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Rete mirabile (RM), an arterial network normally existing in some vertebrate animals interconnecting the extracranial and intracranial arterial circulation, can rarely be found in humans whether asymptomatic or presenting with cerebral ischaemia or haemorrhage. Encompassing diverse angiographic characteristics and similarities with other arterial malformations, proper diagnosis and differential diagnosis is challenging. We hereby describe an unusual RM case variant, presenting to us with lethal subarachnoid haemorrhage owing to a ruptured small aneurysm associated with the RM network. Angiography disclosed an absent P1 segment of the posterior cerebral artery (PCA) and an RM network anastomosing the basilar apex with the normal distal PCA. Brain death was confirmed on the fifth day after admission and attributed to the severity of subarachnoid haemorrhage (SAH). This is an exceedingly rare case representing an intradural-to-intradural RM anastomosis in a patient presenting with lethal SAH. RM epidemiology, pathophysiology, presentation, angiographic findings and prognosis are reviewed.

In some vein of galen aneurysmal malformation (VGAM) patients, transvenous embolization (TVE) is an attractive option, but its safety is unclear. Here we report the first two VGAM patients treated using the Chapot “pressure cooker” technique (ChPC). Methods Two patients, one 5-year-old and one 7-year-old, both presented with congestive heart failure in the newborn period and were subsequently treated in the newborn period with multiple, staged TAEs with n-BCA for choroidal VGAMs. Results We achieved progressive reduction in shunting and flow but were unable to accomplish complete closure of the malformation: in both patients, a small residual with numerous perforators persisted. The decision was made to perform TVE using the CHPC. In this technique, a guiding catheter is placed transjugular into the straight sinus (SS). One or two detachable tip microcatheters are advanced to the origin of the SS. Another microcatheter is advanced and the tip placed between the distal marker and the detachment zone of the former. Coils and n-BCA are used to prevent reflux of Onyx. Conclusions In this study, we recognized two important factors of traditional VGAM treatment that may cause interventionalists to consider the ChPC to treat VGAM: (1) without liquid embolic, deployed coils may not occlude the fistula entirely. (2) There is the concern of causing delayed bleeding should the arterial component of the fistula rupture. ChPC ameliorates these issues by offering complete closure of the fistula with liquid embolic material in TVE.

BackgroundTreatment of vein of Galen malformations (VOGMs) has improved greatly since the inception of endovascular treatment. Transvenous embolization (TVE) is an attractive option to achieve complete obliteration.ObjectiveTo review the literature on TVE of VOGM and then analyze our practice’s unique experience and evolving treatment strategies over 30 years.MethodsA retrospective review of our clinical database for patients with the diagnosis of VOGM treated between January 2004 and August 2021 was performed. A literature review of 49 relevant articles was also carried out.ResultsTVE in VOGM has evolved with initial introduction as a transtorcular (TT) approach, which then lost favor to transarterial embolization (TAE). TAE has been considered the more favorable approach in most high-volume centers. In more recent times, the transvenous embolization (TVE) approach has been revisited as a last treatment to achieve a cure after a series of TAE treatments. We presently favor beginning treatment with staged TAE to reduce flow to the lesion and, importantly, shrink the draining vein. This then allows for the performance of TVE with the Chapot pressure cooker technique (CPCT) with coils and liquid embolic embolization.ConclusionsTT TVE itself carries a high degree of risk and is most highly associated with long-term morbidities and mortality. Traditional transfemoral/transjugular TVE approaches are safe and effective in simple fistulas with a small venous pouch; however, we believe that the CPCT is the safest technique as a last-stage treatment for its security in avoiding reflux and obtaining occlusion of the small perforators.

INTRODUCTION Appropriate treatment of scalp arteriovenous malformations (SAVMs) remains largely unclear given the rarity of reported cases. This single-institution case series presents consecutive patients with extracranial SAVMs and long-term follow up.The primary aim of this study was to review treatment decisions, evaluate clinical outcomes, and compare our experience to available literature in order to better understand SAVMs and improve future outcomes. MATERIALS AND METHODS A retrospective review of consecutive patients with extracranial SAVMs between January 2015 and December 2019 was performed. Treatment factors of interest included embolization method, embolic agents, and decision to proceed with surgical resection. Relevant clinical outcomes included recurrence rates, cure rates, and complications. RESULTS Seven patients were included in the present series. Satisfactory outcomes were ultimately achieved for all 7 patients using embolization with or without combined surgical resection. Embolizations performed in combination with resection were curative in 4 of 4 cases (100%). Embolizations performed without resection were curative in 0 of 4 cases (0%), satisfactory in 2 of 4 cases (50%), and unsatisfactory in 2 of 4 cases (50%). DISCUSSION All SAVM patients in this series were treated satisfactorily using embolization with or without operative resection. This study strongly suggests that embolization combined with surgical resection during the same admission yields the best treatment outcomes for SAVMs, specifically demonstrating lower rates of recurrence and embolization-related complications. Decisions on whether or not to proceed with resection should be made by the interventional radiologist, the plastic surgeon, and the patient together.

Introduction The delivery of flow-diverting stents (FDS) necessitates a degree of catheter support beyond that required for endovascular coiling. The TracStar Large Distal Platform (LDP) is a novel 0.088″ platform intended for navigation into the intracranial internal carotid artery (ICA). We present an early institutional experience using the TracStar LDP in 44 cases of endovascular aneurysm embolization using FDS. Methods Inclusion criteria for this single-center retrospective review encompassed all patients >18 years of age who were treated for intracranial aneurysms. Procedural success was defined as successful stent deployment using the TracStar LDP. Other outcomes included periprocedural complications, use of an intermediate catheter, length of stay, and discharge disposition. Results The TracStar LDP was utilized in 44 consecutive FDS cases in 42 patients. Cavernous segment aneurysms constituted the majority of cases (12/42; 28.6%), followed by posterior communicating artery (8/42; 19.0%) and supraclinoid aneurysms (8/42; 19.0%). Successful FDS deployment was achieved in 43/44 cases. The LDP achieved stable positioning within the ascending cavernous ICA in 63.6% of cases. A biaxial system was utilized in 54.5% of cases. There was one complication potentially related to use of the TracStar LDP, which was an asymptomatic ICA vessel dissection managed conservatively. Conclusions The TracStar LDP is safe and effective during use in the endovascular treatment of intracranial aneurysms with a FDS. Access to the ascending portion of the cavernous ICA was regularly achieved, and the platform allowed for both biaxial and triaxial configurations.

BACKGROUND AND PURPOSE: Racial and socioeconomic disparities in the incidence, treatment, and outcomes of acute ischemic stroke exist and have been described. We aimed to characterize disparities in the use of endovascular thrombectomy in a nationally representative analysis. MATERIALS AND METHODS: Discharge data from the Nationwide Inpatient Sample between 2006 and 2016 were queried using validated International Classification of Disease codes. Patients admitted to US hospitals with acute ischemic stroke were included and stratified on the basis of race, income, and primary payer. Trends in endovascular thrombectomy use, good outcome (discharge to home/acute rehabilitation), and poor outcome (discharge to skilled nursing facility, hospice, in-hospital mortality) were studied using univariate and multivariable analyses. RESULTS: In this analysis of 1,322,162 patients, endovascular thrombectomy use increased from 53/111,829 (0.05%) to 3054/146,650 (2.08%) between 2006 and 2016, respectively. Less increase was observed in black patients from 4/12,733 (0.03%) to 401/23,836 (1.68%) and those in the lowest income quartile from 10/819 (0.03%) to 819/44,984 (1.49%). Greater increase was observed in the highest income quartile from 18/22,138 (0.08%) to 669/27,991 (2.39%). Black race predicted less endovascular thrombectomy use (OR = 0.79; 95% CI, 0.72–0.86). The highest income group predicted endovascular thrombectomy use (OR = 1.24; 95% CI, 1.13–1.36) as did private insurance (OR = 1.30; 95% CI, 1.23–1.38). High income predicted good outcome (OR = 1.10; 95% CI. 1.06–1.14), as did private insurance (OR = 1.36; 95% CI, 1.31–1.39). Black race predicted poor outcome (OR = 1.33; 95% CI, 1.30–1.36). All results were statistically significant (P

BackgroundMost conventional 0.088 inch guide catheters cannot safely navigate intracranial vasculature. The objective of this study is to evaluate the safety of stroke thrombectomy using a novel 0.088 inch guide catheter designed for intracranial navigation.MethodsThis is a multicenter retrospective study, which included patients over 18 years old who underwent thrombectomy for anterior circulation large vessel occlusions. Technical outcomes for patients treated using the TracStar Large Distal Platform (TracStar LDP) or earlier generation TRX LDP were compared with a matched cohort of patients treated with other commonly used guide catheters. The primary outcome measure was device-related complications. Secondary outcome measures included guide catheter failure and time between groin puncture and clot engagement.ResultsEach study arm included 45 patients. The TracStar group was non-inferior to the control group with regard to device-related complications (6.8% vs 8.9%), and the average time to clot engagement was 8.89 min shorter (14.29 vs 23.18 min; p=0.0017). There were no statistically significant differences with regard to other technical outcomes, including time to recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2B). The TracStar was successfully advanced into the intracranial internal carotid artery in 33 cases (73.33%); in three cases (6.67%), it was swapped for an alternate catheter. Successful reperfusion (mTICI 2B-3) was achieved in 95.56% of cases. Ninety-day follow-up data were available for 86.67% of patients, among whom 46.15% had an modified Rankin Score of 0–2%, and 10.26% were deceased.ConclusionsTracstar LDP is safe for use during stroke thrombectomy and was associated with decreased time to clot engagement. Intracranial access was regularly achieved.

Vein of Galen aneurysmal malformation (VGAM) is a rare anomaly associated with poor outcomes from high output cardiac failure and neurologic complications. Studies addressing fetal cardiovascular status and outcomes in this population are limited. A single-center retrospective review was conducted on patients with a prenatal diagnosis of VGAM who underwent a fetal echocardiogram between January 2015 and July 2019. Fetal echocardiographic data, brain magnetic resonance imaging (MRI) findings and outcomes were collected. Nine fetuses [median gestational age at echocardiogram 34 (1.1) weeks] were included. All patients had superior vena cava dilation and reversal of diastolic flow in the transverse aortic arch. Median cardiothoracic (CT) ratio was 0.39 (0.09). Right ventricular (RV) and left ventricular (LV) dysfunction was present in 66% and 11% fetuses, respectively. Four out of five patients that underwent postnatal endovascular neurosurgical interventions at our center were alive at follow-up (mean 2.7 years). Of the non-survivors (n = 5), 3 received comfort care because of severe brain damage and died in the neonatal period. Non-survivors more commonly had > mild tricuspid regurgitation (TR) (40% vs. 25%) and > mild RV dilation (60% vs. 25%). Combined cardiac index (CCI) was higher in non-survivors when compared to survivors (672.7 vs. 530.2 ml/kg/min, p = 0.016). Fetuses with significant parenchymal damage on brain MRI tended to have a higher CCI than those without (979.8 vs. 605.0 ml/kg/min, p = 0.047). RV dysfunction, TR and elevated CCI are more commonly seen in non-survivors with VGAM. A higher CCI is seen in those deemed untreatable due to significant parenchymal volume loss. Future multicenter studies are needed to assess for prenatal prediction of outcomes in this high-risk population.

New York City has become the global epicenter of the coronavirus 2019 (COVID-19) pandemic. Despite a massive shift in health care resources, cerebrovascular disease continues to be a substantial burden. We review the first 10 patients undergoing thrombectomy following a series of governmental and institutional policy changes diverting resources to the care of critically ill patients with COVID-19. Ten patients with emergent large-vessel occlusion underwent thrombectomy between March 23 and April 1, 2020. Five patients tested positive for the COVID-19 virus. Successful reperfusion was achieved in 9 of 10 patients, at a median time of 37 minutes from vascular access. The postprocedural NIHSS score improved by an average of 7.7 points. Of the 5 patients positive for COVID-19, none have experienced a critical respiratory illness. We report the early incidence of COVID-19 positivity in patients with emergent large-vessel occlusion and demonstrate that thrombectomy continues to be an efficacious option, as well as safe for health care providers.

Background: Endovascular aneurysmal coiling is a preventative alternative to clipping to avoid aneurysmal rupture. In the literature and our own experience, some common coiling challenges which arise include: (1) microcatheter kickback, (2) detachment zone rigidity, (3) intrasaccular compartmentalization of coils on deployment, and (4) attainability of high-density and effective packing with as few coils as possible. Methods: We retrospectively reviewed a consecutive case series of 15 intracranial aneurysm patients who received Kaneka i-ED Coils since their initial use in our practice (December 2020) till May 2022. Results: Of the 14 saccular aneurysm patients treated with i-ED coils, 2/14 (14.3%) achieved a Raymond-Roy (RR) score of 3A (internal remnant), 4/14 (28.6%) achieved RR 2 (slight neck remnant) and 8/14 (57.1%) achieved RR 1. One MoyaMoya patient (5.9%) with a fusiform aneurysm also achieved a complete occlusion by parent artery takedown in this series. Aneurysm volumes ranged from 8.15 mm 3 to 315.5 mm 3 with an average packing density of 36.23% and a standard deviation 8.87%. At 30 days, most of our cohort scored a 0 on the modified Rankin scale (mRS) (11/15), with two patients scoring at an mRS score of 1, one at an mRS score of 4, and one at an mRS score of 6. Low-memory shape, coil cases achieved a significantly higher packing density (P < 0.01) and PD/Coils-used ratio (P < 0.05) than other cases in our practice. Conclusion: Our initial experience with i-ED coils has shown that they are a feasible strategy in a number of differently sized and shaped aneurysms. While fewer coils overall were not a statistically significant finding in this study, the future studies with larger cohorts are necessary and in progress.

BackgroundIn the last few decades there has been development of innovative therapies for the treatment of craniofacial lymphatic malformations. Percutaneous sclerotherapy has demonstrated efficacy in the management of macrocystic lymphatic lesions, but it is less suitable for microcystic lesions given their size. The gravity-dependent technique is a novel augmentation of standard percutaneous sclerotherapy: the technique enables a sclerosing agent to permeate the small microchannels seen in microcystic lesions that would otherwise be difficult to treat.MethodsBetween 2005 and 2021, 124 patients with microcystic or mixed lymphatic malformations were treated using a novel gravity-dependent sclerotherapy technique. Bleomycin at a maximum dose of 15 IU per session was used as the main sclerosing agent. Fluoroscopy and ultrasound were used to ensure proper positioning of the catheter prior to injecting the sclerosing agent. The response to treatment was assessed clinically and with cross-sectional imaging.ResultsNearly all cases showed significant improvement after the gravity-dependent technique. There have been no permanent complications from sclerotherapy treatment. There was a mild transient adverse effect from bleomycin in one case of erythema and tenderness that lasted several weeks then ameliorated.ConclusionsThe gravity-dependent sclerotherapy technique is a suitable treatment option for microcystic lymphatic malformations.

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

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

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

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

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

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

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

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

BackgroundArtificial intelligence (AI) software is increasingly applied in stroke diagnostics. However, the actual performance of AI tools for identifying large vessel occlusion (LVO) stroke in real time in a real-world setting has not been fully studied.ObjectiveTo determine the accuracy of AI software in a real-world, three-tiered multihospital stroke network.MethodsAll consecutive head and neck CT angiography (CTA) scans performed during stroke codes and run through an AI software engine (Viz LVO) between May 2019 and October 2020 were prospectively collected. CTA readings by radiologists served as the clinical reference standard test and Viz LVO output served as the index test. Accuracy metrics were calculated.ResultsOf a total of 1822 CTAs performed, 190 occlusions were identified; 142 of which were internal carotid artery terminus (ICA-T), middle cerebral artery M1, or M2 locations. Accuracy metrics were analyzed for two different groups: ICA-T and M1 ±M2. For the ICA-T/M1 versus the ICA-T/M1/M2 group, sensitivity was 93.8% vs 74.6%, specificity was 91.1% vs 91.1%, negative predictive value was 99.7% vs 97.6%, accuracy was 91.2% vs 89.8%, and area under the curve was 0.95 vs 0.86, respectively. Detection rates for ICA-T, M1, and M2 occlusions were 100%, 93%, and 49%, respectively. As expected, the algorithm offered better detection rates for proximal occlusions than for mid/distal M2 occlusions (58% vs 28%, p=0.03).ConclusionsThese accuracy metrics support Viz LVO as a useful adjunct tool in stroke diagnostics. Fast and accurate diagnosis with high negative predictive value mitigates missing potentially salvageable patients.

BACKGROUND AND PURPOSE: Two-thirds of lymphatic malformations in children are found in the head and neck. Although conventionally managed through surgical resection, percutaneous sclerotherapy has gained popularity. No reproducible grading system has been designed to compare sclerotherapy outcomes on the basis of radiologic findings. We propose an MR imaging–based grading scale to assess the response to sclerotherapy and present an evaluation of its interrater reliability. MATERIALS AND METHODS: A grading system was developed to stratify treatment outcomes on the basis of interval changes observed on MR imaging. By means of this system, 56 consecutive cases from our institution with formally diagnosed head and neck lymphatic malformations treated by sclerotherapy were retrospectively graded. Each patient underwent pre- and posttreatment MR imaging. Each study was evaluated by 3 experienced neuroradiologists. Interrater reliability was assessed using the Krippendorff α statistic, intraclass coefficient, and 2-way Spearman ρ correlation. RESULTS: The overall Krippendorff α statistic was 0.93 (95% CI, 0.89–0.95), denoting excellent agreement among raters. Intraclass coefficients with respect to consistency and absolute agreements were both 0.97 (95% CI, 0.96–0.98), illustrating low variability. Every combination of individual rater pairs demonstrated statistically significant (P < .01) linear Spearman ρ correlations, with values ranging from 0.90 to 0.95. CONCLUSIONS: The proposed radiographic grading scale demonstrates excellent interrater reliability. Adoption of this new scale can standardize reported outcomes following sclerotherapy for head and neck lymphatic malformation and may aid in the investigation of future questions regarding optimal management of these lesions.

BackgroundEmbolic stroke with large vessel occlusion (LVO) is a major adverse event during ventricular assist device (VAD) support. In this study we aimed to clarify the efficacy of, and problems associated with, endovascular treatment (EVT) of LVO in patients with VAD support.MethodsWe retrospectively reviewed EVT for LVO in patients with VAD support between 2006 and 2017 at our institute and evaluated baseline characteristics, treatment variables, outcomes, and complications.ResultsThe study cohort comprised 12 consecutive patients (age 35.4±20.4 years), with 15 LVO events involving 20 arterial occlusions, who had undergone EVT. The median Alberta Stroke Program Early CT score was 10 and good collaterals were observed in 10 of 17 occluded middle cerebral artery areas. No study patients had received intravenous thrombolysis therapy. EVT was performed on 18 of the 20 occluded arteries and mechanical thrombectomy on 13 vessels. The successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2 b) rate was 67% in all EVTs and 85% with mechanical thrombectomy. Histological analysis showed fibrin-rich thrombi in four of five samples. Seven of 12 patients (58%) maintained their neurological function (modified Rankin Scale score ≤2 or equal to pre-stroke score) at 90 days. Periprocedural complications comprised two symptomatic intracranial hemorrhages and the 90-day mortality rate was 13%. Seven of 10 cardiac transplant candidates (70%) returned to the waiting list and three of them received transplants.ConclusionsEndovascular therapy for acute LVO stroke is feasible even in patients with VAD support.

Introduction Staged, transarterial embolization (TAE) is currently considered the gold standard for the treatment of vein of Galen aneurysmal malformation (VGAM); however, as transarterial access becomes restricted, further staged TAE may become ineffective or carry an increased risk of hemorrhagic or ischemic stroke when attempting complete obliteration. Objective To describe the first consecutive, retrospective series of VGAM treated with transvenous embolization (TVE) with coils alone, as the final treatment in staged endovascular therapy, at a single institution between January 2004 and September 2021. Results A total of 10 patients with a median age of 5.5 (IQR: 9.25) years were treated with coiling TVE. Patients were treated with a median number of 5 (IQR: 2.75) TAEs prior to the final TVE treatment. Complete or near-complete immediate angiographic obliteration was achieved in eight patients. Immediate post-procedural (within 48 h) hemorrhagic complications were noted in two patients (20%), one of whom passed away while the second suffered from hemiparesis. Stereotactic radiosurgery was performed in two patients with incomplete obliteration after TVE. The median follow-up time after TVE was 17 (IQR: 9) months. At long-term follow up (17 months) for the remaining nine patients, all VGAMs were completely obliterated. Long-term clinical deterioration compared to pre-TVE was noticed in one case. Conclusion Transvenous coil embolization is a technically feasible but risky option, as a final-stage treatment for cure of VGAMs with restricted trans-arterial access. Although TVE with coils remains an effective therapeutic modality, we recommend continuing investigation of safer TVE techniques to achieve cure.

Background Since staged trans-arterial endovascular embolization (TAE) became the main strategy to treat vein of Galen aneurysmal malformation (VGAM), this otherwise lethal disease has become manageable. The antenatally diagnosed cases need proper planning for delivery and neonatal management. Symptomatic neonates with congestive heart failure (CHF) benefit from trans-umbilical TAE with closure of fistulas in order to reduce CHF and improve survival. In infants, symptomatic hydrocephalus or venous hypertension requires urgent TAE to facilitate normal brain development. Even in asymptomatic cases, staged TAE in a safe manner can be beneficial before development delay. Staged TAE of the choroidal feeding arteries has been reported to result in cure. However, some VGAMs remain technically challenging to obtain complete obliteration solely with this technique. If the choroidal feeders are not accessible after prior TAE, other options need to be sought. We reviewed the final few procedures in consecutively cured VGAM patients and assessed the techniques utilized to obtain total obliteration. Materials and Methods This is a retrospective chart and radiographic investigation of a consecutive series of 124 VGAM cases treated between 2004 and 2021 in our institution. Obvious arteriovenous malformation with aneurysmal dilatation of vein of Galen was not included. The strategy in this period was to repeat TAE of the choroidal feeders until the VGAM was totally occluded or until choroidal feeder access was no longer safe. In 81 out of 124 patients, the VGAM was totally or near totally (>95%) obliterated. There were 7 death because of the SHF instead of aggressive TAE or because of the hemorrhagic complication. 36 patients are currently undergoing staged embolization and total obliteration hasn’t been achieved and are therefore excluded from this study. Results Among the 81 cases, 66 cases (81%) achieved total to near total obliteration of the VGAM solely with staged TAE through choroidal artery or thalamoperforating artery feeders. Most of them were found to have total occlusion in the 3 to 6 month follow up angiogram after a final TAE, even when the malformation had been present at the final angiogram in the last TAE. In 4 cases (5%), the dural supply of the malformation was embolized with ONYX from the external carotid artery as the final procedure; and total obliteration was achieved. Transvenous embolization at the last procedure led to complete occlusion of the VGAM in 9 patients (11%). Two cases were referred to stereotactic radiosurgery (SRS) after the age of 10 and total obliteration of the residual malformation was confirmed in the 2 year follow up cerebral angiogram post SRS. There was one hemorrhagic complication occurring in a case after final TVE. Conclusions Staged transarterial n-BCA embolization of the choroidal arteries effected cure of VGAM with a good outcome in more than 80% of the 124 cases. If the access is challenging, multimodal approach with transdural ONYX embolization, transvenous embolization or even SRS can be considered. Further assessment of natural history of patients with near occlusion is warranted. Disclosures T. Shigematsu: None. J. Fifi: None. A. Berenstein: None.

Background Acute ischemic stroke from basilar artery occlusion (BAO) is a devastating disease with high mortality and morbidity rate. The safety and efficacy of endovascular thrombectomy in BAO is not fully understood. We aimed to evaluate the predictors of favorable clinical outcome in these patients. Methods We performed a retrospective analysis of consecutive acute stroke patients with BAO whom underwent endovascular thrombectomy. Demographics, and the rate of successful recanalization (TICI score ≥2B) were reviewed. The primary efficacy outcome was defined as 90-day modified Rankin Scale (mRS) score ≤ 2 (or no worsening of mRS at 90 days compared to pre-stroke mRS in patients with pre-stroke mRS>2). Secondary outcome included early neurological improvement (ENI) defined as ≥8 points reduction in National Institutes of Health Stroke Scale (NIHSS) score, as compared to presentation, or NIHSS score ≤4 at 24 hours. Multivariate analysis was performed to determine predictors of favorable 90-day outcome. Results Sixty-two patients were identified with mean (SD) age 67 (15), 39% women, and 24% African-American. Initial NIHSS median (IQR) was 22 (14), the mean symptoms onset to groin puncture time was 9.7 (5.7) hours. Thirty-one percent of patients were treated with intravenous thrombolytic therapy. Successful recanalization was achieved in 92% of the patients. Total of 34% of the patients had favorable 90-day outcome. Mortality at 90-day was seen in 34% of the patients. ENI was observed in 22 (35%) patients. Patients with ENI were more likely to have favorable 90-day clinical outcome, compared to those without ENI (52% vs 27%, p=0.04). Single pass successful recanalization (OR; 95% CI: 5.56; 1.61–19.81, p=0.005) and initial NIHSS score (OR; 95% CI: 1.11; 1.2–1.19, p=0.043) were independent predictors of ENI. Conclusion ENI is an independent predictor of favorable clinical outcome after BAO thrombectomy. Single pass successful recanalization is associated with higher likelihood of ENI. Disclosures S. Majidi: 1; C; SNIS Foundation. S. Matsoukas: None. R. De Leacy: None. T. Oxley: None. H. Shoirah: None. T. Shigematsu: None. C. Kellner: None. J. Mocco: None. J. Fifi: None.

Background Middle meningeal artery (MMA) embolization has emerged as a promising treatment modality for patients with chronic subdural hematoma (SDH). Onyx, particles, or coils are the most used embolic materials. Therefore, the safety and efficacy of n-butyl cyanoacrylate (n-BCA) embolization in these patients are not fully understood. We present the technical feasibility and efficacy of n-BCA embolization in the largest consecutive cohort to date. Methods This study is a retrospective analysis of a prospectively maintained database of consecutive patients with chronic or recurrent SDH treated with MMA embolization using diluted n-BCA with the ‘Sugar- Rush’ technique. Briefly, a 2.1 Fr microcatheter was used to selectively catheterize the distal frontal and posterior branches of the MMA. A 5-Fr intermediate catheter was advanced proximal to the origin of the MMA in the internal maxillary artery and used for Dextrose 5% (Sugar- Rush) injection via a 60 ml syringe while the primary operator was injecting n-BCA through the microcatheter. Complete obliteration of frontal and posterior branch of the MMA and lack of SDH recurrence in 3-6 months follow up CT scan were defined as efficacy outcomes. Cranial nerve palsy, vision loss, transient neurologic deficit and stroke were defined as safety outcomes. Results A total of 61 patients were identified with a mean (±SD) age of 62.5± 9. Seventy eight percent of the patients were male. Median (IQR) NIHSS score was 1 (3), 67% of the patients had midline shift and 36% had bilateral SDH. Forty nine percent of the patients had craniotomy, burr hole or Subdural Evacuating Port System (SEPS) placement prior to embolization. The embolization was performed under MAC anesthesia in 39 (64%) patients and radial access in 29 (48%) patients. In 6 patients (10%), coil embolization of the origin of the frontal or posterior branch was performed as super-selective catheterization of the branch was unsuccessful due to tortuous anatomy. Complete obliteration of frontal and posterior branches was achieved in 100% of the cases. In 25% of the patients, n-BCA penetrated the contralateral side. Follow up CT scan at 3-months and 6- months were available in 91% of the patients. Recurrent SDH was seen in only 1 patient on the side contralateral to treatment. No incidence of cranial nerve palsy, vision loss, or stroke occurred. One patient suffered a transient neurological deficit. Conclusion MMA embolization using diluted n-BCA with concomitant Dextrose 5% injection (Sugar-Rush) is associated with a high degree of distal penetration and complete branch occlusion and minimal risk of cranial nerve palsy or other thrombo-embolic complications. Clinical trials are warranted to compare long-term efficacy of this procedure with standard of care management. Disclosures S. Majidi: None. S. Matsoukas: None. R. De Leacy: None. P. Morgenstern: None. R. Soni: None. H. Shoirah: None. T. Shigematsu: None. J. Bederson: None. A. Berenstein: None. J. Mocco: None. J. Fifi: None. C. Kellner: None.

Background: 30% of minor stroke symptom (MSS) patients (NIHSS= Methods: Retrospective review of MSS-LVO patients across two multi-hospital centers from June 2015 thru June 2018 was conducted. Patients who underwent immediate EVT without signs of deterioration were excluded. Baseline characteristics, management, and outcomes were compared with t-tests, Mann-Whitney U, Chi-square, Fisher’s exact test, and Fisher-Freeman-Halton test for continuous and categorical variables, as appropriate using SPSS Software. Results: Of the 45 MSS-LVO patients who were included, 12 suffered END. Demographics and baseline characteristics were not significantly different across groups. Weakness was more often a presenting symptom in the No-END cohort (84.8% vs 41.7% in END group, p=0.01). The END group showed a lower diastolic BP at the time of the highest NIHSS (86mmHg vs 72mmHg in END group, p= 0.03). The highest BP was comparable across groups (180/84 in the No END group vs 182/91 in END group, p>0.05); although in the END group, the high BP correlated with a higher NIHSS (3 vs 0 in No END group, p=0.01). Patients in the END group were more likely to receive tpA (58.3% vs 15.2% in No END group, p=0.01). The 24-hour NIHSS was greater in the END group (2.5 vs. 0, p=0.02). 84.4% of patients in the No END group had good functional outcome at 3-5 days (mRS 0-2), compared to 45.5% of the END patients (p=0.02). 25% of the END group had in-hospital mortality, while there were no deaths in the No END group. Fewer patients were discharged home (72.7% in No END vs 58.3% in END group, p=0.04). Conclusion: END in MSS patients is associated with worse outcomes at 3-5 days and higher in-hospital mortality. Presenting symptoms and BP fluctuations may be factors in predicting END. Further studies are needed to elucidate the risk factors associated with END in MSS-LVO patients.

Background There is little evidence in scientific literature assessing the safety and efficacy of dual-lumen balloon catheters (DLBCs) and their performance compared to single-lumen catheters (SLCs). Methods In this PROSPERO-registered, PRISMA-compliant systematic review, we identified all MEDLINE and EMBASE single-arm (DLBCs) and double-arm (DLBCs vs SLCs) cohorts where DLBCs were used for the treatment of cerebral arteriovenous malformations (AVMs) or dural arteriovenous fistulas (dAVFs). Immediate angiographic outcome, vascular complications, technical failures, reflux episodes and entrapment were the primary outcomes. A meta-analysis of the double-arm studies summarized the primary outcomes of total procedural time and immediate angiographic outcome. Results The authors identified 18 studies encompassing 209 treated lesions with reported outcomes. Complete occlusion was achieved in 108/132 treated dAVFs (81.8%, 95% CI: [74–87.8%]) and in 45/77 treated AVMs (58.4%, [46.7–69.4%]). The proportion of completely occluded dAVFs was statistically significantly higher than that of AVMs, p < .001. There were eight reported vascular complications (3.8%, [1.8–7.7%]), five technical failures (2.4%, [0.9–5.8%]), 14 reflux events (6.7%, [3.9–11.2%]), two entrapment events (1%, [0.2–3.8%]) and 0 deaths (mortality rate 0%, [0–2.3%]). In a meta-analysis for the treatment of dAVFs, the total procedural time was significantly less for DLBCs compared to SLCs (64.9 vs 125.7 min, p < .0001). The odds of complete immediate occlusion were significantly higher with DLBCs compared to SLCs (odds ratio (OR) 4.6, [1.5–14.3], p = .008). Conclusion Dual-lumen balloon catheters are safe and effective for the embolization of cerebral AVMs and dAVFs and can achieve faster and potentially superior results compared to SLCs. Registration-URL https://www.crd.york.ac.uk/prospero/ Unique Identifier: CRD42021269096