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Introduction: Flow diverters such as the pipeline embolization device (PED) cause hemodynamic changes of the treated vessel segment. In posterior communicating artery (PcomA), aneurysms’ unique anatomic consideration have to be taken in account due to the connection between the anterior and posterior circulation. We hypothesize that in conjunction with PcomA remodeling, there will also be remodeling of the ipsilateral P1 segment of the posterior cerebral artery (PCA) after PED treatment for PcomA aneurysms. Methods: We retrospectively collected radiological as well as clinical data of PcomA aneurysm patients treated with PED including PcomA and P1 vessel diameters before and after treatment as well as patient and aneurysm characteristics. Results: Overall, 14 PcomA aneurysm patients were included for analysis and PED treatment was performed without complications in all patients. In 10 out of 14 patients (71%), a decrease in PcomA diameter was observed and there was a significant mean decrease of 0.78 mm in PcomA diameter on angiographic last follow-up (LFU) (p = 0.003). In the same patient population (10 out of 14 patients), there was meanwhile a significant mean increase of 0.43 mm in the ipsilateral P1 segment diameter observed (p = 0.015). These vessel remodeling effects were in direct correlation with aneurysm occlusion since all of these patients showed aneurysm occlusion at LFU while 29% showed only partial occlusion without vessel remodeling effects. A decrease in PcomA diameter was directly associated with aneurysm occlusion (p = 0.042). There were no neurologic complications on LFU. Conclusion: In the treatment of PcomA aneurysms with PED, the P1 segment of the PCA increases in diameter while the PcomA diameter decreases. Our results suggest that this remodeling effect is associated with aneurysm occlusion and decrease of PcomA is hemodynamically compensated for by an increase in the ipsilateral P1 diameter.

Transcirculation thrombectomy through the communicating arteries of the circle of Willis has been previously described as a bailout in cases where direct thrombectomy is not feasible.1-3 Here we present a unique case where a retrograde thrombectomy of the proximal basilar artery was performed using the right posterior communicating artery (PCOM) in a patient with bilateral occlusions of the vertebral arteries, believed to be chronic. This was done using a quadriaxial system with multiple concentric catheters to minimize the ledge effect and achieve smooth and safe transition of the catheters from anterior to posterior circulations. A combination of stent retrieval, aspiration and balloon occlusion guide catheters helped retrieve the thrombus, while minimizing emboli in new territory (ENT). The patient had complete resolution of symptoms. The thrombus is believed to be due to stasis at the vertebrobasilar junction and competing flow, hence, the patient was started on anticoagulation. (video 1) neurintsurg;14/6/634/V1F1V1Video 1Disclaimer: this video summarises a scientific article published by BMJ Publishing Group Limited (BMJ). The content of this video has not been peer-reviewed and does not constitute medical advice. Any opinions expressed are solely those of the contributors. Viewers should be aware that professionals in the field may have different opinions. BMJ does not endorse any opinions expressed or recommendations discussed. Viewers should not use the content of the video as the basis for any medical treatment. BMJ disclaims all liability and responsibility arising from any reliance placed on the content.

BackgroundThere is limited evidence on the performance of emergent large-vessel occlusion (LVO) stroke screening tools when used by emergency medical services (EMS) and emergency department (ED) providers. We assessed the validity and predictive value of the vision, aphasia, neglect (VAN) assessment when completed by EMS and in the ED among suspected stroke patients.MethodsWe conducted a retrospective study of VAN performed by EMS providers and VAN inferred from the National Institutes of Health Stroke Scale performed by ED nurses at a single hospital. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAN by EMS and in the ED for LVO and a combined LVO and intracerebral hemorrhage (ICH) outcome.ResultsFrom January 2018 to June 2020, 1,547 eligible patients were identified. Sensitivity and specificity of ED VAN were similar for LVO (72% and 74%, respectively), whereas EMS VAN was more sensitive (84%) than specific (68%). PPVs were low for both EMS VAN (26%) and ED VAN (21%) to detect LVO. Due to several VAN-positive ICHs, PPVs were substantially higher for both EMS VAN (44%) and ED VAN (39%) to detect LVO or ICH. EMS and ED VAN had high NPVs (97% and 96%, respectively).ConclusionsAmong suspected stroke patients, we found modest sensitivity and specificity of VAN to detect LVO for both EMS and ED providers. Moreover, the low PPV in our study suggests a significant number of patients with non-LVO ischemic stroke or ICH could be over-triaged with VAN.

BACKGROUND AND PURPOSE: Flow diversion is being increasingly used to treat bifurcation aneurysms. Empiric approaches have generally led to encouraging results, and a growing body of animal and ex vivo literature addresses the fate of target aneurysms and covered branches. Our prior investigations highlighted the dynamic nature of metal coverage provided by the Pipeline Embolization Device and suggested strategies for creating optimal single and multidevice constructs. We now address the geometric and hemodynamic aspects of jailing branch vessels and neighboring target aneurysms. MATERIALS AND METHODS: Fundamental electric and fluid dynamics principles were applied to generate equations describing the relationships between changes in flow and the degree of vessel coverage in settings of variable collateral support to the jailed territory. Given the high complexity of baseline and posttreatment fluid dynamics, in vivo, we studied a simplified hypothetic system with minimum assumptions to generate the most conservative outcomes. RESULTS: In the acute setting, Pipeline Embolization Devices modify flow in covered branches, principally dependent on the amount of coverage, the efficiency of collateral support, and intrinsic resistance of the covered parenchymal territory. Up to 30% metal coverage of any branch territory is very likely to be well-tolerated regardless of device or artery size or the availability of immediate collateral support, provided, however, that no acute thrombus forms to further reduce jailed territory perfusion. CONCLUSIONS: Basic hemodynamic principles support the safety of branch coverage during aneurysm treatment with the Pipeline Embolization Device. Rational strategies to build bifurcation constructs are feasible.

BACKGROUND AND PURPOSE: Our aim was to propose a conceptually new angioarchitectural model of some dural arteriovenous fistulas based on subset analysis of transverse and sigmoid type lesions. The “common collector” notion argues for convergence of multiple smaller caliber arterial vessels on a common arterial collector vessel within the sinus wall. Communication of this single collector (or constellation of terminal collectors) with the sinus proper defines the site of arteriovenous fistula, which can be closed by highly targeted embolization, preserving the sinus and avoiding unnecessary permeation of indirect arterial feeders. MATERIALS AND METHODS: One hundred consecutive dural arteriovenous shunts were examined. Thirty-six transverse/sigmoid fistulas were identified within this group and analyzed for the presence of a common arterial collector as well as other parameters, including demographics, grade, treatment approach, and outcome. RESULTS: A common collector was identified in nearly all Cognard type I lesions (15 fistulas with 14 single collector vessels seen) and progressively less frequently in higher grade fistulas. Identification of the common collector requires careful angiographic analysis, including supraselective and intraprocedural angiographies during treatment, and final embolic material morphology. CONCLUSIONS: Detailed evaluation of imaging studies allows frequent identification of a vascular channel in the sinus wall, which we argue reflects a compound, common arterial channel (rather than a venous collector) with 1 or several discrete fistulous points between this vessel and the sinus proper. Targeted closure of this channel is often feasible, with sinus preservation and avoidance of embolic material penetration into arteries remote from fistula site.

There is a consensus that most unruptured intracranial aneurysms can be treated with acceptably low morbidity and mortality. However, some studies recently reported postoperative cognitive impairment, suggesting that it could be attributableto neurosurgical clipping. The goal of this report is to review and discuss aspects referring to cognitive function and neurosurgical repair in patients with unruptured intracranial aneurysms.

OBJECTIVEThe Pipeline Embolization Device (PED) is now a well-established option for the treatment of giant or complex aneurysms, especially those arising from the anterior circulation. Considering the purpose of such treatment is to maintain patency of the parent vessel, postembolization occlusion of the parent artery can be regarded as an untoward outcome. Antiplatelet therapy in the posttreatment period is therefore required to minimize such events. Here, the authors present a series of patients with anterior circulation aneurysms treated with the PED who subsequently experienced parent vessel occlusion (PVO).METHODSThe authors performed a retrospective review of all anterior circulation aneurysms consecutively treated at a single institution with the PED through 2014, identifying those with PVO on follow-up imaging. Aneurysm size and location, number of PEDs used, and follow-up digital subtraction angiography results were recorded. When available, pre- and postembolization platelet function testing results were also recorded.RESULTSAmong 256 patients with anterior circulation aneurysms treated with the PED, the authors identified 8 who developed PVO after embolization. The mean aneurysm size in this cohort was 22.3 mm, and the number of PEDs used per case ranged from 2 to 10. Six patients were found to have asymptomatic PVO discovered incidentally on routine follow-up imaging between 6 months and 3 years postembolization, 3 of whom had documented “delayed” PVO with prior postembolization angiograms confirming aneurysm occlusion and a patent parent vessel at an earlier time. Two additional patients experienced symptomatic PVO, one of which was associated with early discontinuation of antiplatelet therapy.CONCLUSIONSIn this large series of anterior circulation aneurysms, the authors report a low incidence of symptomatic PVO, complicating premature discontinuation of postembolization antiplatelet or anticoagulation therapy. Beyond the subacute period, asymptomatic PVO was more common, particularly among complex fusiform or very large–necked aneurysms, highlighting an important phenomenon with the use of PED for the treatment of anterior circulation aneurysms, and suggesting that extended periods of antiplatelet coverage may be required in select complex aneurysms.

Flow-diversion treatment of cerebral aneurysms with the Pipeline Embolization Device (Covidien, Irvine, California) has been around for nearly 13 years, yet we are still struggling with some fundamental issues, such as optimal device-size selection and optimal flow diversion (ie, which aneurysms

Background Early and mid-term safety and efficacy of aneurysm treatment with the Pipeline Embolization Device (PED) has been well demonstrated in prior studies. Objective To present 5-yr follow-up for patients treated in the Pipeline for Uncoilable or Failed Aneurysms clinical trial. Methods In our prospective, multicenter trial, 109 complex internal carotid artery (ICA) aneurysms in 107 subjects were treated with the PED. Patients were followed per a standardized protocol at 180 d and 1, 3, and 5 yr. Aneurysm occlusion, in-stent stenosis, modified Rankin Scale scores, and complications were recorded. Results The primary endpoint of complete aneurysm occlusion at 180 d (73.6%) was previously reported. Aneurysm occlusion for those patients with angiographic follow-up progressively increased over time to 86.8% (79/91), 93.4% (71/76), and 95.2% (60/63) at 1, 3, and 5 yr, respectively. Six aneurysms (5.7%) were retreated. New serious device-related events at 1, 3, and 5 yr were noted in 1% (1/96), 3.5% (3/85), and 0% (0/81) of subjects. There were 4 (3.7%) reported deaths in our trial. Seventy-eight (96.3%) of 81 patients with 5-yr clinical follow-up had modified Rankin Scale scores ≤2. No delayed neurological deaths or hemorrhagic or ischemic cerebrovascular events were reported beyond 6 mo. No recanalization of a previously occluded aneurysm was observed. Conclusion Our 5-yr findings demonstrate that PED is a safe and effective treatment for large and giant wide-necked aneurysms of the intracranial ICA, with high rates of complete occlusion and low rates of delayed adverse events.

Background: Scarce reports exist of permanent deployment of Solitaire FR™ devices for arterial steno-occlusive disease as it is primarily indicated for temporary deployment for thrombectomy in large-vessel, anterior-circulation ischemic strokes. Even more scarce are reports describing permanent deployment of the Solitaire device for posterior circulation strokes. Summary: We present 2 cases where the Solitaire device was electrolytically detached to re-establish flow in an occluded or stenotic basilar artery in acutely symptomatic patients. In both cases, a 4 × 15 mm Solitaire device was positioned across the stenotic or occluded portion of the basilar artery and electrolytically detached to maintain vessel patency. Both cases had good clinical outcomes with a National Institutes of Health Stroke Scale (NIHSS) score of 1 (from 24) on 90-day follow-up and an NIHSS score of 2 (from 7) on 30-day follow-up. Key Messages: Permanent deployment of the Solitaire device may potentially be a safe and effective means of maintaining vessel patency in an occluded or stenotic basilar artery.

BACKGROUND AND PURPOSE: Treatment options for nonsaccular posterior cerebral artery aneurysms include a range of surgical and endovascular reconstructive and deconstructive methods. However, no truly satisfactory treatment option is available to date for lesions arising from the P1 and P2 segments. The purpose of the present case series is to investigate both the efficacy and safety of the Pipeline Embolization Device in treating these challenging aneurysms. MATERIALS AND METHODS: We present a series of 6 consecutive patients who underwent endoluminal reconstruction with the Pipeline Embolization Device for nonsaccular P1 or P2 segment aneurysms between January 2009 and June 2013. RESULTS: Aneurysm location included the P1 segment in 2 patients and the P2 segment in 4 patients. Mean aneurysm diameter was 23 mm (range, 5–44 mm). Mean length of the arterial segment involved was 10 mm (range, 6–19 mm). Clinical presentation included mass effect in 4 patients and perforator stroke and subacute aneurysmal subarachnoid hemorrhage in 1 patient each. Endovascular reconstruction was performed by using 1 Pipeline Embolization Device in 5 patients and 2 overlapping Pipeline Embolization Devices in the remaining patient. Angiographic aneurysm occlusion was immediate in 1 patient, within 6 months in 4 patients, and within 1 year in the remaining patient. Index symptoms resolved in 4 patients and stabilized in the remaining 2. No new permanent neurologic sequelae and no aneurysm recurrence were recorded during the mean follow-up period of 613 days (range, 540–725 days). CONCLUSIONS: Endovascular reconstruction with the Pipeline Embolization Device for nonsaccular aneurysms arising from the P1 and P2 segments compares favorably with historical treatment options in terms of occlusion rate, margin of safety, and neurologic outcome.

BACKGROUND AND PURPOSE: The advent of low-porosity endoluminal devices, also known as flow diverters, exemplified by the Pipeline in the United States, produced the greatest paradigm shift in cerebral aneurysm treatment since the introduction of detachable coils. Despite robust evidence of efficacy and safety, key questions regarding the manner of their use remain unanswered. Recent studies demonstrated that the Pipeline device geometry can dramatically affect its metal coverage, emphasizing the negative effects of oversizing the device relative to its target vessels. This follow-up investigation focuses on the geometry and coverage of multidevice constructs. MATERIALS AND METHODS: A number of Pipeline devices were deployed in tubes of known diameters and photographed, and the resultant coverage was determined by image segmentation. Multidevice segmentation images were created to study the effects of telescoped devices and provide an estimate of coverages resulting from device overlap. RESULTS: Double overlap yields a range of metal coverage, rather than a single value, determined by the diameters of both devices, the size of the recipient artery, and the degree to which strands of the overlapped devices are coregistered with each other. The potential variation in coverage is greatest during overlap of identical-diameter devices, for example, ranging from 24% to 41% for two 3.75-mm devices deployed in a 3.5-mm vessel. Overlapping devices of progressively different diameters produce correspondingly more uniform ranges of coverage, though reducing the maximum achievable value, for example, yielding a 33%–34% range for 3.75- and 4.75-mm devices deployed in the same 3.5-mm vessel. CONCLUSIONS: Rational strategies for building multidevice constructs can achieve favorable geometric outcomes.

OBJECTIVEThe long-term effectiveness of endovascular treatment of large and giant wide-neck aneurysms using traditional endovascular techniques has been disappointing, with high recanalization and re-treatment rates. Flow diversion with the Pipeline Embolization Device (PED) has been recently used as a stand-alone therapy for complex aneurysms, showing significant improvement in effectiveness while demonstrating a similar safety profile to stent-supported coil treatment. However, relatively little is known about its long-term safety and effectiveness. Here the authors report on the 3-year safety and effectiveness of flow diversion with the PED in a prospective cohort of patients with large and giant internal carotid artery aneurysms enrolled in the Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial.METHODSThe PUFS trial is a prospective study of 107 patients with 109 aneurysms treated with the PED. Primary effectiveness and safety end points were demonstrated based on independently monitored 180-day clinical and angiographic data. Patients were enrolled in a long-term follow-up protocol including 1-, 3-, and 5-year clinical and imaging follow-up. In this paper, the authors report the midstudy (3-year) effectiveness and safety data.RESULTSAt 3 years posttreatment, 74 subjects with 76 aneurysms underwent catheter angiography as required per protocol. Overall, complete angiographic aneurysm occlusion was observed in 71 of these 76 aneurysms (93.4% cure rate). Five aneurysms were re-treated, using either coils or additional PEDs, for failure to occlude, and 3 of these 5 were cured by the 3-year follow-up. Angiographic cure with one or two treatments of Pipeline embolization alone was therefore achieved in 92.1%. No recanalization of a previously completely occluded aneurysm was noted on the 3-year angiograms. There were 3 (2.6%) delayed device- or aneurysm-related serious adverse events, none of which led to permanent neurological sequelae. No major or minor late-onset hemorrhagic or ischemic cerebrovascular events or neurological deaths were observed in the 6-month through 3-year posttreatment period. Among 103 surviving patients, 85 underwent functional outcome assessment in which modified Rankin Scale scores of 0–1 were demonstrated in 80 subjects.CONCLUSIONSPipeline embolization is safe and effective in the treatment of complex large and giant aneurysms of the intracranial internal carotid artery. Unlike more traditional endovascular treatments, flow diversion results in progressive vascular remodeling that leads to complete aneurysm obliteration over longer-term follow-up without delayed aneurysm recanalization and/or growth.Clinical trial registration no.: NCT00777088 (clinicaltrials.gov)

OBJECTIVE A detailed analysis was performed of anterior circulation aneurysms treated with a Pipeline Embolization Device (PED) that did not progress to complete occlusion by 1-year follow-up. Angiography was performed with the purpose of identifying specific factors potentially responsible for these failed outcomes. METHODS From among the first 100 patients with anterior circulation aneurysms, 92 underwent 1-year follow-up angiography and were individually studied through review of their pre- and postembolization studies. RESULTS Nineteen aneurysms (21%) remained unoccluded at 12 months. Independent predictors of treatment failure, identified by logistic regression analysis, were found to be fusiform aneurysm morphology, decreasing dome-to-neck ratio, and the presence of a preexisting laser-cut stent. Further examination of individual cases identified several common mechanisms—device malapposition, inadequate coverage of the aneurysm neck with persistent exchange across the device, and the incorporation of a branch vessel into the aneurysm fundus—potentially contributing to failed treatment in these settings. CONCLUSIONS Attention to specific features of the aneurysm and device construct can frequently identify cases predisposed to treatment failure and suggest strategies to maximize favorable outcomes.

Background Stereotactic radiosurgery is an effective treatment modality for small arteriovenous malformations (AVMs) of the brain. For larger AVMs, the treatment dose is often lowered to reduce potential complications, but this decreases the likelihood of cure. One strategy is to divide large AVMs into smaller anatomic volumes and treat each volume separately. Objective To prospectively assess the long-term efficacy and complications associated with staged-volume radiosurgical treatment of large, symptomatic AVMs. Methods Eighteen patients with AVMs larger than 15 mL underwent prospective staged-volume radiosurgery over a 13-year period. The median AVM volume was 22.9 mL (range, 15.7-50 mL). Separate anatomic volumes were irradiated at 3- to 9-month intervals (median volume, 10.9 mL; range, 5.3-13.4 mL; median marginal dose, 15 Gy; range, 15-17 Gy). The AVM was divided into 2 volumes in 10 patients, 3 volumes in 5 patients, and 4 volumes in 3 patients. Seven patients underwent retreatment for residual disease. Results Actuarial rates of complete angiographic occlusion were 29% and 89% at 5 and 10 years. Five patients (27.8%) had a hemorrhage after radiosurgery. Kaplan-Meier analysis of cumulative hemorrhage rates after treatment were 12%, 18%, 31%, and 31% at 2, 3, 5, and 10 years, respectively. One patient died after a hemorrhage (5.6%). Conclusion Staged-volume radiosurgery for AVMs larger than 15 mL is a viable treatment strategy. The long-term occlusion rate is high, whereas the radiation-related complication rate is low. Hemorrhage during the lag period remains the greatest source of morbidity and mortality.

Object Nidal embolization of brain arteriovenous malformations (bAVMs) has become an increasingly important component of bAVM treatment. However, controversy exists as to the relative efficacy and safety of single-stage versus multistage approaches to bAVM embolization, with recent literature favoring multistage strategies. The authors present a series of consecutive bAVMs embolized at their institution, demonstrating the safety and efficacy of a predominantly single-stage embolization strategy. The safety and efficacy of embolization are reported in the context of predetermined treatment strategies to provide more generalizable insight into treatment outcome. Methods One hundred thirty consecutive patients with 131 bAVMs underwent endovascular embolization at a single center. Diagnostic angiography with superselective microcatheterizations was performed in all patients. Postembolization angiograms were reviewed by 3 neuroradiologists for degree of occlusion and angiographic evidence of procedural complications. Patients were divided into cohorts based on the prospectively determined treatment strategy, which included the following: global devascularization of the bAVM (Devasc); targeting of a focal angioarchitectural weakness (Target), typically as an adjunct to surgery or Gamma Knife treatment; and primary occlusion of the bAVM by embolization alone (Occlude). Safety and efficacy were evaluated in the context of these treatment groups. Results The 131 bAVMs were treated over an average of 1.28 embolization sessions per bAVM; 105 bAVMs (80%) were treated in a single stage. The average percentage devascularization in the Devasc arm was 85.3%, which was statistically significantly greater than the 72% aggregate devascularization reported in 8 modern N-butyl cyanoacrylate and Onyx papers based on 1-sample Wilcoxon rank-sum testing (p < 0.001). Focal angioarchitectural weaknesses were successfully embolized for all 24 bAVMs in the Target group, directly with the embolic agent in 23 bAVMs and indirectly in 1 bAVM with a venous aneurysm/pseudoaneurysm by reducing arterial inflow and inducing venous thrombosis. Lesions in all patients in the Occlude arm were 100% occluded with embolization alone. Overall, the bAVMs in the Occlude arm were significantly smaller and required embolization of fewer pedicles than those in the Devasc group. One patient (0.8%) experienced significant morbidity following embolization, and 1 patient in the cohort died (0.8%). Conclusions This research communicates the authors' experience in developing a largely single-stage strategy for embolization of bAVMs. The results suggest that an aggressive, single-stage embolization may be implemented with a margin of safety and effectiveness similar to the multistage approaches more commonly reported in the literature. This work additionally introduces the importance of prospective assignment to a treatment strategy in assessing procedural outcome in bAVM embolization, thereby improving generalizability of the results and allowing for more rigorous interpretation of efficacy and safety.

Summary Purpose: Despite the reported diagnostic value of the intracarotid amobarbital procedure (IAP) or “Wada test” for determining hemispheric lateralization and memory functioning, it has never undergone formal reliability testing because a prospective test–retest study design is neither feasible nor ethical. However, some patients require repeat testing for clinical purposes, a circumstance that allows for exploration of issues related to reliability. The current investigation sought to: (1) evaluate the frequency of and reasons for repeated IAPs and (2) describe the test–retest reliability of repeated IAPs in a large tertiary epilepsy center. Methods: A 10-year review (2001–2011) of the New York University Langone Medical Center Comprehensive Epilepsy Center patient registry revealed 630 IAPs. Review of medical records identified 20 individuals who underwent two or more IAPs on separate days. Because IAPs repeated due to technical problems should be considered separate from IAPs repeated for other reasons because these IAPs likely included a change in the procedure (e.g., lower medication dose) in an attempt to ameliorate the complication, patients were grouped accordingly. Six patients underwent repeated IAPs due to technical complication and 14 patients underwent a repeated IAP due to other reasons (e.g., unexpected memory outcome, reconsideration of surgery years after a previous surgical work-up in which no surgery was performed, and/or consideration of a second surgery). Given that data obtained from injections ipsilateral to a seizure focus are sometimes considered in a manner clinically different from data obtained from injections contralateral to the seizure focus, memory outcome was classified relative to the side of identified seizure focus. The degree to which language and memory data were consistent across repeated IAPs was examined. Key Findings: Language functioning was consistently lateralized across IAPs in all but one case. Among the six patients who experienced technical problems in the first IAP, three were fully participatory in the second procedure such that valid data were obtained. For the other three, the technical problem recurred with no change in outcome across procedures. Among the 14 patients with repeated IAPs due to other reasons, 79% of the available ipsilateral and 73% of the contralateral pass/fail outcomes were consistent across procedures. No difference between ipsilateral or contralateral injections was observed for the likelihood of a change in results (p = 0.57). Significance: Our data identified overall high reliability for both the ipsilateral and contralateral sides with repeated IAP testing. Results indicated that although patients for whom a correctable technical problem was identified during the IAP may benefit from a repeat study, there is little benefit to repeating the IAP in patients with discordant or unexpected results (i.e., results are not likely to change). These data support the overall reliability of both the language and memory data obtained from the IAP.

Metameric lesions of the spine are rare. The authors present a case of patient with a complex metameric vascular lesion of the thoracic spine and describe a management strategy for this entity.

BACKGROUND AND PURPOSE: Concurrent temporary inflation of a nondetachable balloon in the parent artery has been reported to be useful during endovascular coiling of complex, wide-neck aneurysms, facilitating truer coil reconstruction of the native vessel. Nevertheless, there exists concern that adjunctive use of balloon assistance may lead to increased adverse events during aneurysm coiling. MATERIALS AND METHODS: A literature search of all of the unassisted and balloon-remodeling studies published between 1997 and 2006 was conducted with application of strict selection criteria based on the reporting of complication incidence and outcome. The final cohort was analyzed to determine rates and clinical outcomes of iatrogenic aneurysm rupture and thromboembolism. Additional data were collected on the degree of initial and follow-up aneurysm occlusion rates. RESULTS: A total of 83 potential studies (4973 patients) were identified, from which 23 articles reporting results for 867 traditional-unassisted and 273 balloon-assisted coiled aneurysms met inclusion criteria for the analysis of thromboembolic complications, and 21 articles with 993 routinely coiled and 170 balloon-remodeled aneurysms were eligible for iatrogenic perforation analysis. No statistically significant difference was found in the rates of thromboembolism. Iatrogenic perforation rates were also comparable, though the overall numbers were too few for meaningful statistical analysis. Both initial and follow-up aneurysm occlusion rates were higher in balloon-assisted cases. CONCLUSION: This largest-to-date literature review and meta-analysis did not demonstrate a higher incidence of thromboembolic events or iatrogenic rupture with the use of adjunctive balloon remodeling compared with unassisted coiling. Balloon remodeling appears to result in higher initial and follow-up aneurysm occlusion rates.

Foreign material emboli following cerebral, cardiac, and peripheral catheterizations have been reported since the mid-1990s. Catheter coatings have been frequently implicated. The most recent surge of interest in this phenomenon within the neurointerventional community is associated with procedures using flow-diversion devices for the treatment of cerebral aneurysms. Following coil-supported Pipeline embolization in 4 cases and stent-supported coiling in 1, 5 patients developed multiple subcentimeter enhancing lesions, usually with surrounding edema and variable magnetic susceptibility in the vascular territories of the treated aneurysms. Conventional angiography findings were unrevealing. Laboratory work-up showed mild CSF protein elevation with no leukocytosis. Brain biopsy in 2 cases revealed granulomatous angiitis encasing foreign material, identical in stain appearance to a polyvinylpyrrolidone catheter coating. Corticosteroid administration typically produced clinical improvement. A heterogeneous radiographic and clinical course was noted, with rise and fall in the number of enhancing lesions in 2 patients and persistence in others. The etiology may be related to widespread adoption of increasingly sophisticated catheterization techniques.

BACKGROUND AND PURPOSE: Smoking is a major risk factor for patients with intracranial aneurysms, yet the effects of smoking on outcomes of aneurysm with flow-diverter treatment remain unknown. We studied the impact of smoking on long-term angiographic and clinical outcomes after flow-diverter treatment of intracranial aneurysms. MATERIALS AND METHODS: We retrospectively reviewed data from patients treated with the Pipeline Embolization Device and included in the International Retrospective Study of the Pipeline Embolization Device, the Pipeline for Uncoilable or Failed Aneurysms Study, and the Aneurysm Study of Pipeline in an Observational Registry. Patients were stratified according to smoking status into 3 groups: 1) never smoker, 2) current smoker, and 3) former smoker. We studied angiographic and clinical outcomes. Outcomes were compared by using χ 2 and Student t tests. A multivariate analysis was performed to determine whether smoking was independently associated with poor outcomes. RESULTS: Six hundred sixteen patients with 694 aneurysms were included. Current smokers had a smaller mean aneurysm size compared with the other 2 groups ( P = .005) and lower rates of multiple Pipeline Embolization Device use ( P = .015). On multivariate analysis, former smokers (OR, 1.08; 95% CI, 0.43–2.71; P = .57) and current smokers (OR, 0.70; 95% CI, 0.27–1.77; P = .38) had similar odds of long-term angiographic incomplete occlusion compared with never smokers. Former smokers (OR, 1.27; 95% CI, 0.64–2.52; P = .25) and current smokers (OR, 0.74; 95% CI, 0.37–1.46; P = .22) had similar odds of major morbidity and neurologic mortality compared with never smokers. CONCLUSIONS: These results suggest that smoking is not associated with angiographic and clinical outcomes among patients treated with the Pipeline Embolization Device. Nonetheless, patients with intracranial aneurysms should continue to be counseled about the risks of tobacco smoking.

OBJECT Neuroophthalmological morbidity is commonly associated with large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms. The authors sought to evaluate the neuroophthalmological outcomes after treatment of these aneurysms with the Pipeline Embolization Device (PED). METHODS The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial was an international, multicenter prospective trial evaluating the safety and efficacy of the PED. All patients underwent complete neuroophthalmological examinations both before the PED procedure and at a 6-month follow-up. All examinations were performed for the purpose of this study and according to study criteria. RESULTS In total, 108 patients were treated in the PUFS trial, 98 of whom had complete neuroophthalmological follow-up. Of the patients with complete follow-up, 39 (40%) presented with a neuroophthalmological baseline deficit that was presumed to be attributable to the aneurysm, and patients with these baseline deficits had significantly larger aneurysms. In 25 of these patients (64%), the baseline deficit showed at least some improvement 6 months after PED treatment, whereas in 1 patient (2.6%), the deficits only worsened. In 5 patients (5%), new deficits had developed at the 6-month follow-up, while in another 6 patients (6%), deficits that were not originally assumed to be related to the aneurysm had improved by that time. A history of diabetes was associated with failure of the baseline deficits to improve after the treatment. The aneurysm maximum diameter was significantly larger in patients with a new deficit or a worse baseline deficit at 6 months postprocedure. CONCLUSIONS Patients treated with the PED for large and giant ICA aneurysms had excellent neuroophthalmological outcomes 6 months after the procedure, with deficits improving in most of the patients, very few deficits worsening, and few new deficits developing.

BACKGROUND AND PURPOSE: Endoluminal reconstruction with the Pipeline Embolization Device is an effective treatment option for select intracranial aneurysms. However, concerns for the patency of eloquent branch arteries covered by the Pipeline Embolization Device have been raised. We aimed to examine the patency of the anterior choroidal artery and clinical sequelae after ICA aneurysm treatment. MATERIALS AND METHODS: We prospectively analyzed all patients among our first 157 patients with ICA aneurysms treated by the Pipeline Embolization Device who required placement of at least 1 device across the ostium of the anterior choroidal artery. The primary outcome measure was angiographic patency of the anterior choroidal artery at last follow-up. Age, sex, type of aneurysm, neurologic examination data, number of Pipeline Embolization Devices used, relationship of the anterior choroidal artery to the aneurysm, and completeness of aneurysm occlusion on follow-up angiograms were also analyzed. RESULTS: Twenty-nine aneurysms requiring placement of at least 1 Pipeline Embolization Device (median = 1, range = 1–3) across the anterior choroidal artery ostium were identified. At angiographic follow-up (mean = 15.1 months; range = 12–39 months), the anterior choroidal artery remained patent, with antegrade flow in 28/29 aneurysms (96.5%), while 24/29 (82.7%) of the target aneurysms were angiographically occluded by 1-year follow-up angiography. Anterior choroidal artery occlusion, with retrograde reconstitution of the vessel, was noted in a single case. A significant correlation between the origin of the anterior choroidal artery from the aneurysm dome and failure of the aneurysms to occlude following treatment was found. CONCLUSIONS: After placement of 36 Pipeline Embolization Devices across 29 anterior choroidal arteries (median = 1 device, range = 1–3 devices), 1 of 29 anterior choroidal arteries was found occluded on angiographic follow-up. The vessel occlusion did not result in persistent clinical sequelae. Coverage of the anterior choroidal artery origin with the Pipeline Embolization Device, hence, may be considered reasonably safe when deemed necessary for aneurysm treatment.

The use of minimally porous endoluminal devices (MPEDs) such as the Pipeline Embolization Device (PED) has been described for the treatment of brain aneurysms. The benefit of using MPEDs to assist embolization of a direct high-flow carotid cavernous fistula resulting from a ruptured cavernous carotid artery aneurysm is not well documented. We describe our experience with deploying a tailored multidevice PED construct across the cavernous internal carotid artery (ICA) wall defect in combination with transarterial coil embolization using the “jailed microcatheter” technique. A 59-year-old woman presented with acute left-sided ophthalmoplegia. Diagnostic cerebral angiography demonstrated a ruptured giant cavernous carotid aneurysm with fistulous outflow via the ipsilateral left superior ophthalmic vein and into the pterygoid venous plexi bilaterally. Via the Marksman microcatheter, a total of three PEDs measuring 4.5 mm × 18 mm, 4.5 mm × 20 mm, and 4.75 mm × 16 mm were telescoped within the ICA across the aneurysm neck. Coiling of the aneurysm fundus and cavernous sinus via the “jailed” Rapidtransit microcatheter was subsequently achieved. A 2-year follow-up digital subtraction angiography (DSA) demonstrated stable obliteration of the aneurysm and the fistula, coincident with complete resolution of the patient’s symptoms. Based on our long-term clinical and angiographic results, we advocate that the presented method be a valid treatment option for selected cases.

BACKGROUND AND PURPOSE: Recent techniques of endoluminal reconstruction with flow-diverting stents have not been incorporated into treatment algorithms for cavernous carotid aneurysms. This study examines the authors9 institutional experience and a systematic review of the literature for outcomes and complications using the Pipeline Embolization Device in unruptured cavernous carotid aneurysms. MATERIALS AND METHODS: A retrospective search for cavernous carotid aneurysms from a prospectively collected data base of aneurysms treated with the Pipeline Embolization Device at our institution was performed. Baseline demographic, clinical, and laboratory values; intrainterventional data; and data at all follow-up visits were collected. A systematic review of the literature for complication data was performed with inquiries sent when clarification of data was needed. RESULTS: Forty-three cavernous carotid aneurysms were included in the study. Our mean radiographic follow-up was 2.05 years. On last follow-up, 88.4% of the aneurysms treated had complete or near-complete occlusion. Aneurysm complete or near-complete occlusion rates at 6 months, 12 months, and 36 months were 81.4%, 89.7%, and 100%, respectively. Of patients with neuro-ophthalmologic deficits on presentation, 84.2% had improvement in their visual symptoms. Overall, we had a 0% mortality rate and a 2.3% major neurologic complication rate. Our systematic review of the literature yielded 227 cavernous carotid aneurysms treated with the Pipeline Embolization Device with mortality and morbidity rates of 0.4% and 3.1%, respectively. CONCLUSIONS: Endoluminal reconstruction with flow diversion for large unruptured cavernous carotid aneurysms can yield high efficacy with low complications. Further long-term data will be helpful in assessing the durability of the cure; however, we advocate a revisiting of current management paradigms for cavernous carotid aneurysms.

Background and Purpose— Although there is generally thought to be a 2% to 4% per annum rupture risk for brain arteriovenous malformations (bAVMs), there is no way to estimate risk for an individual patient. Methods— In this retrospective study, patients were eligible who had nidiform bAVMs and underwent detailed pretreatment diagnostic cerebral angiography at our medical center from 1996 to 2006. All patients had superselective microcatheter angiography, and films were reviewed for the purpose of this project. Patient demographics, clinical presentation, and angioarchitectural characteristics were analyzed. A univariate analysis was performed, and angioarchitectural features with potential physiological significance that showed at least a trend toward significance were added to a multivariate logistic regression model. Results— One hundred twenty-two bAVMs met criteria for study entry. bAVMs with single venous drainage anatomy were more likely to present with hemorrhage. In addition, patients with multiple draining veins and a venous stenosis reverted to a risk similar to those with 1 draining vein, whereas those with multiple draining veins and without stenosis had diminished association with hemorrhage presentation. Those bAVMs with associated aneurysms were more likely to present with hemorrhage. These findings were robust in both univariate and multivariate models. Conclusions— The results of this article lead to the first physiological, internally consistent model of individual bAVM hemorrhage risk, where 1 draining vein, venous stenosis, and associated aneurysms increase risk.

BACKGROUND AND PURPOSE: Low-porosity endoluminal devices for the treatment of intracranial aneurysms, also known as flow diverters, have been in experimental and clinical use for close to 10 years. Despite rigorous evidence of their safety and efficacy in well-controlled trials, a number of key factors concerning their use remain poorly defined. Among these, none has received more attention to date than the debate on how many devices are optimally required to achieve a safe, effective, and economical outcome. Additional, related questions concern device sizing relative to the parent artery and optimal method of deployment of the devices. While some or all of these issues may be ultimately answered on an empiric basis via subgroup analysis of growing treatment cohorts, we believe that careful in vitro examination of relevant device properties can also help guide its in vivo use. MATERIALS AND METHODS: We conducted a number of benchtop experiments to investigate the varied porosity of Pipeline Embolization Devices deployed in a simulated range of parent vessel diameters and applied these results toward conceptualizing optimal treatment strategies of fusiform and wide-neck aneurysms. RESULTS: The results of our studies confirm a predictable parabolic variability in device porosity based on the respective comparative sizes of the device and recipient artery, as well as device curvature. Even modest oversizing leads to a significant increase in porosity. CONCLUSIONS: The experiments demonstrate various deleterious effects of device oversizing relative to the parent artery and provide strategies for addressing size mismatches when they are unavoidable.

Background and purpose Flow diversion with the Pipeline Embolization Device (PED) has been shown to be effective and safe in several trials and registries. The PUFS trial demonstrated over 90% complete occlusion rate and a 5.6% major ipsilateral stroke and neurologic death rate in large and giant internal carotid artery aneurysms. We sought to determine the relationship between aneurysm shape and these primary endpoint outcomes in the PUFS patient population. Materials and methods Ten centers prospectively enrolled and treated 107 patients with 109 aneurysms in the PUFS trial. All centers obtained IRB or EC approval. Prospectively collected information included demographic characteristics, aneurysm size and location, aneurysm neck size, aneurysm shape, number of PEDs used, and any complications (including stroke and death). All complications were reviewed and adjudicated by a Clinical Events Committee. All angiographic images were evaluated by an independent Core Radiology Laboratory. For the purposes of this analysis, fusiform aneurysm were defined as having an aneurysm neck involving ≥50% of the parent artery circumference vs Results Of the 109 aneurysms treated, 46% (50 aneurysms in 49 patients) were fusiform and 54% (59 aneurysms in 58 patients) were saccular. The rate of major ipsilateral ischemic or hemorrhagic stroke was 6.1% (3/49) for patients with fusiform aneurysms and 3.4% (2/58) for patients with saccular aneurysms. The neurologic death rate was 0% (0/49) and 1.7% (1/58) for patients with fusiform and saccular aneurysms, respectively. The combined rate of major ipsilateral stroke and neurological mortality was 6.1% (3/49) for patients with fusiform aneurysms and 5.2% (3/58) for patients with saccular aneurysms. At 5 years post-procedure, the complete aneurysm occlusion rate was 95.8% (23/24) for fusiform aneurysms and 95% (38/40) for saccular aneurysms. Conclusions The PED demonstrates high levels of safety and effectiveness in the treatment of both fusiform and saccular ICA aneurysms. Disclosures T. Becske: 2; C; Covidien proctor. M. Potts: None. W. Brinjikji: None. D. Kallmes: 1; C; Covidien. 2; C; Covidien. M. Shapiro: 2; C; Covidien proctor. P. Nelson: 2; C; Covidien.

Angioplasty and intracranial stenting (ICS) are both endovascular revascularization procedures that have emerged as treatment options for intracranial atherosclerotic disease (ICAD). Some believe angioplasty alone is better, while others believe stenting is better. This study examines recent trends in utilization and outcomes of angioplasty alone and ICS in the United States using a population-based cohort.The National Inpatient Sample (NIS) database was queried for patients with ICAD who underwent angioplasty or ICS from 2005 to 2010.There were 1115 patients (angioplasty: n=495, ICS: n=620) with ICAD who underwent endovascular revascularization. Over time, the number of endovascular revascularization procedures increased. The percentage of symptomatic patients (p=0.015) as well as in the number of comorbidities of patients treated (p0.001) also increased. Combined post-procedure stroke and death rates were 16% and 28.9% for angioplasty and ICS, respectively (p0.001). A larger percentage of angioplasty patients presented symptomatically compared to those who underwent ICS (p0.001).Angioplasty appears to be associated with higher rates of peri-procedural complications; however, that may represent patient selection bias. Further studies are needed to identify patients who would benefit from revascularization and to clarify the roles of angioplasty and ICS.

We report a case of temporary Solitaire FR stent (Covidien, Mansfield, MA, USA) scaffolding to reduce coil herniation during embolization of a large neck anterior communicating artery aneurysm. In contrast to classic stent-assisted coiling, the fully retrievable stent is recaptured prior to detachment of the last coil. The presented technical nuance hence does not require institution of prolonged antiplatelet coverage. But the door is left open for coil-repositioning in case of coil basket instability. Permanent stent redeployment remains a fall-back option if critical hardware conflict occurs. In comparison to classic balloon remodeling, the presented method may offer easier distal access, particularly in tortuous arterial anatomy. Temporary occlusion of the parent artery, side branches, and perforators is also avoided. Given its specific potential advantages, temporary stent scaffolding using the fully retrievable Solitaire FR device may find its niche as a bailout option, primarily in a very specific subset of distally located wide neck aneurysms.

Background and objective Treatment of non-saccular vertebrobasilar aneurysms remains highly challenging despite significant recent advances in endovascular techniques. Establishing the natural history of this heterogeneous disease, as best as currently available data allows, is crucial to help guide counseling and management. Methods A review of the literature was conducted to identify publications describing the presentation and natural history of vertebrobasilar dolichoectasia and non-saccular aneurysms. Results Nine studies of 440 patients met the analysis inclusion criteria. The majority of patients presented with ischemia, mass effect, or incidentally; hemorrhage was uncommon and overlapped with the population of vertebrobasilar dissection. Overall mortality was ∼40% after 7 years of follow-up, with 43% of these deaths resulting from non-neurologic causes. Neurologic course was dominated by ischemic stroke rather than hemorrhage. Mass effect prognosis was especially poor, with 40% mortality after ∼4 years. Incidentally discovered lesions which remain morphologically stable have a favorable long term course. Conclusions Initial clinical presentation is a strong predictor of subsequent disease course. Although overall prognosis is poor, nearly half of all deaths resulted from non-neurologic causes, underscoring the importance of comprehensive medical management. Aneurysms characterized by expansion, established mass effect, or hemorrhage have a poor natural history, and may be considered for invasive treatment, which is increasingly endovascular in nature. Lesions presenting with ischemia or incidentally are likely best addressed with aggressive neurologic and overall medical management.

To evaluate the safety and effectiveness of the Pipeline Embolization Device (PED; ev3/Covidien, Irvine, Calif) in the treatment of complex intracranial aneurysms.The Pipeline for Uncoilable or Failed Aneurysms is a multicenter, prospective, interventional, single-arm trial of PED for the treatment of uncoilable or failed aneurysms of the internal carotid artery. Institutional review board approval of the HIPAA-compliant study protocol was obtained from each center. After providing informed consent, 108 patients with recently unruptured large and giant wide-necked aneurysms were enrolled in the study. The primary effectiveness endpoint was angiographic evaluation that demonstrated complete aneurysm occlusion and absence of major stenosis at 180 days. The primary safety endpoint was occurrence of major ipsilateral stroke or neurologic death at 180 days.PED placement was technically successful in 107 of 108 patients (99.1%). Mean aneurysm size was 18.2 mm; 22 aneurysms (20.4%) were giant (25 mm). Of the 106 aneurysms, 78 met the study's primary effectiveness endpoint (73.6%; 95% posterior probability interval: 64.4%-81.0%). Six of the 107 patients in the safety cohort experienced a major ipsilateral stroke or neurologic death (5.6%; 95% posterior probability interval: 2.6%-11.7%).PED offers a reasonably safe and effective treatment of large or giant intracranial internal carotid artery aneurysms, demonstrated by high rates of complete aneurysm occlusion and low rates of adverse neurologic events; even in aneurysms failing previous alternative treatments.

Solitary focal demyelination (SFD) in the brain is an uncommon and poorly understood disorder of uncertain etiology that may represent an intermediate entity between multiple sclerosis and acute disseminated encephalomyelitis. In a few reported cases of SFD, the patient was briefly noted to have a nonneurological malignancy. We studied two patients who had solitary focal lesions in the brain. Utilizing magnetic resonance imaging and tissue biopsy, we found the characteristics of the brain lesions in these two patients to be those of SFD. In our combined experience over the past 10 years, we have encountered no similar brain lesions at our medical center. We found it remarkable that both of these patients also had malignancy outside of the nervous system. One had a seminoma, and the other a lymphoma. We conclude that some cases of SFD in the brain may occur as a paraneoplastic disorder associated with nonneurological malignancies.

Introduction Ischemic strokes in the post-surgical period may negatively impact clinical outcome. Major surgery within the previous 14 days is a relative contraindication to intravenous-tPA administration. Mechanical thrombectomy may thus become a valid treatment option. We present our experience in a series of patients who presented with a clinical stroke syndrome in the post-surgical period who underwent emergent angiography with intent to treat. Methods This is a retrospective review of patients who were treated from January 2012 to March 2015 in our institution. Patients who had emergent angiography after presenting with clinical stroke during the post-surgical period were included. Type of surgery, clinical characteristics, imaging studies, treatment variables, and discharge modified Rankin scores were collected. Results 15 patients had emergent angiography in the post-surgical period. The mean age is 68.87 years. 87% (13/15) had cardiovascular surgery, 8 (62%) of which were valvular repairs. 57% (8/14) presented in the immediate post-surgical period. The mean NIHSS was 18. Mean symptom duration from time last known well was 256 minutes. 10/11 (91%) had perfusion deficits on CTP. 60% (9/15) had proximal vessel occlusion while 33% (5/15) had distal occlusions, and 1 had no occlusion. Of the 9 patients with proximal vessel occlusions, 7 underwent thrombectomy with the Solitaire device achieving a 57% (4/7) TICI 2 b/3 recanalization rate. The mean mRS for all patients in the series is 3.79. Patients with TICI 2 b/3 recanalization did significantly better at discharge than those who did not, mean mRS of 1.67 vs. 5, p = 0.019. Conclusion In our experience, emergent angiography among post-surgical stroke patients showed proximal vessel occlusion in more than half of patients, making them potential candidates for mechanical thrombectomy. Those who achieved TICI 2 b/3 recanalization performed clinically better than those who did not. This may indicate the potential benefit of mechanical thrombectomy among post-surgical stroke patients. The overall lower recanalization rates in this cohort may reflect atypical clot characteristics encountered in post-surgical patients and would be an interesting avenue for further investigation. Disclosures M. Litao: None. H. Bhamra: None. K. DeSousa: None. E. Raz: None. E. Nossek: None. A. Favate: None. M. Shapiro: 2; C; Covidien. T. Becske: 2; C; Covidien. P. Nelson: 2; C; Covidien.

Nidal embolization of brain arteriovenous malformations (bAVMs) has become an increasingly important component of bAVM treatment. However, controversy exists as to the relative efficacy and safety of single-stage versus multistage approaches to bAVM embolization, with recent literature favoring multistage strategies. The authors present a series of consecutive bAVMs embolized at their institution, demonstrating the safety and efficacy of a predominantly single-stage embolization strategy. The safety and efficacy of embolization are reported in the context of predetermined treatment strategies to provide more generalizable insight into treatment outcome.One hundred thirty consecutive patients with 131 bAVMs underwent endovascular embolization at a single center. Diagnostic angiography with superselective microcatheterizations was performed in all patients. Postembolization angiograms were reviewed by 3 neuroradiologists for degree of occlusion and angiographic evidence of procedural complications. Patients were divided into cohorts based on the prospectively determined treatment strategy, which included the following: global devascularization of the bAVM (Devasc); targeting of a focal angioarchitectural weakness (Target), typically as an adjunct to surgery or Gamma Knife treatment; and primary occlusion of the bAVM by embolization alone (Occlude). Safety and efficacy were evaluated in the context of these treatment groups.The 131 bAVMs were treated over an average of 1.28 embolization sessions per bAVM; 105 bAVMs (80%) were treated in a single stage. The average percentage devascularization in the Devasc arm was 85.3%, which was statistically significantly greater than the 72% aggregate devascularization reported in 8 modern N-butyl cyanoacrylate and Onyx papers based on 1-sample Wilcoxon rank-sum testing (p0.001). Focal angioarchitectural weaknesses were successfully embolized for all 24 bAVMs in the Target group, directly with the embolic agent in 23 bAVMs and indirectly in 1 bAVM with a venous aneurysm/pseudoaneurysm by reducing arterial inflow and inducing venous thrombosis. Lesions in all patients in the Occlude arm were 100% occluded with embolization alone. Overall, the bAVMs in the Occlude arm were significantly smaller and required embolization of fewer pedicles than those in the Devasc group. One patient (0.8%) experienced significant morbidity following embolization, and 1 patient in the cohort died (0.8%).This research communicates the authors' experience in developing a largely single-stage strategy for embolization of bAVMs. The results suggest that an aggressive, single-stage embolization may be implemented with a margin of safety and effectiveness similar to the multistage approaches more commonly reported in the literature. This work additionally introduces the importance of prospective assignment to a treatment strategy in assessing procedural outcome in bAVM embolization, thereby improving generalizability of the results and allowing for more rigorous interpretation of efficacy and safety.

Despite the reported diagnostic value of the intracarotid amobarbital procedure (IAP) or "Wada test" for determining hemispheric lateralization and memory functioning, it has never undergone formal reliability testing because a prospective test-retest study design is neither feasible nor ethical. However, some patients require repeat testing for clinical purposes, a circumstance that allows for exploration of issues related to reliability. The current investigation sought to: (1) evaluate the frequency of and reasons for repeated IAPs and (2) describe the test-retest reliability of repeated IAPs in a large tertiary epilepsy center.A 10-year review (2001-2011) of the New York University Langone Medical Center Comprehensive Epilepsy Center patient registry revealed 630 IAPs. Review of medical records identified 20 individuals who underwent two or more IAPs on separate days. Because IAPs repeated due to technical problems should be considered separate from IAPs repeated for other reasons because these IAPs likely included a change in the procedure (e.g., lower medication dose) in an attempt to ameliorate the complication, patients were grouped accordingly. Six patients underwent repeated IAPs due to technical complication and 14 patients underwent a repeated IAP due to other reasons (e.g., unexpected memory outcome, reconsideration of surgery years after a previous surgical work-up in which no surgery was performed, and/or consideration of a second surgery). Given that data obtained from injections ipsilateral to a seizure focus are sometimes considered in a manner clinically different from data obtained from injections contralateral to the seizure focus, memory outcome was classified relative to the side of identified seizure focus. The degree to which language and memory data were consistent across repeated IAPs was examined.Language functioning was consistently lateralized across IAPs in all but one case. Among the six patients who experienced technical problems in the first IAP, three were fully participatory in the second procedure such that valid data were obtained. For the other three, the technical problem recurred with no change in outcome across procedures. Among the 14 patients with repeated IAPs due to other reasons, 79% of the available ipsilateral and 73% of the contralateral pass/fail outcomes were consistent across procedures. No difference between ipsilateral or contralateral injections was observed for the likelihood of a change in results (p = 0.57).Our data identified overall high reliability for both the ipsilateral and contralateral sides with repeated IAP testing. Results indicated that although patients for whom a correctable technical problem was identified during the IAP may benefit from a repeat study, there is little benefit to repeating the IAP in patients with discordant or unexpected results (i.e., results are not likely to change). These data support the overall reliability of both the language and memory data obtained from the IAP.

BACKGROUND AND PURPOSE: Stent-supported aneurysm coiling has been utilized with increasing frequency over the past few years, particularly for addressing treatment of complex and wide-neck aneurysms. A sizable body of literature describing various experiences with stent-supported coiling now exists. The purpose of this research was to carry out a comprehensive literature survey of stent-supported aneurysm coiling. MATERIALS AND METHODS: A survey of papers reporting results with stent-assisted aneurysm coiling through January 2011 was conducted to identify the prevalence of stent-related and other complications, occlusion rates, and clinical and angiographic follow-up data. RESULTS: Thirty-nine articles with 1517 patients met inclusion criteria for initial analysis, follow-up analysis, or both. Overall, 9% of cases were confounded by a technical stent-related issue, including 4% failure of deployment. The overall procedure complication rate was 19%, with periprocedural mortality of 2.1%. Approximately 45% of aneurysms were completely occluded at first treatment session, increasing to 61% on follow-up. Approximately 3.5% in-stent stenosis and 0.6% stent occlusion were observed at angiographic follow-up. Delayed stroke or transient ischemic attack was reported in 3% of subjects. Within a subset of articles, the incidence of stent-related issues in the first 10 patients was significantly higher than in subsequent subjects, supporting the notion of a procedural “learning curve.” CONCLUSIONS: In experienced hands, the morbidity of stent-supported coiling is somewhat higher compared with “traditional” coiling. As might be expected, execution of the procedure appears improved with experience. Complete occlusion rates remain somewhat low. More and longer term angiographic follow-up information is needed to understand delayed stent-related issues and to better define the durability of treatment.

This article discusses the vascular anatomy of the vertebra-spinal axis and covers such topics as vascular supply to the spine, spinal dura, and paraspinal musculature; vascular supply to the spinal cord; and spinal veins.

Purpose To report a wide-necked renal artery aneurysm treated successfully with stent-assisted Gugliemi detachable coil occlusion, assisted by three-dimensional (3-D) angiography. Case Report A 56-year-old woman with history of hypertension presented with a 2.5-cm wide-necked saccular aneurysm involving her distal right renal artery. A balloon-expandable stent was positioned across the neck of the aneurysm and multiple Gugliemi detachable coils were deployed through a microcatheter inserted through the interstices of the stent into the aneurysm sac, guided by 3-D angiography. Follow-up 3-D angiography at 6 months revealed a patent renal artery with continued exclusion of the aneurysm and preservation of renal blood flow. Conclusion Stent-assisted coil occlusion assisted by 3-D angiography is a potential renal-sparing endovascular approach to treating wide-necked renal artery aneurysms with complex vascular anatomy.

Background and purpose Flow diversion with the Pipeline Embolization Device (PED) has been shown to be effective and safe in several trials and registries. The PUFS trial demonstrated a 5.6% major stroke and neurologic death rate in large and giant internal carotid artery aneurysms. Multiple prior publications suggested a higher complication risk with increasing aneurysm size. We sought to determine the relationship between aneurysm size and primary safety events in the PUFS patient population. Materials and methods Ten centers prospectively enrolled 107 patients with 109 aneurysms into the safety arm of the PUFS trial. All centers had obtained IRB approval. Prospectively collected information included demographic characteristics, aneurysm size and location, aneurysm neck size, number of PEDs used, and any complications (including stroke and death). All angiographic images were evaluated by an independent Core Radiology Laboratory. All complications were reviewed and adjudicated by a Clinical Events Committee. Results The rate of major ischemic or hemorrhagic stroke was 4.7% (5/107). Two of these events were fatal. An additional patient experienced a fatal event that was thought to be possibly of neurologic origin, making the neurologic mortality rate 2.8% (3/107). Combined major stroke and neurological mortality rate for the trial was 5.6% (6/107). All primary safety events occurred within the first 6 months post treatment. Of the 109 aneurysms treated, 86 (78.9%) were large (10–24.9 mm), 22 (20.2%) giant (≥25 mm), and 1 (0.9%) small. All of the primary safety events were observed the large aneurysm group, for a major stroke / neurologic death rate of 7.1% (6/84). Complete aneurysm occlusion was noted in 91.8% (79/86) of large and in 90.9% (20/22) of giant aneurysms. However, 4 of the total 6 parent vessel occlusions encountered in the trial occurred in the giant aneurysm group (4/22=18.2%); while only 2 of 86 vessels harboring large aneurysms suffered occlusion (2.3%). Conclusions All 6 major neurologic morbidity and neurologic mortality events in the PUFS trial was observed in 84 patients harboring large aneurysms, for 7% complication rate in this subgroup. Patients with giant aneurysms suffered no such complications, however, their parent vessel occlusion rates were higher at 18.2% (4/22). More aggressive or more prolonged antiplatelet treatment may be necessary in patients with giant aneurysms treated with flow diversion alone. Disclosures T. Becske: 2; C; Proctor for Covidien. M. Potts: None. W. Brinjikji: None. D. Kallmes: 1; C; funding for enrollment in clinical trials. 2; C; Covidien: funding for Principal Investigator duties, Steering Committee and Adverse Event Adjudication Committee;. M. Shapiro: 2; C; Covidien proctor. P. Nelson: 2; C; Covidien proctor.

OBJECTIVE: The purposes of this article are to summarize recent developments and concerns in endovascular aneurysm therapy leading to the adjunctive use of endoluminal devices, to review the published literature on stent-supported coil embolization of cerebral aneurysms, and to describe our experience with this technique in a limited subgroup of problematic complex aneurysms over a medium-term follow-up period. METHODS: Between January 2003 and June 2004, 28 individuals among 157 patients with cerebral aneurysms we evaluated were identified as harboring aneurysms with exceptionally broad necks. Out of these 28 patients, 16 were treated with a combination of stents and detachable coils, preserving the parent artery. Recorded data included patient demographics, the clinical presentation, aneurysm location and characteristics, procedural details, and clinical and angiographic outcome. RESULTS: Over an 18-month period, 16 patients with large cerebral aneurysms additionally characterized by neck sizes between 7 and 14 mm were treated, using combined coil embolization of the aneurysm with stent reconstruction of the aneurysm neck. Thirteen out of the 16 aneurysms were occluded at angiographic reevaluation between 11 and 24 months (mean angiographic follow-up, 17.5 mo). There were no treatment-related deaths or clinically evident neurological complications. Thirteen patients experienced excellent clinical outcomes, with good outcomes in two patients and a poor visual outcome in one patient (mean clinical follow-up, 29 mo). A single technical complication occurred, involving transient nonocclusive stent-associated thrombus, which was treated uneventfully with abciximab. CONCLUSION: Stent-supported coil embolization of large, complex-neck cerebral aneurysms seems to provide superior medium-term anatomic reconstruction of the parent artery compared with historic series of aneurysms treated exclusively with endosaccular coils. In the near future, increasingly sophisticated endoluminal devices offering higher coverage of the neck defect will likely enable more definitive endovascular treatment of complex cerebral aneurysms and further expand our ability to manipulate the vascular biology of the parent artery.

Background: Subarachnoid hemorrhage (SAH) due to intracranial aneurysm rupture is a major neurosurgical emergency associated with significant morbidity and mortality. Rapid aneurysm growth is associated with rupture. Systemic lupus erythematosus (SLE) is a multi-system autoimmune disorder whose complications can include cerebral vasculitis and vasculopathy. Intracranial aneurysms are not known to occur more frequently in SLE patients than the general population; however, aneurysm growth rates have not been studied in SLE. Case Description: We present a 43-year-old female with SLE on prednisone, hydroxychloroquine, and azathioprine with moderate disease activity who presented with severe, acute-onset headache and was found to have Hunt and Hess grade II SAH due to rupture of an 8 mm saccular anterior communicating artery (ACoA) aneurysm. The patient developed severe vasospasm, re-ruptured, and was taken for angiography and embolization, which was challenging due to a high degree of vasospasm and arterial stenosis. Review of imaging from less than 2 years prior demonstrated a normal ACoA complex without evidence of an aneurysm. Conclusion: We review the literature and discuss the risk factors and pathophysiology of rapid aneurysm growth and rupture, as well as the pathologic vascular changes associated with SLE. Although SLE patients do not develop intracranial aneurysm at an increased rate, these changes may predispose them to higher incidence of growth and rupture. This possibility-coupled with increased morbidity and mortality of SAH in SLE-suggests that SAH should be considered in SLE patients presenting with headache, and advocates for more aggressive treatment of SLE patients with unruptured aneurysms.

Study Design This is a case report. Objectives To present a case of cervical kyphosis after resolution of myopathic head drop. Summary of Background Data Myopathic head drop is a severe and persistent focal myopathy that never progresses beyond the neck extensor muscles. Methods A case is reported of a hospitalized psychiatric patient who experienced the sudden onset of severe neck extensor weakness consistent with myopathic head drop. Results Although myopathic head drop resolved after 2 years, it left a disabling residual skeletal deformity of the cervical spine. Conclusions Myopathic head drop may be a cause of cervical kyphosis.