, and neurology) had a large presence in the performance of intracranial ENIs, although other groups predominate vascular interventions in the neck. The purpose of this study is to appraise the afore-stated information with new data reflecting changes in CPT coding, and to assess any changes in the involvement of radiologists, neurosurgeons, and other physicians in the performance of ENIs. Methods The Medicare Part B fee-for-service databases for 2015–2016 (covering 37.5 million enrollees in 2015) were the data source. We selected the CPT codes for ENIs of the head and neck. The databases provided nationwide Medicare volumes for those codes, as well as the specialties of the providers utilizing these codes. We compared ENI volumes and utilization rates by radiologists, neurosurgeons, neurologists, cardiologists, vascular surgeons and other physicians. Results Since 2013, the total volume of ENIs of the head and neck performed increased from 15 625 to 26 865 in 2015 and 21 992 in 2016 respectively. Of these volumes, radiologists performed 39% in 2015 and 35% in 2016 respectively, compared with 38% and 35% respectively by neurosurgeons, 10% and 13% respectively by cardiologist, and 5% and 7% respectively by both neurologist and vascular surgeons. For intracranial procedures only, both radiologist and neurosurgeons performed 47% (Radiology: 54% and Neurosurgery: 33% in 2013) of procedures in 2015, and 44% by radiologist and 47% by neurosurgeons respectively in 2016 comprising the majority. Cardiologists (45% in 2015, and 40% in 2016) and vascular surgeons (20% in 2015, and 23% in 2016) performed the majority of extracranial ENIs, with approximately 98% of their procedures being carotid artery stenting procedures. Conclusion Since 2013, patient utilization rates of ENIs increased 1.7 times in 2015 and 1.4 times in 2016. The largest clinical specialties that engage in ENIs continue to be radiology and neurosurgery, largely performing intracranial ENIs, and with cardiologist and vascular surgeons largely performing extracranial ENIs. Despite minor fluctuations in the subtypes of ENIs performed from year to year, radiologists continue to maintain a large presence in the performance of ENIs of the head and neck, with neurosurgery performance volumes steadily rising. The continued increase in ENI volumes should reflect a good market environment for aspiring neuro-interventional trainees, particularly from radiology, neurosurgery, and neurology backgrounds. Disclosures K. Atsina: None. M. Cox: None. R. Hurst: None. L. Parker: None. D. Levin: None.

Intracranial dural arteriovenous fistulae (DAVF) are rare vascular malformations. They are generally considered to be acquired lesions, often attributed to dural sinus thrombosis and intracranial venous hypertension. The authors encountered a case of DAVF associated with an octreotide-positive vestibular schwannoma. A 46-year-old female had symptoms of right ear congestion accompanied by pulsatile tinnitus and mild hearing loss. Magnetic resonance imaging (MRI) identified a lobulated mass centered at the cerebellopontine angle. Preoperatively, on cerebral angiography, there was an incidental discovery of a DAVF in the right posterior fossa. The decision was made to proceed with resection of the tumor in a staged fashion. Her latest follow-up MRI showed no evidence of recurrent tumor. This is the second reported case of DAVF associated with an intracranial schwannoma. Findings are discussed along with a thorough review of the literature. This case, combined with the data from the literature review, led us to believe that tumor-related angiogenesis might contribute to DAVF formation.

Spontaneous regression of an arteriovenous malformation (AVM) is the phenomenon of partial or complete obliteration of the vascular anomaly without any therapeutic intervention. Complete spontaneous regression is a rare event with limited previously reported cases in the literature. We present a new case of complete spontaneous regression of a right frontal AVM and report findings from the imaging studies. Furthermore, we present the findings of a detailed literature review and discuss hypotheses regarding the pathophysiology of this rare occurrence.

Objective Mechanical thrombectomy after acute ischemic stroke has been shown to improve clinical outcomes. Data on short-term hospitalization outcomes after thrombectomy are needed. Our objective was to quantify 30- and 90-day readmissions after thrombectomy and identify factors associated with readmissions. Methods Retrospective observational analysis of adult patients hospitalized between January and November 2014, using data from the 2014 Nationwide Readmissions Database. Readmission rates were calculated and examined according to patient, clinical, and hospital characteristics using descriptive statistics. Weighted unconditional logistic regression models estimated the odds of readmission and examine the associations between select characteristics and readmission. Results 4850 individuals who underwent mechanical thrombectomy for acute ischemic stroke in 2014 were eligible for 30-day readmissions analyses. The nonelective readmission rate was 12.5% at 30 days, 20.7% at 90 days. Sepsis and stroke were the most common reasons for readmission. Female sex (adjusted odds ratio [AOR] 1.34, 1.02-1.77 at 30 days), discharge to inpatient postacute care facility (AOR 1.61, 1.07-2.41 at 30 days, AOR 1.99, 1.47-2.69 at 90 days), and longer initial length of stay (AOR 1.52, 1.04-2.23 at 30 days, AOR 1.67, 1.14-2.43 at 90 days) were associated with a higher likelihood of readmission. Thrombectomy complications were rare and not associated with readmission. Conclusions 1 in 8 thrombectomy patients had a short-term readmission in 2014. Characteristics suggestive of a complicated hospital course or greater physical disability were the primary predictors of readmission. This study provides preliminary data for evaluations of the public health impact of mechanical thrombectomy in real world settings.

Cerebral vasospasm after aneurysmal subarachnoid hemorrhage typically occurs 3–14 days after aneurysm rupture. We describe a series of patients who developed vasospasm within minutes of aneurysm rupture. This phenomenon, which we term, “hyperacute vasospasm,” has been reported in animal models of SAH, but hitherto has been poorly described in humans. Eleven patients were identified from an institutional registry who had aneurysmal rupture during catheter cerebral angiography between 1997 and 2009. We quantified the degree of vasoconstriction using vascular diameter index (VDI). The change in VDI (delta VDI or DVDI) was calculated by determining the difference in VDI before and after the procedure. We also examined the relationship between hyperacute vasospasm and delayed cerebral ischemia. Ten of eleven (91 %) patients with intraoperative aneurysm rupture had cerebral vasoconstriction within minutes of intra-procedural aneurysmal rupture. Six of eleven patients (55 %) with hyperacute vasospasm developed delayed cerebral infarction. Hyperacute vasospasm is likely common in patients with intraoperative aneurysm rupture and may be an unrecognized element of the natural history of aneurysmal subarachnoid hemorrhage. In this limited series, there was an association between hyperacute vasospasm and delayed cerebral infarction.

Background Intracranial vasculopathy in adult patients with human-acquired immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a rare but increasingly recognized disease entity. Objective We aimed to contribute to and summarize the adult literature describing patients with HIV/AIDS who have intracranial vasculopathy. Methods A retrospective review of adult patients with HIV/AIDS undergoing diagnostic cerebral angiography at our institution from 2007–2013 was performed. A literature review of relevant existing studies was performed. Results Five adult patients with HIV-related aneurysmal and occlusive vasculopathy were diagnosed and/or treated at our institution. A comprehensive review of the literature yielded data from 17 series describing 28 adult patients with HIV/AIDS and intracranial vasculopathy. Our review suggests that low CD4 count, motor weakness, and meningismus may be associated with the sequelae of intracranial vasculopathy/vasculitis in patients with HIV/AIDS. Conclusion Patients with HIV/AIDS who have aneurysmal and stenotic vascular disease may benefit from earlier surveillance with the onset of neurological symptoms. The roles of medical, open surgical, and endovascular therapy in this unique entity will be further defined as the pathological basis of the disease is better understood.

Aim: Super absorbent polyvinyl alcohol-sodium acrylate copolymer microspheres, Quadrasphere microspheres (QSM), are commonly used for drug-eluting bead therapy, however, the literature only reports its use with small molecule chemotherapeutics. This study evaluates the loading and elution characteristics of bevacizumab-loaded QSM. Methods & results: A single vial of QSM was reconstituted with 200 mg of bevacizumab. Drug concentration was determined by ELISA immunoassay. At approximately 90 min, there was maximal loading at 59% of the starting dose. In vitro elution demonstrated 52% of bound bevacizumab was released within the first hour and 68% by 16 h. Conclusion: Bevacizumab can load onto QSM and elute over time. This targeted delivery vehicle may potentially result in more effective treatment and fewer complications related to systemic toxicity.

Object The use of cerebral intraoperative angiography has been described in resection of arteriovenous malformations (AVMs) in adults. More recently, studies have described experiences with intraoperative angiography in a small number of children. However, data on the safety and clinical utility of intraoperative angiography in the pediatric population remains limited in comparison with available data in adults. The aim of the study was to evaluate the use of cerebral intraoperative angiography in children undergoing AVM resection. The clinical utility of intraoperative angiography and procedure-related complications were evaluated. Methods A retrospective review was performed for all patients undergoing cerebral AVM resection with intraoperative angiography at The Children's Hospital of Philadelphia between 2008 and 2012. Patient imaging and operative and medical notes were reviewed to evaluate for end points of the study. A total of 17 patients (8 males, 9 females) were identified, with a median age of 12.1 years (range 1.2–17.9 years) and median weight of 45.5 kg (range 12.1–78.9 kg). Results A total of 21 intraoperative angiography procedures were performed for 18 AVM resections in 17 patients. The technical success rate was 94%. In 2 cases (11%), intraoperative angiography demonstrated a residual AVM, and repeat resections were performed. In both cases, no recurrent disease was noted on postoperative follow-up. One procedure-related complication (4.8%) occurred in 1 patient who was positioned prone. Recurrence to date was noted in 2 (14%) of the 14 cases with available postoperative follow-up at 3.5 and 4.7 months following resection with intraoperative angiography. The median follow-up time from intraoperative angiography to the most recent postoperative angiography was 1.1 years (range 4.3 months to 3.8 years). Conclusions Intraoperative angiography is an effective and safe adjunct for surgical management of cerebral AVMs in the pediatric population.

Although usually asymptomatic, a persistent trigeminal artery (PTA) can rarely be associated with a direct fistula to the cavernous sinus (ie, trigemino-cavernous fistula). We present three patients with trigemino-cavernous fistulas; two were subsequently treated using modern endovascular techniques while the third initially declined therapy. We then review the literature of reported cases of this unusual entity. The aberrant anatomy associated with a PTA presents unique challenges to the management of these lesions, and must be well delineated prior to treatment. Finally, conservative management of trigemino-cavernous fistulas, either de novo or recurrent, may be considered if they demonstrate no evidence of cortical venous reflux and patient symptoms are tolerable.

Adequate dual antiplatelet (AP) therapy is imperative when performing neurovascular stenting procedures. Currently, no consensus for the ideal AP regimen exists. Thus the present study aimed to gain a better understanding of real world practice AP patterns by surveying neurointerventional surgeons.Survey links were emailed to 296 neurointerventional surgeons practicing in the USA, asking 51 questions including demographics, stent specific use, AP pre and post-medication, types of APs, point of care (POC) assessment, complications, and outcomes. Data were collected and analyzed using Research Electronic Data Capture (REDCap).74 participants responded; 56.8% were from academic centers. Participants treated an average of 5.5 aneurysms per month. They placed an average of 1.6 intracranial stents and 1.4 cervical stents per month. Mean number of pipeline embolization devices (PEDs) placed per year was 15.2. Heterogeneity existed regarding AP regimens; the most frequent included acetylsalicylic acid (ASA) 325 mg+Plavix 75 mg daily (for 7 days prior) and ASA 325 mg+Plavix 75 mg daily (for 5 days prior) for routine placement of intracranial and cervical stents, respectively. For emergency placement, ASA 325 mg+Plavix 600 mg (at time of surgery) was the most frequently used. 46.8% routinely used POC testing, most frequently VerifyNow (Accumetrics, San Diego, California, USA); the most common threshold determining a non-responder was30% inhibition. 85.7% used POC for PED placement. Management changes based on POC testing were diverse.The results highlight the heterogeneity of current practices regarding AP medication regimens during neurovascular stenting. Given its importance, evidence based protocols are imperative. Minimal literature exists focusing on neurovasculature, and therefore understanding current practice patterns represents a first step toward generating these protocols.

Object Gunshot wounds to the atlantoaxial spine are uncommon injuries and rarely require treatment, as a bullet traversing this segment often results in a fatal injury. Additionally, these injuries are typically biomechanically stable. The authors report a series of 10 patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex. Their care is discussed and conclusions are drawn from these cases to identify the optimal treatment for these injuries. Methods A retrospective review was conducted of patients presenting to the emergency rooms of 3 institutions with gunshot wounds involving the atlantoaxial spine. Mechanism of injury and neurological status were obtained, as was the extent of the osteoligamentous, vascular, and neurological injuries. Nonoperative and operative treatment, complications, and clinical and radiographic outcome were recorded. The data were then analyzed to determine the neurological and biomechanical prognosis of these injuries, the utility of the various diagnostic modalities in the acute management of the injuries, and the nature and effectiveness of the nonoperative and operative treatment modalities. Results Ten patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex were identified. All but 2 patients sustained a vertebral artery injury. Each patient was evaluated using cervical radiographs, CT scans, and vascular imaging, 8 in the form of digital subtraction angiography and 2 with high-resolution CT angiography. Uncomplicated patients were treated conservatively using cervical collar immobilization, local wound care, and antibiotics. One patient was treated using a halo for instability and 1 underwent posterior fusion following a posterolateral decompression for delayed myelopathy. One patient underwent transoral resection of a bullet fragment. One patient underwent embolization for a symptomatic arteriovenous fistula and a second patient underwent a neck exploration and a jugular vein ligation. None of the patients received anticoagulation therapy. The mean follow-up duration was 13 months. All but 2 patients regained their previous functional status and all ultimately attained a mechanically stable spine. Conclusions These 10 patients represent a rare form of cervical spine penetrating injury. Unilateral gunshot wounds to the atlantoaxial complex are usually stable and the need for acute surgical intervention is rare. Unilateral vertebral artery injury is well tolerated and any information provided by angiography does not alter the acute management of the patient. Vascular complications from gunshot wounds can be managed effectively by endovascular techniques.

Object Pial arteriovenous fistulas (PAVFs) are a rare form of cerebrovascular disease that tend to be overrepresented in the pediatric population. There have been limited studies of the clinical features and outcomes in this group of patients. Here, the authors attempt to better delineate this clinical entity with institutional cases and a review of the literature. Methods A retrospective review of cases at our institution was performed to identify all pediatric patients treated for a PAVF between 2000 and 2012. Results Five patients treated for a PAVF were identified. Patients had a mean age of 1.9 years at diagnosis, and the most common presenting symptoms were seizure and macrocephaly. Patients were treated primarily with embolization, and 3 patients required both N-butyl cyanoacrylate (NBCA) glue and coiling. Four of the patients had complete obliteration of the PAVF and had a pediatric overall performance category score of either 1 (n = 3) or 2 (n = 1) at follow-up. There was 1 death due to heart failure. Analysis of the literature review suggested that a younger age or presence of intracerebral hemorrhage (ICH) or congestive heart failure (CHF) at presentation likely predicts a worse prognosis. Older patients presented more often with ICH, whereas younger patients presented significantly more often in CHF. The majority of pediatric patients reported on in the literature were treated with endovascular embolization, most commonly with NBCA glue alone. Most patients (65.4%) in the literature had an excellent outcome without neurological deficit. Conclusions Pial AVFs represent a serious yet rare form of cerebrovascular disease. Pediatric patients with ICH or CHF at presentation or those who are very young are likely to have a worse prognosis. Endovascular management of these patients has greatly changed the natural history of this disease, but the complication and mortality rates suggest the need for continued insights and advances in treatment.

Background Placement of an external ventricular drain (EVD) is a commonly performed and often lifesaving procedure. Although hemorrhage is one of the commonest complications associated with the procedure, ventricular catheter-induced vascular injury is rarely reported. Objective To describe 9 cases of EVD-related vascular trauma: 7 arteriovenous fistulas and 2 traumatic aneurysms. Methods During a 3-year period, 299 patients had EVDs placed. Eight patients (2.75%), 3 male and 5 female (mean age, 48 ± 20 years), developed vascular lesions associated with EVDs. Six patients developed arteriovenous fistulas and 2 patients developed a traumatic aneurysm. The arterial feeders of 5 superficial draining fistulas arose from the middle meningeal artery, and the arterial feeder of a deep-draining fistula originated from a lenticulostriate artery. One traumatic aneurysm arose from a distal branch of the anterior cerebral artery, and the second from a branch of the superficial temporal artery. Four of the superficial fistulas were treated with transarterial embolization. Results Two superficial fistulas and the deep-draining fistula resolved spontaneously after EVD removal. The intracranial aneurysm was embolized with Onyx18, and the superficial temporal artery aneurysm was managed conservatively. There were no hemorrhages associated with any of these vascular lesions and no complications after treatment. Conclusion Our data suggest that iatrogenic vascular trauma associated with EVD insertions (2.75%) may be more common than is currently appreciated. Endovascular treatment is effective and may be necessary when these lesions do not resolve spontaneously.

Purpose A novel endovascular therapy to treat a pseudoaneurysm as a complication of molar tooth extraction is described. Patients and Methods A 20-year-old man presented 2 weeks after third molar tooth extraction with an enlarging pulsatile jaw mass, identified as a facial artery pseudoaneurysm. Endovascular embolization with microcoils and a liquid embolic agent, Onyx, was performed. The use of Onyx in this manner is an off-label use. Results Immediately after treatment, the pulsatile mass resolved and remained obliterated at 2 months of follow-up. Conclusions Onyx embolization of facial artery vascular lesions can be safely accomplished while avoiding microvascular complications and provides a satisfactory and durable result.

BACKGROUND AND IMPORTANCE Endovascular management of dural arteriovenous fistulas (DAVFs) has become an accepted primary and often definitive therapy. We present the first documented case of Onyx pulmonary embolism after embolization of a low-flow DAVF. CLINICAL PRESENTATION A 63-year-old man presented with subarachnoid hemorrhage secondary to a DAVF. Computed tomographic angiography, magnetic resonance imaging, and initial conventional angiogram were negative. A repeat angiogram demonstrated a DAVF, which was cured with Onyx embolization. A routine chest computed tomography after intervention revealed an asymptomatic Onyx embolization cast in a subsegmental pulmonary artery. CONCLUSION Endovascular treatment options include transarterial embolization with microcoils, polyvinyl alcohol particles, n-butyl-2cyanoacrylate, and Onyx (ev3 Neurovascular, Irvine, California). Complications associated with the use of Onyx are low but include embolizate pulmonary embolism. Patients often remain asymptomatic, but for symptomatic patients, conservative treatment options usually result in resolution of symptoms.

Purpose To assess the role of three-dimensional (3D) contrast-enhanced, time-resolved MR angiography (CE TR MRA) in patients with intracranial arteriovenous malformations (AVMs). Methods We studied 12 patient with intracranial AVMs on a 3.0 T MR imaging system (Magentom TIM Trio, Siemens Medical Solutions, Erlangen, Germany) using 3D CE TR MRA with autocalibrating partially parallel acquisitions and echo sharing schemes, which provided temporal resolution of 0.58 or 1.7 s and near isotropic voxels. We qualitatively assessed image quality of the 3D CE TR MRA and compared the grading of the AVMs based on modified Spetzler–Martin system for 3D CE TR MRA and catheter digital subtraction angiography (DSA). Results CE TR MRA provided good quality images in the 3 standard orthogonal planes, and good arterial-venous separation in all cases. All AVMs were correctly graded by CE TR MRA when compared with DSA. 3D CE TR MRA provides a non-invasive alternative to DSA for the evaluation of cerebral AVMs.