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Background and purposeThe ability of polymer-modified coils to promote stable aneurysm occlusion after endovascular treatment is not well-documented. Angiographic aneurysm recurrence is widely used as a surrogate for treatment failure, but studies documenting the correlation of angiographic recurrence with clinical failure are limited. This trial compares the effectiveness of Matrix(2) polyglycolic/polylactic acid biopolymer-modified coils with bare metal coils and correlates the angiographic findings with clinical failure (ie, target aneurysm recurrence), a composite end point that includes any incident of posttreatment aneurysm rupture, retreatment, or unexplained death.Materials and methodsThis was a multicenter randomized noninferiority trial with blinded end point adjudication. We enrolled 626 patients, divided between Matrix(2) and bare metal coil groups. The primary outcome was target aneurysm recurrence at 12 ± 3 months.ResultsAt 455 days, at least 1 target aneurysm recurrence event had occurred in 14.6% of patients treated with bare metal coils and 13.3% of Matrix(2) (P = .76, log-rank test) patients; 92.8% of target aneurysm recurrence events were re-interventions for aneurysms that had not bled after treatment, and 5.8% of target aneurysm recurrence events resulted from hemorrhage or rehemorrhage, with or without retreatment. Symptomatic re-intervention occurred in only 4 (0.6%) patients. At 455 days, 95.8% of patients with unruptured aneurysms and 90.4% of those with ruptured aneurysms were independent (mRS ≤ 2). Target aneurysm recurrence was associated with incomplete initial angiographic aneurysm obliteration, presentation with rupture, and a larger aneurysmal dome and neck size.ConclusionsTested Matrix(2) coils were not inferior to bare metal coils. Endovascular coiling of intracranial aneurysms was safe, and the rate of technical success was high. Target aneurysm recurrence is a promising clinical outcome measure that correlates well with established angiographic measurements.

Minimally invasive neural interfaces can be used to diagnose, manage and treat many disorders, with reduced risks of surgical complications. However, endovascular probes lack access to key cortical, subcortical and spinal targets, and are not typically explantable after endothelialization. Here we report the development and testing, in sheep, of endocisternal neural interfaces that approach brain and spinal cord targets through inner and outer spaces filled with cerebrospinal fluid. Thus, the interfaces gain access to the entire brain convexity, to deep brain structures within the ventricles and to the spinal cord from the spinal subarachnoid space. We combined an endocisternal neural interface with wireless miniature magnetoelectrically powered bioelectronics so that it can be freely navigated percutaneously from the spinal space to the cranial subarachnoid space, and from the cranial subarachnoid space to the ventricles. In sheep, we show recording and stimulation functions, as well as repositioning of the flexible electrodes and explantation of the interface after chronic implantation. Minimally invasive endocisternal bioelectronics may enable chronic and transient therapies, particularly for stroke rehabilitation and epilepsy monitoring., Competing Interests: Competing interests J.T.R., Sunil A. Sheth, Sameer A. Sheth and J.E.W. receive monetary or equity compensation from Motif Neurotech. Sameer A. Sheth has consulting agreements with Boston Scientific, Zimmer Biomet, Koh Young, Neuropace, Sensoria Therapeutics and Varian Medical. Sunil A. Sheth has consulting agreements with Viz.ai, Penumbra, Medtronic and Imperative Care, as well as grant funding from the McNair Foundation and the NIH. The terms of these agreements have been reviewed and approved by Rice University, UTHealth and Baylor College of Medicine in accordance with their policies on conflicts of interest in research. A.K.W. is a cofounder of Deinde and P.K. is an investor in Deinde. The other authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Intracranial aneurysms (IAs) remain a challenging neurological diagnosis associated with significant morbidity and mortality. There is a plethora of microsurgical and endovascular techniques for the treatment of both ruptured and unruptured aneurysms. There is no definitive consensus as to the best treatment option for this cerebrovascular pathology. The Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts discussed best practices and the most promising approaches to improve the management of brain aneurysms., Methods: A group of experts from academia, industry, and federal regulators convened to discuss updated clinical trials, scientific research on preclinical system models, management options, screening and monitoring, and promising novel device technologies, aiming to improve the outcomes of patients with IA., Results: Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts suggested the incorporation of artificial intelligence to capture sequential aneurysm growth, identify predictors of rupture, and predict the risk of rupture to guide treatment options. The consensus strongly recommended nationwide systemic data collection of unruptured IA radiographic images for the analysis and development of machine learning algorithms for rupture risk. The consensus supported centers of excellence for preclinical multicenter trials in areas such as genetics, cellular composition, and radiogenomics. Optical coherence tomography and magnetic resonance imaging contrast-enhanced 3T vessel wall imaging are promising technologies; however, more data are needed to define their role in IA management. Ruptured aneurysms are best managed at large volume centers, which should include comprehensive patient management with expertise in microsurgery, endovascular surgery, neurology, and neurocritical care., Conclusions: Clinical and preclinical studies and scientific research on IA should engage high-volume centers and be conducted in multicenter collaborative efforts. The future of IA diagnosis and monitoring could be enhanced by the incorporation of artificial intelligence and national radiographic and biologic registries. A collaborative effort between academic centers, government regulators, and the device industry is paramount for the adequate management of IA and the advancement of the field., Competing Interests: Disclosures Dr Tjoumakaris reports compensation from Medtronic for consultant services, MicroVention, Inc, for consultant services, and MicroVention, Inc, for consultant services. Dr Hanel reports compensation from Cerenovous for consultant services; stock holdings in eLum and BlinkTBI; compensation from Medtronic for consultant services; stock holdings in Endostream; compensation from Stryker for consultant services; stock holdings in Scientia, Cerebrotech, and RisT; compensation from MicroVention, Inc, for consultant services; compensation from Balt USA, LLC, for consultant services; stock holdings in Corindus, Inc, InNeuroCo, NTI, and Three Rivers Medical, Inc; and compensation from phenox, Inc, Q’Apel, and Rapid Medical Ltd for consultant services. Dr Mocco reports compensation from CVAid for consultant services; stock options in Tulavi; compensation from Penumbra, Inc, for other services; stock holdings in Q’Apel, Spinaker, Endostream, Sim&Cure, and Cerebrotech; compensation from Perflow for consultant services; stock options in Songbird, NRT, and Borvo; grants from PCORI; stock options in E8; employment by Mount Sinai Health System; stock holdings in Imperative Care, Inc; compensation from CVAid and RIST for consultant services; stock holdings in Viseon, Inc, Radical, Vastrax, and Neurolutions; compensation from Synchron for consultant services; stock options in Spinaker; compensation from MicroVention, Inc, for other services; stock holdings in Blinktbi, Echovate, NTI Managers, and Vizai; and compensation from Stryker for other services. Dr Ali-Aziz Sultan reports compensation from MicroVention, Inc, for other services. Dr Froehler reports compensation from OCULUS, Inc, Cerenovus, and Siemens for consultant services; grants from Genentech, Inc; grants from Siemens; and compensation from Balt USA, LLC, for consultant services. Dr Lieber reports stock holdings in Prometheus Therapapeutics, Inc. Dr Coon reports compensation from Medtronic, Inc, Imperative Care, Inc, MicroVention, Inc, Rapid Medical Ltd, Stryker Corporation, and Johnson and Johnson for consultant services. Dr Tateshima reports compensation from Rapid Medical Ltd, Medtronic, phenox, Inc, Cerenovus, MicroVention, Inc, and Stryker for consultant services. Dr Altschul reports securities holdings in Von Vascular, Inc, and compensation from Johnson and Johnson International, Stryker Corporation, Medtronic USA, Inc, and MicroVention, Inc, for consultant services. Dr Narayanan reports compensation from MicroVention, Inc, Johnson & Johnson Health Care Systems, Inc, and Imperative Care, Inc, for consultant services. Dr Taussky reports compensation from Medtronic for consultant services; compensation from phenox, Inc, for data and safety monitoring services; and compensation from Johnson & Johnson Health Care Systems, Inc, for consultant services. Dr Hoh reports stock options in Progressive Neuro; compensation from AstraZeneca for other services; stock options in Galaxy Therapeutics; grants from the National Institutes of Health; compensation from Janssen Pharmaceuticals for other services; employment by the College of Medicine, University of Florida; grants from the Brain Aneurysm Foundation; and stock options in Proprio Vision. Dr Gounis reports compensation from Wallaby Medical, Imperative Care, Inc, and Mivi Neurosciences for consultant services; stock holdings in GalaxyTherapeutics; compensation from Medtronic Neurovascular for consultant services; stock holdings in InNeuroCo, LLC; compensation from Q’Apel Medical, phenox, Inc, Cerenovus, Route 92 Medical, Inc, Alembic, LLC, and Stryker Corporation for consultant services; and stock holdings in Imperative Care, Inc, and Synchron. Dr Liebeskind reports compensation from Stryker, Medtronic, Rapid Medical Ltd, Cerenovus, and Genentech for consultant services. Dr Volovici reports employment by Erasmus Medisch Centrum and compensation from JAMA for consultant services. Dr Toth reports compensation from Medtronic USA, Inc, for other services and compensation from EBSCO and Penumbra, Inc, for consultant services. Dr Arthur reports compensation from Balt USA, LLC, Penumbra, Inc, MicroVention, Inc, Johnson and Johnson International, Siemens Medical Solutions USA, Inc, Stryker Corporation, Perfuze, Scientia, and Medtronic USA, Inc, for consultant services. Dr Wakhloo reports compensation from Stryker Corporation for consultant services, an ownership stake in Deinde Medical, compensation from Acotec for consultant services, an ownership stake in Prometheus Therapeutics, grants from Philips, an ownership stake in Neurofine, and compensation from Cerenovus Johnson & Johnson for consultant services. The other authors report no conflicts.

ARISE (Aneurysm/AVM/cSDH Roundtable Discussion With Industry and Stroke Experts) organized a one-and-a-half day meeting and workshop and brought together representatives from academia, industry, and government to discuss the most promising approaches to improve outcomes for patients with chronic subdural hematoma (cSDH). The emerging role of middle meningeal artery embolization in clinical practice and the design of current and potential future trials were the primary focuses of discussion. Existing evidence for imaging, indications, agents, and techniques was reviewed, and areas of priority for study and key questions surrounding the development of new and existing treatments for cSDH were identified. Multiple randomized, controlled trials have met their primary efficacy end points, providing high-level evidence that middle meningeal artery embolization is a potent adjunctive therapy to the standard (surgical and nonsurgical) management of neurologically stable cSDH patients in terms of reducing rates of disease recurrence. Pooled data analyses following the formal conclusion and publication of these trials will form a robust foundation upon which guidelines can be strengthened for cSDH treatment modalities and optimal patient selection, as well as delineate future lines of investigation., Competing Interests: Disclosures Dr Kan reports compensation from Imperative Care, Inc, for consultant services; compensation from MicroVention, Inc, for consultant services; grants from Siemens Medical Solutions USA, Inc, the National Institutes of Health, and the Joe Niekro Foundation; and stock holdings in Vena Medical. Dr Fiorella reports compensation from Johnson & Johnson Health Care Systems, Inc, for consultant services. Dr Lanzino reports compensation from the American Heart Association for consultant services. Dr Siddiqui reports stock options in Createch Medical, Inc; securities holdings in VICIS, Inc; employment by the Jacobs Institute; stock holdings in NextGen Biologics, Inc; stock options in Three Rivers Medical, Inc; compensation from W. L. Gore & Associates, Inc, for consultant services; securities holdings in SongBird Therapy; compensation from Johnson & Johnson Medical Devices & Diagnostics Group-Latin America, LLC, for consultant services; stock holdings in Neurotechnology Investors; and stock holdings in Truvic Medical, Inc. Dr Khalessi reports compensation from Proximie for consultant services and stock options in Asayena. Dr Colby reports compensation from Cerenovus, Medtronic, Stryker, Balt USA, LLC, Rapid Medical Ltd, and MicroVention, Inc, for consultant services. Dr Wakhloo received grants from Philips and compensation from Acotec for consultant services; disclosures provided by Dr Wakhloo in compliance with the American Heart Association’s annual Journal Editor Disclosure Questionnaire are available at https://www.ahajournals.org/editor-coi-disclosures. Dr Arthur reports compensation from Perfuze for consultant services. The Aneurysm/AVM/Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts I roundtable discussion event was collectively sponsored by Imperative Care, Stryker, InNeuroCo, the Brain Aneurysm Foundation, Philips, Bendit, Kaneka Neurovascular, Fluid Biomed, Johnson and Johnson Cerenovus, Penumbra, MicroVention, RapidAI, Viz.ai, Siemens Healthineers, and Medtronic. The content and writing of this article were not sponsored by industry. The other authors report no conflicts.

Brain arteriovenous malformations (bAVMs) are complex, and rare arteriovenous shunts that present with a wide range of signs and symptoms, with intracerebral hemorrhage being the most severe. Despite prior societal position statements, there is no consensus on the management of these lesions. ARISE (Aneurysm/bAVM/cSDH Roundtable Discussion With Industry and Stroke Experts) was convened to discuss evidence-based approaches and enhance our understanding of these complex lesions. ARISE identified the need to develop scales to predict the risk of rupture of bAVMs, and the use of common data elements to perform prospective registries and clinical studies. Additionally, the group underscored the need for comprehensive patient management with specialized centers with expertise in cranial and spinal microsurgery, neurological endovascular surgery, and stereotactic radiosurgery. The collection of prospective multicenter data and gross specimens was deemed essential for improving bAVM characterization, genetic evaluation, and phenotyping. Finally, bAVMs should be managed within a multidisciplinary framework, with clinical studies and research conducted collaboratively across multiple centers, harnessing the collective expertise and centralization of resources., Competing Interests: Disclosures Dr Samaniego provided consultant services for Rapid Medical, Medtronic, iSchemaView, MicroVention, Inc and compensation Cerenovus. Dr Dabus provided consultant services for Cerenovus, Medtronic, Microvention Inc, Penumbra, Phenox Inc, Route 92 Medical Inc, and Stryker. Stock in InNeuroCo and RIST. Dr Kan worked as consultant services for Imperative Care Inc, and Stryker. Stock in Deinde, Neurofine, Prometheus, Vena Medical and Vented. He received grants from Joe Niekro, National Institutes of Health, and Siemens Medical Solutions. Dr Frösen is employed at Academy of Finland, Tampere University Hospital, and Tampereen Yliopisto. Dr Lanzino provided consultant services for the American Heart Association. Dr Volovici provided consultant services for JAMA and is employed at Erasmus Meisch Centrum. Dr Hoh received grants from the Brain Aneurysm Foundation and the National Institutes of Health. He is employed at the College of Medicina, University of Florida. Dr Khalessi provided consultant services for Medtronic, Proximie, and Stryker. Dr Pereira provided consultant services for Balt USA, LLC, Medtronic, and Stryker. Dr Bain provided consultant services for Borvo, Cerenovus, CIT Ortho, Integra LifeSciences Corporation, Medtronic, Microvention Inc, and Stryker. Dr Colby provided consultant services for Cerenovus, Medtronic, Microvention Inc, Rapid Medical Ltd, and Stryker. Dr Narayanan provided consultant services for Imperative Care Inc, Johnson and Johnson Health Care Systems Inc, and Microvention Inc. Dr Tateshima provided consultant services for Cerenovus, Medtronic, Microvention Inc, Phenox Inc, Rapid Medical Ltd, and Stryker. Dr Siddiqui provided consultant services for Amnis Therapeutics, Apellis Pharmaceuticals Inc, Boston Scientific Corporation, Cannon Medical Systems USA Inc, Cardinal Health 200 LLC, Cordis Corporation, Corindus Inc, Hyperfine Operations Inc, IRRAS USA Inc, Johnson and Johnson Medical Devices and Diagnostic Group – Latin America, LLC, Medtronic Vascular, Microvention Inc, Minnetronix Neuro Inc, Penumbra Inc, Rapid Medical Ltd, Stryker Corporation, Vassol, vizai Inc, and W.L. Gore and Associates Inc. Stocks in Adona Medical Inc, Bend IT Tehcnologies Ltd, BlinkTBI Inc, Borvo Medical Inc, Cerebrotech Medical Systems Inc, Code Zero Medical Inc, Cognition Medical, Collavidence Medical Inc, E8 Inc, Endostream Medical Ltd, Galaxy Therapeutic Inc, Hyperion Surgical Inc, Imperative Care Inc, Instylla Inc, Neurosolutions Inc, NeuroRadial Technologies Inc, Neurotechnology Investors, NexGen Biologics Inc, Peijia Medical, Peraeus Medical Inc, Q’Apel Medical Inc, Radical Catheter Technologies Inc, Sense Diagnostics Inc, Serenity Medical Inc, Silk Road Medical Inc, Sin and Cure, Spinnaker Medical Inc, Synchron Inc, Truvic Medical Inc, Tulavi Therapeutics Inc, Viseon Inc, Whisper Medical Inc, and Willow Medtech Inc. Stock options in Cerevatech Medical Inc, CVAID Ltd, InspireMD Inc, PerFlow Medical Ltd, Silk Road Medical Inc, StimMed, LLC, Three Rivers Medical Inc, and vizai Inc. Other securities in Cognition Medical, Neurovascular Diagnostics, QAS.ai Inc, SongBird Therapy, Vastrax, LLC, and VICIS Inc. Other business ownership Integra Lifesciences, Corp, and Medtronic. Employment at Jacobs Institute and University at Buffalo Neurosurgery Inc. Dr Wakhloo provided consultant services for Acotec, Cerenovus J&J, Philips and Stryker Corporation. Other business ownership: Deinde Medical, Neurofine and Prometheus Therapeutics. Dr Arthur provided consultant services for Balt USA, LLC, Johnson and Johnson International, Medtronic USA Inc, Microvention Inc, Penumbra Inc, Perfuze, Scientia, Siemens Medical Solutions USA Inc, and Stryker Corporation. The other authors report no conflicts.

Background: To report the 3-year safety and effectiveness of the Surpass Streamline flow diverter in the SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms)., Methods: The Surpass Streamline flow diverter device was evaluated in a multicenter, prospective, single-arm, non-randomized interventional trial including patients with uncoilable or previously treated but failed aneurysms of the intracranial internal carotid artery. 3-year outcomes were tabulated with descriptive statistics and compared with 1-year outcomes., Results: Of 180 patients in the modified intent-to-treat (mITT) cohort, 36-month clinical and angiographic follow-up was available in 134 and 117 cases, respectively. Effectiveness endpoint of complete aneurysm occlusion without clinically significant stenosis or retreatment was met in 71.8% (79/110, 95% CI 62.4% to 80.0%) of cases. Safety composite endpoint was 12.2% (22/180) over the 3-year period, with two major safety events (ipsilateral ischemic strokes) occurring between 12-36 months. Complete aneurysm occlusion was noted in 77.8% (91/117), and 99.1% (116/117) of the patients demonstrated adequate aneurysm occlusion (complete occlusion or neck residual). There were four cases (2.2%) of aneurysm rupture, all occurring within the first month of the index procedure. Target aneurysm retreatment rate was 2.8% (5/180)., Conclusion: The present findings support the long-term safety and effectiveness of the Surpass Streamline flow diverter device., Trial Registration: NCT01716117., Competing Interests: Competing interests: RAH is a consultant for Stryker, Medtronic, Cerenovous, Microvention, Balt, Phenox, Rapid Medical, and Q’Apel. He is on the advisory board for MiVI, eLum, Three Rivers, Shape Medical, and Corindus. Unrestricted research grant from NIH, Interline Endowment, Microvention, Stryker, CNX. Investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RIST, BlinkTBI, and Corindus. GMC has no disclosures to report. ALC serves as a consultant for Stryker, Medtronic, Microvention, InNeuroCo, Rapid Medical, Q’Apel, Imperative Care, and AVAIL Medsystems. PTK serves as a consultant for Stryker, Imperative Care, Cerenovus, and Microvention; research grant from NIH, Siemens, Joe Niekro, and Medtronic; Journal of NeuroInterventional Surgery editorial board. PT serves as a consultant for Stryker, Cerenovus, and Medtronic. AKW has research grants from Philips Medical, fellowship grant from Medtronic; serves as a consultant for Stryker, Phenox, and Cerenovus JNJ; is a stockholder of InNeuroCo, EpiEP, Neural Analytics, RISt, Analytics 4 Life, and ThrombX; and is on the Speakers’ Bureau for SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms) presentations. BGW served as a consultant/proctor for Stryker and is the past Chair of AANS/CNS Cerebrovascular section. AD has no disclosures to report. MDB serves as a consultant for Stryker and was on the hemorrhagic advisory board for Stryker. JDV serves as a consultant for Stryker Neurovascular and Evasc Ltd and was part of the screening committee French EESIS study (Evasc). KE serves as a consultant for Stryker and Microvention and was a member of the Cerebrovascular Section Joint Guidelines Review Committee. PMM serves as a consultant for Stryker, Medtronic, and Penumbra., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Flow diverters (FDs) have demonstrated a safe and effective profile. However, the use of FDs for posterior communicating artery (PComA) aneurysms remains controversial., Objective: To evaluate the safety and effectiveness of FDs for PComA aneurysms using a systematic review and meta-analysis of the literature., Methods: We performed a systematic search from inception until June 2022 for flow diversion in PComA aneurysms. Primary effectiveness was the rate of complete aneurysm occlusion defined by Raymond-Roy class 1. Primary safety outcomes were treatment-related ischemic/hemorrhagic (composite) events causing morbidity and mortality. Secondary safety was PComA patency at follow-up. Random-effects meta-analyses were used to calculate proportions, and statistical heterogeneity was assessed., Results: A total of 13 studies with 397 patients harboring 403 aneurysms were included. Mean age was 48 years, and the mean aneurysm size was 5.3 mm. Most aneurysms were unruptured (65%). Complete occlusion at final follow-up was 73% (CI 66%-79%), and adjunctive coils were used in 10% of aneurysms. Retreatment rate was 2% (CI 0%-9%). The primary safety composite outcome was 4% (CI 3%-7%), and mortality was 1%. PComA patency at final follow-up was 76% (CI 57%-89%). Subgroup analysis, patients with fetal PComAs had a lower complete occlusion rate (42% fetal PComA vs 77%, psubgroupdifference = <.01)., Conclusion: The performance of FDs in PComA aneurysms is comparable with outcomes found in other subtypes of supraclinoid aneurysms. Effectiveness was acceptable and safety favorable. However, effectiveness was suboptimal in patients with fetal-type PComAs; alternative treatments should be considered in these cases., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background and Purpose: Flow diversion has established as standard treatment for intracranial aneurysms, the Surpass Streamline is the only FDA-approved braided cobalt/chromium alloy implant with 72-96 wires. We aimed to determine the safety and efficacy of the Surpass in a post-marketing large United States cohort., Materials and Methods: This is a retrospective multicenter study of consecutive patients treated with the Surpass for intracranial aneurysms between 2018 and 2021. Baseline demographics, comorbidities, and aneurysm characteristics were collected. Efficacy endpoint included aneurysm occlusion on radiographic follow-up. Safety endpoints were major ipsilateral ischemic stroke or treatment-related death., Results: A total of 277 patients with 314 aneurysms were included. Median age was 60 years, 202 (73%) patients were females. Hypertension was the most common comorbidity in 156 (56%) patients. The most common location of the aneurysms was the anterior circulation in 89% (279/314). Mean aneurysm dome width was 5.77 ± 4.75 mm, neck width was 4.22 ± 3.83 mm, and dome/neck ratio was 1.63 ± 1.26. Small-sized aneurysms were 185 (59%). Single device was used in 94% of the patients, mean number of devices per patient was 1.06. At final follow-up, complete obliteration rate was 81% (194/239). Major stroke and death were encountered in 7 (3%) and 6 (2%) cases, respectively., Conclusion: This is the largest cohort study using a 72-96 wire flow diverter. The Surpass Streamline demonstrated a favorable safety and efficacy profile, making it a valuable option for treating not only large but also wide-necked small and medium-sized intracranial aneurysms.

Background: The Surpass flow diverter was developed to treat intracranial aneurysms not amenable to standard treatment. Indications for use allow placement in the internal carotid artery to the terminus, including the communicating artery segment., Methods: The Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms (SCENT) trial is an international, multicenter, prospective, non-randomized trial comparing the outcomes of Surpass flow diverter treatment with historic control designed to evaluate the effectiveness and safety of Surpass for the treatment of wide neck (≥4 mm) large or giant intracranial aneurysms ≥10 mm. The primary effectiveness endpoint is the percentage of subjects with 100% aneurysm occlusion without significant stenosis of the parent artery and without retreatment of the target aneurysm at 12 months. The primary safety endpoint is the percentage of subjects experiencing neurologic death or major ipsilateral stroke at 12 months. We report the effectiveness and safety of flow diversion in the subgroup of posterior communicating artery (PComA) aneurysms., Results: Of the 180 patients treated, 38 harbored a PComA aneurysm. Mean aneurysm size was 12.2 mm and mean neck width was 4.8 mm. The mean number of Surpass devices used was 1.1 per procedure, with 94.7% of aneurysms treated with one flow diverter. The 12 month primary effectiveness rate was 73.7% (28/38). At 36 months, 68.4% (26/38) of aneurysms remained completely occluded. The 12 month major ipsilateral stroke or neurological death rate was 10.5%. No patients with PComA occlusion after flow diverter placement (54.5%) had clinical sequelae., Conclusions: SCENT demonstrated acceptable 12 month effectiveness of flow diversion in PComA aneurysms. Despite associated PComA occlusions in many cases, arterial occlusions were clinically silent., Trial Registration Number: URL: https://www., Clinicaltrials: gov. Unique identifier: NCT01716117., Competing Interests: Competing interests: PK: consultant for Stryker and Cerenovus, and stockholder of InNeuroCo; editorial board member of Journal of NeuroInterventional Surgery; and education chair of the Society of NeuroInterventional Surgery. PMM: consultant for Stryker, Medtronic, and Penumbra. ALC: consultant for Stryker, Medtronic, Microvention, and InNeuroCo. AKW: research grant from Philips Medical; serves as a consultant for Stryker; is a stockholder of InNeuroCo, NovaSignal, Rist, Analytics 4 Life, and ThrombX; and is on the speakers’ bureau for the SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms) presentations. JD: consultant for Stryker and Evasc. KE: consultant for Stryker and Microvention. RAH: research grant from Medtronic, Stryker, Microvention, and Cerenovus; consultant for Stryker, Medtronic, Cerenovus, and Microvention; stockholder in Neurvana, Elum, EndoStream, Three Rivers Medical Inc, Rist, Cerebrotech, and InNeuroCo; scientific advisor for MIVI, Elum, Three Rivers Medical Inc, and Shape Medical. PT: consultant for Medtronic, Cerenovus, and Stryker., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Dolichoectatic vertebrobasilar fusiform aneurysms (DVBFAs) have poor natural history when left untreated and high morbimortality when treated with microsurgery. Flow diversion (FD) with dual-antiplatelet therapy (DAPT) is feasible but carries high risk of perforator occlusion and progression of brainstem compression. Elaborate antithrombotic strategies are needed to preserve perforator patency while vessel remodeling occurs. We compared triple therapy (TT (DAPT plus oral anticoagulation)) and DAPT alone in patients with DVBFAs treated with FD., Methods: Retrospective comparison of DAPT and TT in patients with DVBFAs treated with FD at eight US centers., Results: The groups (DAPT=13, TT=14) were similar in age, sex, clinical presentation, baseline disability, and aneurysm characteristics. Radial access use was significantly higher in the TT group (71.4% vs 15.3%; P=0.006). Median number of flow diverters and adjunctive coiling use were non-different between groups. Acute ischemic stroke rate during the oral anticoagulation period was lower in the TT group than the DAPT group (7.1% vs 30.8%; P=0.167). Modified Rankin Scale score decline was significantly lower in the TT group (7.1% vs 69.2%; P=0.001). Overall rates of hemorrhagic complications (TT, 28.6% vs DAPT, 7.7%; P=0.162) and complete occlusion (TT, 25% vs DAPT, 54.4%; P=0.213) were non-different between the groups. Rate of moderate-to-severe disability at last follow-up was significantly lower in the TT group (21.4% vs 76.9%; P=0.007)., Conclusions: Patients with DVBFAs treated with FD in the TT group had fewer ischemic strokes, less symptom progression, and overall better outcomes at last follow-up than similar patients in the DAPT group., Competing Interests: Competing interests: AHS: Consulting fees: Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Cerevatech Medical, Inc., Cordis, Corindus, Inc., Endostream Medical, Ltd, Imperative Care, InspireMD, Ltd, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Peijia Medical, Penumbra, Q’Apel Medical, Inc., Rapid Medical, Serenity Medical, Inc., Silk Road Medical, StimMed, LLC, Stryker Neurovascular, Three Rivers Medical, Inc., VasSol, Viz.ai, Inc. Leadership or fiduciary role in other board, society, committee or advocacy group: Secretary, Board of the Society of NeuroInterventional Surgery 2020–2021, Chair, Cerebrovascular Section of the AANS/CNS 2020–2021. Stock or stock options: Adona Medical, Inc., Amnis Therapeutics, Bend, IT Technologies, Ltd, BlinkTBI, Inc., Cerebrotech Medical Systems, Inc., Cerevatech Medical, Inc., Cognition Medical, CVAID Ltd, E8, Inc., Endostream Medical, Ltd, Galaxy Therapeutics, Inc., Imperative; Care, Inc., InspireMD, Ltd, Instylla, Inc., International Medical Distribution Partners, Launch NY, Inc., Neurolutions, Inc., NeuroRadial Technologies, Inc., NeuroTechnology Investors, Neurovascular Diagnostics, Inc., Peijia; Medical, PerFlow Medical, Ltd, Q’Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp.), Rist Neurovascular, Inc. (purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, Sim & Cure, SongBird Therapy, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Three Rivers Medical, Inc., Truvic Medical, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, VICIS, Inc., Viseon, Inc. Other financial or non-financial interests: National PI/Steering Committees: Cerenovus EXCELLENT and ARISE II Trial; Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFT DIRECT Trials; MicroVention FRED Trial & CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial, MIVI Neuroscience EVAQ Trial; Rapid Medical SUCCESS Trial; InspireMD C-GUARDIANS IDE Pivotal Trial. AM: none. RAH: Grants or contracts: NIH, Interline Endowment, MicroVention, Stryker, CNX; Consulting fees: Medtronic (also a proctor), Balt, Stryker (also a proctor), Q’Apel Medical Inc, Codman Neuro (J&J), Cerenovus, MicroVention, Imperative Care Inc., Phenox Inc, Rapid Medical; Participation on a Data Safety Monitoring Board or Advisory Board: MiV, eLuma, Three Rivers, Shape Medical, Cordindus; Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc., Scientia, RisT, Blink TBI, Corindus. PK: Grant: NIH U18EB029353-01, Medtronic unrestricted research grant, Joe Niekro Foundation research grant; Consulting Fees: Stryker Neurovascular, Imperative Care, MicroVention; Leadership or fiduciary roles in other board society, committee or advocacy group, paid and unpaid: JNIS editorial board member. AM: none. GMC: none. MR: none. CM: Grant: NIH R21NS119992; Consulting fees: Penumbra, Stryker, Silk Road Medical; Speaker: Penumbra; Silk Road Medical; Other financial or non-financial interest: Steering Committee Member (ADVANCE, Medtronic). NS: none. CR: none. JS: none. KE: Consulting fees: Stryker Neurovascular, MicroVention; Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: Joint Guidelines Review Committee member. LF: none. SKN: none. BO-A: none. SO-G: Consulting fees: Medtronic, MicroVention, Stryker. JV-S: none. AKW: Grants or contracts: Philips, Medtronic fellowship grant, Microbot; Consulting fees: Stryker Neurovascular, Philips, Cerenovus, Microbot; Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: Deinde Med, Neurofine, InNeuroCo, Prometheus, ThrombX, NovaSignal, Neurostream. Shareholder: Corvista, Neurostream, Medtronic RIST, Prometheus, InNeuroCo, ThrombX, NovaSignal, Neurofine, Neurostream, Hyperion. EIL: Shareholder/ownership interest: NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care, Rebound Therapeutics, StimMed, Three Rivers Medical; Patent: Bone Scalpel; Honorarium for training & lectures: Medtronic, Penumbra, MicroVention, Integra, Consultant: Clarion, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, StimMed, Misionix, Mosiac; Chief Medical Officer: Haniva Technology; National PI: Medtronic- Steering Committees for SWIFT Prime and SWIFT Direct Trials; Site PI Study: MicroVention (CONFIDENCE Study) Medtronic (STRATIS Study-Sub 1); Advisory Board: Stryker (AIS Clinical Advisory Board), NeXtGen Biologics, MEDX, Cognition Medical; Endostream Medical, IRRAS AB (Consultant/Advisory Board, Medical Legal Review: render medical/legal opinions as an expert witness; leadership or fiduciary roles in other board society, committee or advocacy group, paid and unpaid: CNS, ABNS, UBNS., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The treatment of acute ischemic stroke continues to advance. The mainstay of treatment remains intravenous thrombolysis with alteplase. Recent studies demonstrated that later treatment with alteplase is beneficial in patients selected with advanced imaging techniques. Tenecteplase has been evaluated as an alternative thrombolytic drug and evidence suggests that it is as least as effective as alteplase and may lyse large vessel clots more effectively. Endovascular therapy with mechanical thrombectomy has now been shown to be beneficial up to 24 hours after stroke onset in carefully selected patients with proximal, large vessel occlusions. Ongoing studies are evaluating the effectiveness of thrombectomy in patients with more distal vessel occlusions and patients with proximal large vessel occlusions with larger ischemic core volumes and also in patients with milder neurological deficits. Cytoprotection is another potential acute stroke therapy that has not demonstrated efficacy in prior clinical trials. It should be reconsidered as an adjunct to reperfusion and a variety of new clinical trials can be envisioned to evaluate the potential benefits of cytoprotection in patients before and after reperfusion.

Background: To analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome., Methods: Multicentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications., Results: A total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age >60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p<0.001), diabetes mellitus (aOR: 2.66, 95% CI 1.16 to 6.09, p=0.021), higher NIHSS at admission (aOR: 1.08, 95% CI 1.02 to 1.14, p=0.006), LVO (aOR: 2.45, 95% CI 1.04 to 5.78, p=0.042), and higher NLR level (aOR: 1.06, 95% CI 1.01 to 1.11, p=0.028) were significantly associated with poor functional outcome., Conclusion: There is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: patients with a subarachnoid hemorrhage (SAH) might need a flow diverter (FD) placement for complex acutely ruptured intracranial aneurysms (IAs). We conducted a meta-analysis and developed a prediction model to estimate the favorable clinical outcome after the FD treatment in acutely ruptured IAs., Methods: a systematic literature search was performed from 2010 to January 2021 in PubMed and Embase databases. Studies with more than five patients treated with FDs within fifteen days were included. In total, 1157 studies were identified. The primary outcome measure was the favorable clinical outcome (mRS 0-2). Secondary outcome measures were complete occlusion rates, aneurysm rebleeding, permanent neurologic deficit caused by procedure-related complications, and all-cause mortality. A prediction model was constructed using individual patient-level data., Results: 26 retrospective studies with 357 patients and 368 aneurysms were included. The pooled rates of the favorable clinical outcome, mortality, and complete aneurysm occlusion were 73.7% (95% CI 64.7-81.0), 17.1% (95% CI 13.3-21.8), and 85.6% (95% CI 80.4-89.6), respectively. Rebleeding occurred in 3% of aneurysms (11/368). The c-statistic of the final model was 0.83 (95% CI 0.76-0.89). All the studies provided a very low quality of evidence., Conclusions: FD treatment can be considered for complex ruptured IAs. Despite high complication rates, the pooled clinical outcomes seem favorable. The prediction model needs to be validated by larger prospective studies before clinical application.

Background: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study's objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines., Methods: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation., Findings: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p<0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p<0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile., Interpretation: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction., Competing Interests: Competing interests: TNN: PI CLEAR study (Medtronic). DCH: Stryker, Vesalio, Cerenovus consultant. AEH: consultant and speaker for Medtronic, Stryker, Microvention, Penumbra, Balt, Scientia, Genentech and GE Healthcare. PJ: Medtronic, Microvention, Balt, Cerenovus consultant. SO-G: Medtronic, Stryker consultant. DSL: Cerenovus, Genentech, Stryker, Medtronic consultant. TGJ: advisor/investor for Anaconda, Route92, FreeOx, and Blockade Medical; Medtronic grants, DAWN, AURORA PI (Stryker). WJM: consultant: Rebound Therapeutics, Viseon Imperative Care, Q’Apel, Stryker, Stream Biomedical, Spartan Micro; Investor: Cerebrotech, Endostream, Q’Apel, Viseon, Rebound, and Spartan Micro. RGN: Stryker; Cerenovus/Neuravi; Anaconda, Cerebrotech, Ceretrieve, Vesalio (Advisory Board); Imperative Care., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Existing travel restrictions limit the mobility of proctors, significantly delaying clinical trials and the introduction of new neurointerventional devices. We aim to describe in detail technical and legal considerations regarding international teleproctoring, a tool that could waive the need for in-person supervision during procedures., Methods: International teleproctoring was chosen to provide remote supervision during the first three intracranial aneurysm treatments with a new flow diverter (currently subject of a clinical trial) in the US. Real-time, high-resolution transmission software streamed audiovisual data to a proctor located in Canada. The software allowed the transmission of images in a de-identified, HIPAA-compliant manner., Results: All three flow diverters were implanted as desired by operator and proctor and without complication. The proctor could swap between images from multiple sources and reported complete spatial and situational awareness, without any significant lag or delay in communication. Procedural times and radiologic dose were similar to those of uncomplicated, routine flow diversion cases at our institution., Conclusions: International teleproctoring was successfully implemented in our clinical practice. Its first use provided important insights for establishing this tool in our field. With no clear horizon for lifting the current travel restrictions, teleproctoring has the potential to remove the need for proctor presence in the angiography suite, thereby allowing the field to advance through the continuation of trials and the introduction of new devices in clinical practice. In order for this tool to be used safely and effectively, highly reliable connection and high-resolution equipment is necessary, and multiple legal nuances have to be considered., Competing Interests: Competing interests: VMP is a consultant for Stryker. ALC is a consultant and proctor for Stryker. AKW has a research grant from Philips Medical and serves as a consultant for Stryker., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: No randomized trial of intracranial aneurysm coiling has compared long-term efficacy of polymer-modified coils to bare metal coils (BMCs). We report 5-year results comparing Matrix 2 coils to BMCs. The primary objective was to compare the rates of target aneurysm recurrence (TAR) at 12 months. Secondary objectives included angiographic outcomes at TAR or 12 months and TAR at 5 years., Methods: A total of 626 patients were randomized to BMCs or Matrix 2 coils. Detailed methods and 1-year results have been published previously., Results: Of 580 patients eligible for 5-year follow-up, 431 (74.3%) completed follow-up or reached TAR. Matrix 2 coils were non-inferior to BMCs (P=0.8) but did not confer any benefit. Core lab reported post-treatment residual aneurysm filling (Raymond III) correlated with TAR (P<0.0001) and with aneurysm hemorrhage after treatment (P<0.008). Repeat aneurysmal hemorrhage after treatment, but before hospital discharge, occurred in three patients treated for acutely ruptured aneurysms. Additionally, two patients treated for unruptured aneurysms experienced a first hemorrhage during follow-up. All five hemorrhages resulted from aneurysms with Raymond III residual aneurysm filling persisting after initial treatment. After 5 years follow-up, 2/626 (0.3%) patients are known to have had target aneurysm rupture following hospital discharge. The annualized rate of delayed hemorrhage after coiling was 2/398/5=0.001 (0.1%) per year for unruptured aneurysms and 0 for ruptured aneurysms., Conclusions: After 5 years Matrix 2 coils were non-inferior to BMCs but no benefit was demonstrated. Post-treatment residual angiographic aneurysm filling (Raymond III) is strongly associated with TAR (P<0.0001) and post-treatment aneurysmal hemorrhage (P=0.008)., Competing Interests: Competing interests: SWH: core lab services for Stryker and MicroVention Terumo (money paid to UCSF, over $5K); consulting for Microvention Terumo (money paid to Dr Hetts, under $5K). CGM: consultant for Medtronic and Microvention. JCC: consultant for Stryker. AB: consultant for Stryker, Microvention, Balt, and Phenox. AKW: research grant from Philips Medical; serves as a consultant for Stryker and Phenox; is a stockholder of InNeuroCo, EpiEP, Neural Analytics, Rist, Analytics 4 Life, and ThrombX; and is on the Speakers’ Bureau for SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms) presentations. AG: consultant for Microvention and emeritus consultant at Newcastle upon Tyne Hospitals NHS Trust. CFD: chief adjudicator, Stryker EVOLVE Trial Core Angiography Lab (salary support to department)., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Catheter retention and difficulty in retrieval have been observed during embolization of brain arteriovenous malformations (bAVMs) with the Onyx liquid embolic system (Onyx). The Apollo Onyx delivery microcatheter (Apollo) is a single lumen catheter designed for controlled delivery of Onyx into the neurovasculature, with a detachable distal tip to aid catheter retrieval. This study evaluates the safety of the Apollo for delivery of Onyx during embolization of bAVMs., Methods: This was a prospective, non-randomized, single-arm, multicenter, post-market study of patients with a bAVM who underwent Onyx embolization with the Apollo between May 2015 and February 2018. The primary endpoint was any catheter-related adverse event (AE) at 30 days, such as unintentional tip detachment or malfunction with clinical sequelae, or retained catheter. Procedure-related AEs (untoward medical occurrence, disease, injury, or clinical signs) and serious AEs (life threatening illness or injury, permanent physiological impairment, hospitalization, or requiring intervention) were also recorded., Results: A total of 112 patients were enrolled (mean age 44.1±17.6 years, 56.3% men), and 201 Apollo devices were used in 142 embolization procedures. The mean Spetzler-Martin grade was 2.38. The primary endpoint was not observed (0/112, 0%). The catheter tip detached during 83 (58.5%) procedures, of which 2 (2.4%) were unintentional and did not result in clinical sequelae. At 30 days, procedure related AEs occurred in 26 (23.2%) patients, and procedure-related serious AEs in 12 (10.7%). At 12 months, there were 3 (2.7%) mortalities, including 2 (1.8%) neurological deaths, none of which were device-related., Conclusion: This study demonstrates the safety of Apollo for Onyx embolization of bAVMs., Clinical Trial Registration: CNCT02378883., Competing Interests: Competing interests: JF reports grants and non-financial support from Stryker, grants and other funding from Penumbra, grants from Microvention, and equity in Cerebrotech and The Stroke Project. CAG serves on the speaker’s bureau and as a consultant and proctor for Medtronic and Stryker, and serves on the speaker’s bureau for Genentech. MM serves as a consultant for Toshiba/Canon Medical. PK serves as a consultant for Stryker Neurovascular, Medtronic, and Cerenovus. TY serves as a consultant and proctor for Medtronic. OD serves as a proctor for Microvention/Terumo. DF serves as a consultant for Balt, Marblehead Medical, Medtronic, Stryker, Microvention, Penumbra, and Cerenovus, receives research support from Cerenovus, Medtronic, Stryker, Siemens, Microvention, and Penumbra, receives royalties from Codman, and is a stockholder in Marblehead, Neurogami, and Vascular simulations outside the submitted work. RVC has received research funding from Microvention, Cerenovus, and Medtronic. AKW has received research grants from Philips Medical, serves as a consultant for Stryker and Phenox, is a stockholder in InNeuroCo, EpiEP, Neural Analytics, Rist, Analytics 4 Life, and ThrombX, and serves on the speaker’s bureau for SCENT trial presentations. ASP serves as a consultant for and has received research grants from Medtronic Neurovascular and Stryker Neurovascular. RAH serves as a consultant for Medtronic, Stryker, Codman, and Microvention, and is a stockholder in InNeuroCo. LFG holds stock in Culvert Therapeutics and NeuroCool, serves as a proctor for Medtronic Neurovascular, and participates in training other physicians in the use pipeline embolization device. MAA-S serves as a proctor for Medtronic Neurovascular, and participates in training other physicians in the use of the embolic agent Onyx and the pipeline embolization device., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background Acute ischemic stroke (AIS) in the context of COVID-19 has received considerable attention for its propensity to affect patients of all ages. We aimed to evaluate the effect of age on functional outcome and mortality following an acute ischemic event. Methods and Results A prospectively maintained database from comprehensive stroke centers in Canada and the United States was analyzed for patients with AIS from March 14 to September 30, 2020 who tested positive for SARS-CoV-2. The primary outcome was Modified Rankin Scale score at discharge, and the secondary outcome was mortality. Baseline characteristics, laboratory values, imaging, and thrombectomy workflow process times were assessed. Among all 126 patients with COVID-19 who were diagnosed with AIS, the median age was 63 years (range, 27-94). There were 35 (27.8%) patients with AIS in the aged ≤55 years group, 47 (37.3%) in the aged 56 to 70 group, and 44 (34.9%) in the aged >70 group. Intravenous tissue plasminogen activator and thrombectomy rates were comparable across these groups, ( P =0.331 and 0.212, respectively). There was a significantly lower rate of mortality between each group favoring younger age (21.9% versus 45.0% versus 48.8%, P =0.047). After multivariable adjustment for possible confounders, a 1-year increase in age was significantly associated with fewer instances of a favorable outcome of Modified Rankin Scale 0 to 2 (odds ratio [OR], 0.95; 95 CI%, 0.90-0.99; P =0.048) and higher mortality (OR, 1.06; 95 CI%, 1.02-1.10; P =0.007). Conclusions AIS in the context of COVID-19 affects young patients at much greater rates than pre-pandemic controls. Nevertheless, instances of poor functional outcome and mortality are closely tied to increasing age.

Background and Purpose: A basilar artery intraluminal septation is an exceedingly rarely reported, presumed congenital abnormality. In our clinical practice, we have occasionally noticed an intraluminal band within the inferior aspect of the basilar artery on CTA. Furthermore, we have noticed, at times, the presence of a punctate calcification associated with this finding. We hypothesized that what previous studies have called "basilar septations" in fact represent miniature and thus aberrant basilar fenestrations., Materials and Methods: We retrospectively reviewed CTA studies obtained between January 1, 2017, and August 31, 2019. Identified intraluminal basilar abnormalities were classified as either basilar septations or basilar fenestrations. Association with other posterior circulation abnormalities was documented., Results: A total of 3509 studies were examined. A basilar intraluminal abnormality was evident in 80 patients (2.3%). Of these 80 patients, 59 were classified as having a basilar fenestration (1.7%) and 21 were classified as having basilar septations (0.6%). Associated calcification was evident in 3 of the basilar fenestration cases and 13 of the basilar septation cases., Conclusions: Basilar septations most likely represent and should be referred to as aberrant basilar fenestrations. They should be interpreted as benign congenital incidental findings and should not be misinterpreted as focal dissections or arterial webs. Important variations in the morphology of aberrant basilar fenestrations exist, including areas of thinning, varying thickness, and nodularity. Therefore, when associated with calcification or nodularity, aberrant basilar fenestrations should not be confused with focal intraluminal thrombi or calcified or noncalcified emboli., (© 2021 by American Journal of Neuroradiology.)

Background: Treatment of intracranial aneurysms with flow diverters (FDs) showed promising results. However, a subset of patients treated for posterior communicating artery (PComA) aneurysms has variable occlusion rates. Especially the fetal type-associated PComA aneurysms seemed to respond differently to treatment. We analyze our series of fetal type PComA aneurysms treated with a FD. The literature on this subject is reviewed., Methods: Data from patients treated with FD for all PComA aneurysms at the RadboudUMC Nijmegen were retrospectively analysed. Primary end-point was complete aneurysm occlusion at six months. Secondary end-points were clinical outcome, treatment safety, and results of secondary treatment after non-closure. The results for the fetal PComA aneurysms were compared to the literature., Results: Nineteen consecutive patients harboring 21 PComA aneurysms were treated. Three aneurysms had ipsilateral fetal type PCA (14.3%). Overall, none of the fetal type PcomA aneurysm showed complete occlusion versus 77.8% of the others ( p = 0.03). Mortality and permanent morbidity rates were respectively 5.3% and 0%., Conclusions: FD treatment for PComA aneurysm with fetal type circulation seemed to be less effective compared to other types of PComA aneurysms. Flow characteristics at the PComA bifurcation are thought to be causative Alternative strategies should be considered as first line treatment.

Endovascular treatment of intracranial aneurysms (IAs) has evolved considerably over the past decades. The technological advances have been driven by the experience that coils fail to completely exclude all IAs from the blood circulation, the need to treat the diseased parent vessel segment leading to the aneurysm formation, and expansion of endovascular therapy to treat more complex IAs. Stents were initially developed to support the placement of coils inside wide neck aneurysms. However, early work on stent-like tubular braided structure led to a more sophisticated construct that then later was coined as a flow diverter (FD) and found its way into clinical application. Although FDs were initially used to treat wide-neck large and giant internal carotid artery aneurysms only amenable to surgical trap with or without a bypass or endovascular vessel sacrifice, its use in other types of IAs and cerebrovascular pathology promptly followed. Lately, we have witnessed an explosion in the application of FDs and subsequently their modifications leading to their ubiquitous use in endovascular therapy. In this review we aim to compile the available FD technology, evaluate the devices' peculiarities from the authors' perspective, and analyze the current literature to support initial and expanded indications, recognizing that this may be outdated soon., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Academic physicians aim to provide clinical and surgical care to their patients while actively contributing to a growing body of scientific literature. The coronavirus disease 2019 (COVID-19) pandemic has resulted in procedural-based specialties across the United States witnessing a sharp decline in their clinical volume and surgical cases., Objective: To assess the impact of COVID-19 on neurosurgical, stroke neurology, and neurointerventional academic productivity., Methods: The study compared the neurosurgical, stroke neurology, and neurointerventional academic output during the pandemic lockdown with the same time period in previous years. Editors from a sample of neurosurgical, stroke neurology, and neurointerventional journals provided the total number of original manuscript submissions, broken down by months, from the year 2016 to 2020. Manuscript submission was used as a surrogate metric for academic productivity., Results: 8 journals were represented. The aggregated data from all eight journals as a whole showed that a combined average increase of 42.3% was observed on original submissions for 2020. As the average yearly percent increase using the 2016-2019 data for each journal exhibited a combined average increase of 11.2%, the rise in the yearly increase for 2020 in comparison was nearly fourfold. For the same journals in the same time period, the average percent of COVID-19 related publications from January to June of 2020 was 6.87%., Conclusion: There was a momentous increase in the number of original submissions for the year 2020, and its effects were uniformly experienced across all of our represented journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the results in patients treated with the Surpass Evolve (SE) device, the new generation of Surpass flow diverters., Methods: Twenty-five consecutive patients (20 women, average age 58 years), with anterior or posterior circulation aneurysms treated with SEs in two early-user centers, were included. Device properties and related technical properties, imaging and clinical follow-up data, and intraprocedural, early (<30 days) and delayed (>30 days) neurological complications, further divided into minor (silent/non-permanent) and major (permanent) complications, were recorded and analyzed., Results: Twenty-nine SEs were successfully implanted in all subjects to treat 26 aneurysms using an 0.027" microcatheter with an average of 1.2 stents per patient. No intraprocedural thromboembolic or hemorrhagic complications were seen. At clinical follow-up, 24/25 (96%) patients had a modified Rankin Score of 0-2. Mortality was 0%. Imaging follow-up, available in 22/25 (88%) patients (median follow-up time 4 months), showed a complete aneurysm occlusion in 13/23 (57%) imaged lesions. Minor, transitory neurological deficits were recorded in 5/25 (20%) patients. One (4%) major complication was seen in one patient (4%) with a left-sided hemispheric stroke on postprocedural day 4 due to an acute stent thrombosis., Conclusions: Preliminary experience in patients demonstrates a good performance of the SE. This newly designed implant maintains the engineering characteristics of Surpass flow diverters, including precise placement due to its lower foreshortening and a high mesh density, yet can be deployed through a significantly lower-profile delivery system., Competing Interests: Competing interests: VMP is a consultant for Stryker, Balt, Medtronic, and Cerenovous and holds a grant from Philips Healthcare.TK is a consultant for Medtronic, Stryker, and Penumbra and is a stockholder in Marblehead Inc. AKW has research grant from Philips Medical; serves as a consultant for Stryker and Phenox; is a stockholder of InNeuroCo, EpiEP, Neural Analytics, Rist, Analytics 4 Life, and ThrombX; and is on the Speakers’ Bureau for SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms) presentations. ALC is consultant and proctor for Stryker, Medtronic, and Microvention and is on the Medical Advisory Board for InNeuroCo. HR is a consultant and proctor for, and receives educational support from, Stryker, Medtronic, Philips, Microvention, and Penumbra. All other Authors have no disclosures., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: Flow diverters are sometimes used in the setting of acutely ruptured aneurysms. However, thromboembolic and hemorrhagic complications are feared and evidence regarding safety is limited. Therefore, in this multicenter study we evaluated complications, clinical, and angiographic outcomes of patients treated with a flow diverter for acutely ruptured aneurysms., Methods: We conducted a retrospective observational study of 44 consecutive patients who underwent flow diverter treatment within 15 days after rupture of an intracranial aneurysm at six centers. The primary end point was good clinical outcome, defined as modified Rankin Scale score (mRS) 0-2. Secondary endpoints were procedure-related complications and complete aneurysm occlusion at follow-up., Results: At follow-up (median 3.4 months) 20 patients (45%) had a good clinical outcome. In 20 patients (45%), 25 procedure-related complications occurred. These resulted in permanent neurologic deficits in 12 patients (27%). In 5 patients (11%) aneurysm re-rupture occurred. Eight patients died resulting in an all-cause mortality rate of 18%. Procedure-related complications were associated with a poor clinical outcome (mRS 3-6; OR 5.1(95% CI 1.0 to 24.9), p=0.04). Large aneurysms were prone to re-rupture with rebleed rates of 60% (3/5) vs 5% (2/39) (p=0.01) for aneurysms with a size ≥20 mm and <20 mm, respectively. Follow-up angiography in 29 patients (median 9.7 months) showed complete aneurysm occlusion in 27 (93%)., Conclusion: Flow diverter treatment of ruptured intracranial aneurysms was associated with high rates of procedure-related complications including aneurysm re-ruptures. Complications were associated with poor clinical outcome. In patients with available angiographic follow-up, a high occlusion rate was observed., Competing Interests: Competing interests: JdV and HDB: consultancy relationships to Stryker Neurovascular. CT: grants, personal fees and non-financial support from Microvention; personal fees and non-financial support from Stryker Neurovascular; grants, personal fees, and non-financial support from Acandis (all outside the presented work). RRau: consultant for Stryker Neurovascular and Microvention. AKW: consultant for Stryker Neurovascular, research grants from Philips Healthcare and Wyss Institute (all outside the presented work). ASP: consultant for Medtronic Neurovascular and Stryker Neurovascular; research grants from Medtronic Neurovascular and Stryker Neurovascular (all outside the presented work)., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Despite widespread use of flow diverters, wide-necked large and giant aneurysms are still treated with other techniques as well. A contemporary review of results from different endovascular treatments is timely., Methods: A literature review of the English language literature since 2011 was conducted using PubMed and Science Direct. Keywords and Medical Subheadings included large and giant aneurysms, ruptured aneurysms, aneurysms located in posterior circulation, and aneurysm occlusion status. Case reports were excluded. A combined model was built including both flow diverter and coil treatments in addition to separate models. Efficacy and safety were pooled using random effects analysis and regression., Results: The review comprised 29 studies. For coiling techniques, complete occlusion was 40.2%-82.8%, and adjusted regression resulted in 53% (95% confidence interval [CI] 22%-81%). Flow diverter complete occlusion rate was 40.5%-87.8%, and adjusted regression resulted in 87% (95% CI 76%-93%). Overall occlusion rate for both techniques combined was 62%-75%, and adjusted regression resulted in 81% (95% CI 68%-89%). Overall stroke and death regression rate was 5% (95% CI 3%-10%); flow diverters showed slightly higher rates than coiling (6% vs. 3%)., Conclusions: All current treatments of large and giant wide-necked aneurysms have comparable safety and efficacy with a trend of superiority of efficacy toward flow diverters. Results of future treatment options and devices can be compared with current technology to evaluate feasibility., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The purpose of this study was to evaluate safety and efficacy of the pipeline embolization device (PED) in different patient age groups with unruptured intracranial aneurysms (UIA). All patients with UIA treated with the PED between 2011 and 2017 were included. Based on their age, patients were trichotomized to: young (≤45 years), middle-aged (46 to <65 years) and older (≥65 years) groups. Patient's vascular risk factors, presenting symptoms and mRS on admission were collected. Follow-up imaging was evaluated for presence/absence of aneurysm occlusion. Clinical outcome at discharge, 3-9 months and 12-18 months was also documented when available. A total of 260 patients harboring 307 aneurysms (young = 57, middle-age = 144 and older age group = 64). Most aneurysms were located in the anterior circulation (94.8%). Overall morbidity and mortality was 2.3% each (6/260). At 3-9 months near complete to complete aneurysm occlusion was 82.5% (47/57) in the young age group, 82.6% (100/121) in the middle age, and 70.2% (40/57) in the older age group. At 12-18-month, near complete to complete occlusion was 100% in the young age group (32/32), 91.4% (64/70) in the middle age, and 78.4% (29/37) in the older age group. After adjustment for potential confounders, older age patients less frequently achieved near complete to complete occlusion by 3 years than younger subjects (p = 0.009, HR 1.34 95%, CI 1.08-1.66). Our results indicate feasibility and safety of PED across different age groups. Further study is required to determine age-related factors relating to aneurysm occlusion after PED to improve outcome and patient counseling., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background and Purpose- To evaluate the safety and effectiveness of the Surpass Flow Diverter (Surpass; Stryker Neurovascular, Fremont, CA) in the treatment of large or giant wide-neck intracranial aneurysms at one year, we hypothesize that treatment with Surpass meets or improves on historical safety and efficacy end points. Methods- SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms) is a multicenter, prospective, single-arm, nonrandomized, interventional trial of the Surpass Flow Diverter for uncoilable or previously treated but failed aneurysms of the intracranial internal carotid artery extending from the petrous segment to the carotid terminus at its bifurcation into anterior and middle cerebral arteries. For enrollment in SCENT, target aneurysms had to be wide-neck (≥4 mm) and large or giant size (≥10 mm). Study results are compared with performance goals derived from a thorough review of the medical literature. The primary effectiveness end point included 3 components: complete aneurysm occlusion, absence of significant parent artery stenosis (≥50%), and no retreatment at 12 months. The primary safety end point was major ipsilateral stroke (increase in National Institutes of Health Stroke Scale score of ≥4) or neurological death within 12 months. Results- At 26 medical centers, 180 patients with 180 target aneurysms were enrolled in the modified intention-to-treat cohort. Per angiographic core lab assessment, there were 15 (8.3%) fusiform, 164 (91.1%) saccular aneurysms, and 1 (0.6%) blister aneurysm. Mean aneurysm size was 12.0 mm. Thirteen (7.4%) aneurysms were giant (≥25 mm). Fifty-eight (32.2%) aneurysms were located in the supraclinoid and distal (including posterior communicating artery) segments of the internal carotid artery. Mean procedure duration was 53.6 minutes. The device was successfully implanted in 97.8% of patients with a mean of 1.1 devices per patient. SCENT met both primary safety and effectiveness end points: 12-month primary effectiveness rate was 62.8% [(113/180); 95% CI, 55.3-69.9] and 12-month major ipsilateral stroke or neurological death rate was 8.3% [(15/180); 95% CI, 4.7-13.4]. Conclusions- Surpass provides safe and effective flow diversion of large or giant, wide-neck, intracranial internal carotid artery aneurysms. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT01716117.

Flow diverter malapposition has been described as a technical complication during endovascular procedures and can be associated with, potentially delayed, life-threatening aneurysm rupture or ischemic events. We performed a retrospective review of our flow diverter database to identify all patients in whom device malapposition was detected on follow-up angiogram immediately after device deployment. Feasibility and technical success of different endovascular approaches aiming to correct the inadequate vessel wall apposition were evaluated. Successful endovascular techniques for manipulation of the flow diverter included use of wires, catheters and additional flow diverter/stent devices. In our practice, we found six successful endovascular techniques for device manipulation, which allowed us to safely achieve good flow diverter wall apposition.

Background: To evaluate the feasibility and efficacy of the pipeline embolization device in the treatment of unruptured intracranial mirror segment aneurysms., Methods: Out of a total of 338 subjects, 14 were identified harboring a total of 32 internal carotid artery mirror segment aneurysms that were treated with the pipeline embolization device and were consecutively enrolled into our study. We collected data on patient demographics, modified Rankin scale (mRS) at admission, aneurysm characteristics, clinical outcome at discharge, 3-9 and at 12-18 months as well as angiography results at follow-up., Results: Patients' mean age was 52.9 years; baseline mRS was 0 in all subjects. Pipeline embolization device placement was successful in all cases. Post-treatment mRS remained 0 in 13/14 patients. One patient experienced a small intraparenchymal hemorrhage and subarachnoid hemorrhage, associated with a frontoparietal infarction resulting in right upper extremity weakness and aphasia (post-treatment mRS 3). His mRS evaluation remained stable at the 3-9-month follow-up. Three to 9-month follow-up angiography (13/14 subjects) showed complete aneurysm occlusion in 24/30 aneurysms (80%), near complete and partial occlusion in three of 30 (10%) aneurysms each. At the 9-month follow-up, one patient experienced a complete occlusion of the anterior temporal artery branch but did not present with any clinical deficits. No mRS changes were encountered over a median 6-month follow-up period. Mid-term follow-up angiography (12-18 months) available in eight of 14 subjects showed complete aneurysm occlusion in all patients. Mild intimal hyperplasia was observed in one patient., Conclusions: Flow diversion technology can be used for the treatment of unruptured mirror segment aneurysms in selected patients.

Background: Blood blister aneurysms (BBA) are a rare subset of intracranial aneurysms that represent a therapeutic challenge from both a surgical and endovascular perspective., Objective: To report multicenter experience with flow diversion exclusively for BBA, located at non-branching segments along the anteromedial wall of the supraclinoidal internal carotid artery (ICA)., Methods: Consecutive cases of BBA located at non-branching segments along the anteromedial wall of the supraclinoidal ICA treated with flow diversion were included in the final analysis., Results: 49 patients with 51 BBA of the ICA treated with devices to achieve the flow diversion effect were identified. 43 patients with 45 BBA of the ICA were treated with the pipeline embolization device and were included in the final analysis. Angiographic follow-up data were available for 30 patients (32 aneurysms in total); 87.5% of aneurysms (28/32) showed complete obliteration, 9.4% (3/32) showed reduced filling, and 3.1% (1/32) persistent filling. There was no difference between the size of aneurysm (≤2 mm vs >2 mm) or the use of adjunct coiling and complete occlusion of the aneurysm on follow-up (P=0.354 and P=0.865, respectively). Clinical follow-up data were available for 38 of 43 patients. 68% of patients (26/38) had a good clinical outcome (modified Rankin scale score of 0-2) at 3 months. There were 7 (16%) immediate procedural and 2 (5%) delayed complications, with 1 case of fatal delayed re-rupture after the initial treatment., Conclusions: Our data support the use of a flow diversion technique as a safe and effective therapeutic modality for BBA of the supraclinoid ICA., Competing Interests: Competing interests: ASA: consultant for Covidien, Johnson and Johnson, Siemens, Stryker, and Terumo; grants from Siemens and Terumo. BWB: personal fees from Penumbra Inc, Stryker, Medtronic, Route 92 Medical, and Pulsar. MIC: consultant for Penumbra, Medtronic, Microvention, Codman, Pulsar Vascular, Q’Apel, Rebound Medical, and Blockade Medical. GD: consultant for Proctor; speakers bureau for Medtronic and Microvention; shareholder in Medina Medical, InNeuroCo, and Stryker/Surpass. LE: consultant for Stryker Neurovascular, Microvention, and Codman Neurovascular. RH: consultant for Covidien, Stryker, Codman, and MicroVention. PK: consultant for Stryker Neurovascular, Covidien, and MicroVention. EIL: shareholder/ownership interests in Intratech Medical Ltd, Blockade Medical LLC, and Medina Medical; principal investigator in Covidien US SWIFT PRIME Trials; honoraria for training and lecturing from Covidien; consultant for Pulsar, Medina Medical, and Blockade Medical; other financial support from Abbott for carotid training for physicians. IL: consultant and speaker bureau for Covidien, Codman, and Stryker. DKL: consultant for Covidien and Stryker; shareholder/ownership in Penumbra and Blockade Medical; advisory board for Siemens; principal investigator for Liberty Trial (Penumbra). VMP: consultant for Medtronic, Stryker, Penumbra, and BALT; research grant from Philips. MM: consultant for Toshiba (Canon) Medical. ASP: consultant for Medtronic Neurovascular and Stryker Neurovascular; research grants from Medtronic Neurovascular and Stryker Neurovascular. AJR: consultant for Stryker, MicroVention, and Covidien/ev3. AHS: grants from National Institutes of Health/NINDS/NIBIB, University at Buffalo–none related to present study; financial interests in Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade Medical, and Lazarus Effect; consultant for Codman & Shurtleff Inc, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra, Stryker, Pulsar Vascular, MicroVention, Lazarus Effect, and Blockade Medical; speakers bureau for Codman & Shurtleff Inc; National Steering Committee for Penumbra Inc 3D Separator Trial, Covidien SWIFT PRIME trial, and MicroVention FRED trial; advisory boards for Codman & Shurtleff and Covidien Neurovascular; honoraria from Abbott Vascular, Codman & Shurtleff, and Penumbra Inc. AST: consultant for Stryker, Codman, Penumbra, and Microvention; research grants (not related to the present study) from Stryker, Codman, Micorvention, Penumbra, and Covidien; financial interests in Medina Medical, Lazarus Effect, Pulsar Vascular, and Blockade Medical. RDT: consultant for Penumbra, Medtronic, Microvention, Codman, Pulsar Vascular, Q’Apel, Rebound Medical, and Blockade Medical. AKW: consultant for Stryker Neurovascular; research grants from Philips Healthcare, and Wyss Institute; speaker for Harvard Postgraduate Course and Miami Cardiovascular Institute. BGW: consultant for Stryker and Medtronic., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background Use of flow-diversion technology in the treatment of incidental and recanalized posterior communicating artery (PComA) aneurysms. Methods Patients treated with the Pipeline embolization device (PED) for PComA aneurysms were identified and included in our retrospective analysis. We evaluated aneurysm characteristics, modified Rankin Scale score (mRS) on admission, angiography follow-up, and patient clinical outcome at discharge, at three to nine months, and at 12-18 months. Results We included 56 patients with a mean age of 56 years. Median mRS on admission was 0. All aneurysms involved the PComA and were either new findings or found to have shown recanalization at angiography follow-up from previous coil embolization or surgical clipping. Intraprocedural device foreshortening was observed in one case requiring additional placement of a self-expanding stent. One intraprocedural aneurysm rupture occurred because of a broken distal wire. This patient had an mRS of 4 after the procedure. Three- to nine-month and 12- to 18-month follow-up angiography showed near complete or complete aneurysm occlusion in most cases. Minimal to mild intimal hyperplasia was seen in five cases at three to nine months. PComA patency over time showed 29 of 46 initially patent vessels still patent at six months. Thirteen and seven PComAs showed progressive decrease in flow at three to nine months and 12-18 months, respectively. Median mRS remained 0 for all patients at three- to nine-month and 12- to 18-month follow-up. Conclusions Our preliminary results show that flow-diversion technology is an effective and safe treatment option. Larger studies with long-term follow-up are needed to validate our promising results.

Progress in clinical development of magnetic resonance imaging (MRI) substrate-sensors of enzymatic activity has been slow partly due to the lack of human efficacy data. We report here a strategy that may serve as a shortcut from bench to bedside. We tested ultra high-resolution 7T MRI (µMRI) of human surgical histology sections in a 3-year IRB approved, HIPAA compliant study of surgically clipped brain aneurysms. µMRI was used for assessing the efficacy of MRI substrate-sensors that detect myeloperoxidase activity in inflammation. The efficacy of Gd-5HT-DOTAGA, a novel myeloperoxidase (MPO) imaging agent synthesized by using a highly stable gadolinium (III) chelate was tested both in tissue-like phantoms and in human samples. After treating histology sections with paramagnetic MPO substrate-sensors we observed relaxation time shortening and MPO activity-dependent MR signal enhancement. An increase of normalized MR signal generated by ultra-short echo time MR sequences was corroborated by MPO activity visualization by using a fluorescent MPO substrate. The results of µMRI of MPO activity associated with aneurysmal pathology and immunohistochemistry demonstrated active involvement of neutrophils and neutrophil NETs as a result of pro-inflammatory signalling in the vascular wall and in the perivascular space of brain aneurysms.

Background Treatment of true ophthalmic artery (OA) or anterior choroidal artery (AChA) aneurysms with preservation of the parent vessel may be challenging. Flow diverters have limitations when dealing with branch vessels arising from the aneurysm sac. Visual loss or AChA territory infarcts have been reported both for surgical and endovascular treatment. Methods We evaluated the safety and efficacy of an open-cell design, laser-cut, self-expanding Nitinol stent, and use of cone-beam computed tomography (CBCT) for stent-assisted coil embolization. Results A total of seven patients with unruptured OA or AChA aneurysms were enrolled in this prospective small case study and the data were analyzed retrospectively. A complete obliteration was achieved in all aneurysms immediately post-intervention or at six-month follow-up without any evidence for recanalization at up to three-year follow-up. All patients tolerated the procedure well and there was no change in baseline modified Rankin Scale. Conclusions Our study suggests that specific features of an open-cell stent allow a safe and effective treatment of OA or AChA aneurysms with a high technical success rate and excellent mid-term angiographic and clinical outcome. CBCT is a useful intraoperative imaging tool.

Background: Pericallosal artery aneurysm treatment may be challenging using traditional endovascular techniques., Objective: To demonstrate the feasibility, efficacy, and safety of endovascular treatment of pericallosal artery aneurysm using flow diverters., Methods: We performed a retrospective review of our institutional database from July 2013 through July 2016 and identified 7 subjects with a pericallosal artery aneurysm treated with the Pipeline embolization device (ev3 Neurovascular, Medtronic, Dublin, Ireland) and at least 1 follow-up angiogram. Technical feasibility, procedural complication, angiographic results, and clinical outcome were evaluated., Results: Placement of the Pipeline embolization device was successful in all cases without evidence of procedural complication. Five out of 7 subjects showed a complete aneurysm occlusion at 6- to 12-mo follow-up angiogram. The 2 subjects with persistent aneurysm filling showed decreased aneurysm sac volume on follow-up angiograms (96% and 60%). There was no evidence of in-implant stenosis or intimal hyperplasia. No thromboembolic or hemorrhagic complications were seen during the follow-up period. Only 1 patient had a transient change in Modified Rankin scale score from baseline as a result of different unrelated procedure., Conclusion: Our preliminary results demonstrate feasibility of the use of flow diverter stent for treatment of aneurysms of the pericallosal artery with rate of aneurysm occlusion comparable to literature and without evidence of increased procedural or short-term morbidity. A long-term and larger cohort study is needed to validate our findings.

Objective: Evaluation of the safety and efficacy of the Pipeline embolization device (PED) when used as second-line treatment for recurrent or residual, pretreated ruptured and unruptured intracranial aneurysms (IAs)., Methods: Retrospective review of our database to include all patients who were treated with a PED for recurrent or residual IAs following surgical clipping or coiling. We evaluated neurological outcome and angiograms at discharge, 6- and 12-months' follow-up and assessed intimal hyperplasia at follow-up., Results: Twenty-four patients met our inclusion criteria. Most IAs were located in the anterior circulation (n=21). No change of preprocedure modified Rankin Scale score was seen at discharge or at any scheduled follow-up. Complete or near-complete aneurysm occlusion on 6- and 12-month angiograms was seen in 94.4% (17/18 cases) and 93.3% (14/15 cases), respectively. Complete or near-complete occlusion was seen in 100% of previously ruptured and 85.7% (6/7 cases) and 83.3% (5/6 cases) of previously unruptured cases at the 6- and 12-months' follow-up, respectively. One case of moderate intimal hyperplasia was observed at 6 months and decreased to mild at the 12-months' follow-up. No difference in device performance was observed among pretreated unruptured or ruptured IAs., Conclusions: Treatment of recurrent or residual IAs with a PED after previous coiling or clipping is feasible and safe. There is no difference in device performance between ruptured or unruptured IAs., Competing Interests: Competing interests: MJG is a consultant for Codman Neurovascular and Stryker Neurovascular; research grants: NIH, eV3/Covidien Neurovascular, Codman Neurovascular, Fraunhofer Institute, Wyss Institute, Philips Healthcare, Stryker Neurovascular, Silk Road, Lazarus-Effect. AKW is a consultant for Stryker Neurovascular; research grants: Philips Healthcare, Wyss Institute; speaker: Harvard Postgraduate Course, Miami Cardiovascular Institute. ASP is a consultant for Codman Neurovascular, Stryker Neurovascular, and Covidien; research grant from Stryker Neurovascular and Covidien; speaker: Miami Cardiovascular Institute., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Vascular remodeling in response to implantation of a tissue engineering scaffold such as a flow diverter (FD) leads to the cure of intracranial aneurysms. We hypothesize that the vascular response is dependent on FD design, and CD34+ progenitor cells play an important role in the endothelialization of the implant., Methods: Sixteen rabbit aneurysms were randomly treated with two different single-layer braided FDs made of cobalt-chrome alloys. The FD-48 and FD-72 devices had 48 and 72 wires, respectively. Aneurysm occlusion rate was assessed during the final digital subtraction angiogram at 10, 20, 30, and 60 days (n=2 per device per time point). Implanted vessels were analyzed with scanning electron microscopy for tissue coverage, endothelialization, and immuno-gold labeling for CD34+ cells., Results: Complete aneurysm occlusion rates were similar between the devices; however, complete or near complete occlusion was more frequently observed in aneurysms with neck ≤4.2 mm (p=0.008). Total tissue coverage at 10 days over the surface of the FD-48 and FD-72 devices was 56.4±11.6% and 76.6±3.6%, respectively. Endothelial cell growth over the surface was time-dependent for the FD-72 device (Spearman's r=0.86, p=0.013) but not for the FD-48 device (Spearman's r=-0.59, p=0.094). The endothelialization score was marginally correlated with the distance from the aneurysm neck for the FD-48 device (Spearman's r=1, p=0.083) but not for the FD-72 device (Spearman's r=0.8, p=0.33). CD34+ cells were present along the entirety of both devices at all time points., Conclusions: This study gives preliminary evidence that temporal and spatial endothelialization is dependent on FD design. Circulating CD34+ progenitor cells contribute to endothelialization throughout the healing process., Competing Interests: Competing interests: MJG has been a consultant on a fee-per-hour basis for Codman Neurovascular and Stryker Neurovascular; holds stock in InNeuroCo; and has received research support from the National Institutes of Health (NIH), Codman Neurovascular, Stryker Neurovascular, Microvention, Medtronic Neurovascular, Philips Healthcare, InNeuroCo, Neuronal Protection Systems, the Wyss Institute and Silk Road. ASP has received research grants from Medtronic Neurovascular and Stryker Neurovascular. AKW: Consultant for Codman Neurovascular and Stryker Neurovascular; research grant: NIH, Philips Healthcare, Wyss Institute; speaker: Harvard Postgraduate Course, Miami Cardiovascular Institute; co-founder of InNeuroCo and major stockholder; stocks in EpiEB and Pulsar Medical. IS: Consultant for Stryker Neurovascular and ev3/ Covidien, Chestnut Medical. JA and SL are employed by Stryker Neurovascular., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: To evaluate the safety and efficacy of the 'Baby Trevo' (Trevo XP ProVue 3×20 mm Retriever) stent retriever for large vessel occlusions (LVOs) in acute ischemic stroke (AIS)., Materials and Methods: We retrospectively analyzed our stroke database and included all patients treated with the Baby Trevo for distal LVOs in AIS. Patient gender, mean age, vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score at presentation, and modified Rankin Scale (mRS) score at baseline and 90-day follow-up were documented. Reperfusion rates for the vessels treated were recorded using the Thrombolysis in Cerebral Infarction (TICI) classification. Occurrence of vasospasm and new or evolving infarcts in the treated vascular territory was documented., Results: Thirty-five subjects with a mean NIHSS score of 18 were included. The Baby Trevo device was used in 38 branches of the anterior and posterior circulations. TICI 2b/3 blood flow was restored after one single pass in 20/38 (52.6%) and after two or three passes in 11 vessels. The remaining vessels required either more than three passes, showed less than a TICI 2b/3 reperfusion (n=3), or demonstrated failure to retrieve the clot (n=4). TICI 2b/3 reperfusion was achieved in 30 patients (85.7%). No vessel injuries, rupture, or significant vasospasm were seen. Overall, a mRS score of ≤2 was seen in 56.5% of the subjects successfully treated with the Baby Trevo at 90 days and in 81.3% of surviving patients; seven patients died (20%)., Conclusions: Our preliminary data suggest that the 'Baby Trevo' achieves a high recanalization rate without any significant risk. Larger cohort studies are needed to validate the clinical benefit., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background Flow diverter (FD) malapposition is associated with stroke-related complications. We document the use of self-expanding nitinol stents to remove/reduce the ledge of a FD deployed for aneurysm treatment. Methods We identified five patients who were treated with the Pipeline embolization device (PED) in conjunction with a Neuroform EZ stent for inadequate wall apposition of the ends of the FD at our institution between May 2014 and July 2015. Among other parameters, angiographic results, cone-beam computed tomography assessment of wall apposition and patient clinical outcome were evaluated. Results Incomplete device end apposition was seen in three cases, and precarious positioning of the distal end of the PED over the aneurysm neck was seen in two cases. In all five cases, successful treatment with good wall apposition and proper pinning of the PED distal edge was achieved using an additional Neuroform EZ stent. Appropriate aneurysm neck coverage and flow stagnation was seen in all cases. The combination of high radial outward force and open-cell design permits the Neuroform EZ stent to jail the malappositioned edges of the FD while maintaining good vessel-wall apposition itself and prevent migration of the PED. Short-term follow-up angiography showed device patency and complete aneurysm obliteration in all cases. Conclusions Preliminary results of this small case series suggest that the Neuroform EZ stent allows for effective treatment of FD malapposition in selected patients amenable for this endovascular approach. Long-term and larger cohort studies are needed to validate these results.

We describe an interesting case of trigeminocardiac reflex (TCR) caused by selective angiography of the middle meningeal artery (MMA). A 28-year-old woman presented with a symptomatic meningioma. Preoperative tumour embolisation was performed. In the procedure, when selective MMA angiography was done with Omnipaque 300 mg I/mL for 3 mL by manual injection, the patient complained of flashing lights in her eye followed by vomiting and bradycardia down to 40 bpm without increased intracranial pressure signs. On selective MMA angiography, the choroidal crescent and arteries of the periorbital region were opacified by anastomosis from the MMA via the meningo-ophthalmic artery. We diagnosed that her symptoms were caused by selective MMA angiography leading to high pressure stimulation towards the ophthalmic nerve innervation around the orbit as a TCR. We suggest that the operator should be prepared to manage TCR during treatment with expected selective MMA angiography, and gentle low pressure contrast injection should be attempted., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)