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Background The Pipeline Embolization Device (PED) has been increasingly used for the treatment of posterior circulation aneurysms. The purpose of the present study was to examine the clinical and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. Methods We performed a retrospective review of vertebrobasilar aneurysms treated with the PED at 4 high-volume neurovascular centers. Patient, aneurysm, and procedural data were collected, including perioperative and delayed complications. Aneurysm occlusion on follow-up imaging studies was defined as complete (100%), near-complete (>90%), or incomplete ( Results The cohort included 35 patients with 37 vertebrobasilar aneurysms who underwent 36 treatment sessions. Of the 35 patients, 10 were men (29%), and the mean patient age was 54.1 years (range, 32–75). Eight patients (23%) underwent urgent treatment because of a ruptured aneurysm (n = 6), brainstem perforator stroke (n = 1), or post-traumatic pseudoaneurysm (n = 1). Of the 37 aneurysms, 22 arose from the vertebral artery (59%) and 15 from the basilar artery (41%). Also, 19 were saccular aneurysms (51%), with a mean size of 7.7 mm (range, 1.7–38.0); 17 were fusiform aneurysms (46%), with a mean size of 11.0 mm (range, 4.3–34); and 1 was a 2.9-mm blister aneurysm. The overall procedural complication rate was 14% (5 of 36), including 3 neurologically symptomatic complications. At a mean follow-up period of 14 months (range, 3–59), 24 of 34 aneurysms (71%) were completely occluded and 29 of 34 (85%) were completely or near-completely occluded. Conclusion Our results show that Pipeline embolization of vertebrobasilar aneurysms is associated with acceptable occlusion and complication rates.

BackgroundThe pipeline embolization device (PED) is approved for the treatment of large aneurysms of the proximal internal carotid artery (ICA). Its off-label application in treating aneurysms located specifically at the ICA terminus (ICA-T) has not been studied.MethodsWe conducted a retrospective chart review of patients from 2011 to 7 treated with PEDs. Out of 365 patients, 10 patients with ICA-T aneurysms were included. Patient demographics, procedural information, follow-up imaging, and clinical assessments were recorded.ResultsMean age was 46.9 years (± 8.8), and 6 (60%) patients were women. The mean maximum diameter of the aneurysms treated was 14.7 mm (± 10.7) and the mean neck diameter was 9.3 mm (± 6.6). Reasons for presentation included six incidental findings, one acute subarachnoid hemorrhage (SAH), and three patients with prior SAH. Kamran–Byrne Occlusion Scale scores for the treated aneurysms were as follows: three class IV (complete obliteration), four class III (ConclusionThe PED has potential for treating ICA-T aneurysms not amenable to conventional treatment strategies. Further studies are warranted to confirm the long term outcomes.

BackgroundThere are limited outcome data to guide the choice of treatment in pediatric patients with cerebral aneurysms.ObjectiveTo describe our institutional experience treating pediatric patients with cerebral aneurysms and to conduct a meta-analysis of available studies to provide the best current evidence on treatment related outcomes.MethodsWe identified pediatric patients with cerebral aneurysms evaluated or treated at our institution using a comprehensive case log. We also identified studies to include in a meta-analysis through a systematic search of Pubmed, SCOPUS, EMBASE, and the Cochrane Database of Systematic Reviews. As part of both the local analysis and meta-analysis, we recorded patient characteristics, aneurysm characteristics, management, and outcomes. Statistical analysis was performed using Fisher’s exact test and the two tailed Student’s t test, as appropriate.Results42 pediatric patients with 57 aneurysms were evaluated at our institution, and treatment specific outcome data were available in 560 patients as part of our meta-analysis. Endovascular and surgical treatments yielded comparable rates of favorable outcome in all children (88.3% vs 82.7%, respectively, P=0.097), in children with ruptured aneurysms (75% vs 83%, respectively, P=0.357), and in children with unruptured aneurysms (96% vs 97%, respectively, P=1.000).ConclusionEndovascular and surgical treatment yield comparable long term clinical outcomes in pediatric patients with cerebral aneurysms.

Flow diversion is a viable alternative for treatment of wide-neck and fusiform aneurysms originating from the posterior inferior cerebellar artery (PICA), but coverage of the PICA and vertebral perforating arteries may be a concern. The aim of this study was to examine procedural, clinical, and angiographic outcomes of patients with PICA aneurysms treated with the Pipeline Embolization Device.Retrospective review was performed of PICA aneurysms treated with the Pipeline device at 3 neurovascular centers, including periprocedural complications and clinical and angiographic outcomes.In 16 procedures, 14 PICA aneurysms were treated with the Pipeline device. These included 11 saccular aneurysms with a mean size of 7.4 mm (range, 2.0-11.1 mm) and 3 fusiform aneurysms with a mean diameter of 6.1 mm (range, 5.0-8.0 mm) and mean length of 10.3 mm (range, 6.0-15.0 mm). One patient developed a PICA territory infarct with mild leg weakness that resolved in7 days. Overall complication rate was 7% (1/14) per patient and 6% (1/16) per procedure. Mean duration of clinical follow-up was 13.5 months (range, 3 weeks to 61.7 months), with all patients returning to baseline functional status. Complete or near-complete aneurysm occlusion was achieved in 58% (7/12) of cases with angiographic follow-up (mean, 15 months; range, 4-61 months). All covered PICAs remained patent.Flow diversion of PICA aneurysms is a safe and viable treatment option when traditional endovascular options are unlikely to preserve parent vessel patency.

To evaluate the effectiveness of percutaneous image-guided thermal ablation in achieving local tumor control and pain palliation of sarcoma metastases within the musculoskeletal system. Retrospective review of 64 sarcoma metastases within the musculoskeletal system in 26 women and 15 men (total = 41) treated with ablation between December 2011 and August 2016 was performed. Mean age of the cohort was 42.9 years ± 16.0 years. Two subgroups were treated: oligometastatic disease (n = 13) and widely metastatic disease (n = 51). A variety of sarcoma histologies were treated with average tumor volume of 42.5 cm3 (range 0.1–484.7 cm3). Pain scores were recorded before and 4 weeks after therapy for 59% (38/64) of treated lesions. Follow-up imaging was evaluated for local control and to monitor sites of untreated disease as an internal control. Fifty-eight percent (37/64) were lost to imaging follow-up at varying time points over a year. Complication rate was 5% (3/64; one minor and two major events). One-year local tumor control rates were 70% (19/27) in all patients, 67% (12/18) in the setting of progression of untreated metastases, and 100% (10/10) in the setting of oligometastatic disease. Median pain scores decreased from 8 (interquartile range 5.0–9.0) to 3 (interquartile range 0.1–4.0) 1 month after the procedure (P

BACKGROUND AND PURPOSE: A lower radiation dose can have a detrimental effect on the quality of head CT images. The aim of this study performed in a pediatric population was to test whether an image-processing algorithm (Correlative Image Enhancement) based on the correlation among intensities of neighboring pixels can improve gray-white differentiation in head CTs. MATERIALS AND METHODS: Sixty baseline head CT images with normal findings obtained from scans of 30 children were processed using Correlative Image Enhancement to produce corresponding enhanced images. Gray-white differentiation in baseline and enhanced images was assessed quantitatively by calculating the contrast-to-noise ratio and conspicuity in equivalent ROIs in gray and white matter. Two masked readers rated the images for visibility of gray-white differentiation on a 5-point Likert scale. Differences in both quantitative and qualitative measures of gray-white differentiation between baseline and enhanced images were tested for statistical significance. P values < .05 were considered significant. RESULTS: Image processing resulted in improvement in the contrast-to-noise ratio (from 1.86 ± 0.94 to 2.26 ± 1.00, P = .02) as well as conspicuity (from 37.28 ± 11.56 to 46.4 ± 11.5, P < .001). This was accompanied by improved subjective visibility of gray-white differentiation as reported by both readers (P < .01). CONCLUSIONS: Image processing using Correlative Image Enhancement had a beneficial effect on quantitative measures of gray-white differentiation. This translated into improved perception of gray-white differentiation by readers. Further studies are needed to assess the effect of such image processing on the detection of disease processes using head CTs.

Study design A retrospective review. Objective The aim of this study was to demonstrate proof-of-concept of preoperative percutaneous intraosseous fiducial marker placement before thoracic spine surgery. Summary of background data Wrong-level spine surgery is defined as a never event by Center for Medicare Services, yet the strength of data supporting the implementation of Universal Protocol to limit wrong level surgery is weak. The thoracic spine is especially prone to intraoperative mislocalization, particularly in cases of morbid obesity and anatomic variations. Methods We retrospectively reviewed all cases of preoperative percutaneous image-guided intraosseous placement of a metallic marker in the thoracic spine. Indications for surgery included degenerative disc disease (16/19), osteochondroma resection, spinal metastasis, and ligation of dural arteriovenous malformation. All metallic markers were placed from a percutaneous transpedicular approach under imaging guidance [fluoroscopy and computed tomography (CT) or CT alone]. Patient body mass index (BMI) was recorded. Overweight and obese BMI was defined greater than 25 and 30 kg/m, respectively. Results All 19 patients underwent fiducial marker placement and intraoperative localization successfully without complication. Twenty-two thoracic spine levels were localized. The T7, T9, T10, and T11 levels were the most often localized at rate of 18.1% for each level (4/22). The most cranial and caudal levels localized were T4 and T11. About 84.2% (16/19) of the cohort was overweight (57.9%; 11/19) or obese (26.3%; 5/19). The median BMI was 30.2 kg/m (range, 23.9-54.3 kg/m). Conclusion Preoperative percutaneous thoracic fiducial marker placement under imaging guidance is a safe method for facilitating intraoperative localization of the target spinal level, especially in obese patients. Further studies are needed to quantify changes in operative time and radiation exposure. Level of evidence 4.

BACKGROUND: Flow diversion is now an established technique to treat unruptured intracranial aneurysms not readily amenable to endovascular coil embolization or open microsurgical occlusion. The role of flow-diverting devices in treating ruptured aneurysms is less clear. PURPOSE: To estimate rates of angiographic occlusion and good clinical outcome in patients with ruptured intracranial aneurysms treated with flow-diverting devices. DATA SOURCES: Systematic review of Ovid MEDLINE, PubMed, Cochrane databases, and EMBASE from inception to December 2015 for articles that included ruptured aneurysms treated with flow diversion. STUDY SELECTION: One hundred seventy-two records were screened, of which 20 articles contained sufficient patient and outcome data for inclusion. DATA ANALYSIS: Clinical and radiologic characteristics, procedural details, and outcomes were extracted from these reports. Aggregated occlusion rates and clinical outcomes were analyzed by using the Fisher exact test (statistical significance, α = .05). DATA SYNTHESIS: Complete occlusion of the aneurysm was achieved in 90% of patients, and favorable clinical outcome was attained in 81%. Aneurysm size greater than 7 mm was associated with less favorable clinical outcomes (P = .027). Aneurysm size greater than 2 cm was associated with a greater risk of rerupture after treatment (P LIMITATIONS: Observational studies and case reports may be affected by reporting bias. CONCLUSIONS: Although not recommended as a first-line treatment, the use of flow diverters to treat ruptured intracranial aneurysms may allow high rates of angiographic occlusion and good clinical outcome in carefully selected patients. Aneurysm size contributes to treatment risk because the rerupture rate following treatment is higher for aneurysms larger than 2 cm.

Purpose To evaluate the safety and effectiveness of cryoablation of musculoskeletal metastases in terms of achieving pain palliation and local tumor control. Materials and Methods A retrospective review was performed of 92 musculoskeletal metastases in 56 patients treated with percutaneous image-guided cryoablation. Mean age of the cohort was 53.9 y ± 15.1, and cohort included 48% (27/56) men. Median tumor volume was 13.0 cm 3 (range, 0.5–577.2 cm 3 ). Indications for treatment included pain palliation (41%; 38/92), local tumor control (15%; 14/92), or both (43%; 40/92). Concurrent cementoplasty was performed after 28% (26/92) of treatments. Results In 78 tumors treated for pain palliation, median pain score before treatment was 8.0. Decreased median pain scores were reported 1 day (6.0; P P P P = .01, n=28) after treatment. The median pain score at 6-month follow-up was 7.5 ( P = .33, n=11). Radiographic local tumor control rates were 90% (37/41) at 3 months, 86% (32/37) at 6 months, and 79% (26/33) at 12 months after treatment. The procedural complication rate was 4.3% (4/92). The 3 major complications included 2 cases of hemothorax and 1 transient foot drop. Conclusions Cryoablation is an effective treatment for palliating painful musculoskeletal metastases and achieving local tumor control.

INTRODUCTION To evaluate the safety and efficacy of minimally invasive percutaneous thermal ablation alone or in combination with cementoplasty for pain palliation and local tumour control of renal cell carcinoma osseous metastases. METHODS Imaging-guided thermal ablation was performed in 59 renal cell carcinoma osseous metastatic tumours in 23 patients (concomitant cementoplasty in 43 tumours) selected following multidisciplinary consultations to achieve local tumour control and pain palliation (75%, 44/59) or pain palliation alone (25%, 15/59) in this retrospective study. Tumour characteristics, procedural details and complications were documented. Pain palliation was assessed using pre- and post-procedural Numeric Rating Scale scores at 1-week, 1-month, 3-month and 6-month time intervals. Pre- and post-procedural cross-sectional imaging was reviewed to assess local tumour control rates at 3-month, 6-month, and 12-month post-treatment time intervals. RESULTS All procedures were technically successful and performed as pre-operatively planned. The median pre- and post-procedural Numeric Rating Scale scores were 8.0 and 3.0 (at all time intervals), respectively (P

BACKGROUND AND PURPOSE: Flow diversion is an established method to treat complex intracranial aneurysms. The natural history of flow-diversion treatment failure resulting in aneurysm remnants is not well-defined. We aimed to delineate the clinical and angiographic features of this entity. MATERIALS AND METHODS: Review of a prospectively maintained Pipeline Embolization Device data base from inception to October 2017 was performed for aneurysms that demonstrated residual filling on follow-up imaging. Procedural and follow-up clinical details were recorded. Independent, blinded, angiographic assessment of occlusion was performed on the basis of the O9Kelly-Marotta scale. Aggregated outcomes were analyzed using the Fisher exact and Mann-Whitney U tests for categoric and continuous variables, respectively (statistical significance, α = .05). RESULTS: During the study period, 283 sequential patients were treated; 87% (246/283) were women. The median patient age was 55 years (interquartile range, 47–65 years). Six-month follow-up imaging was available in 83.7% (237/283) of patients, which showed 62.4% (148/237) complete occlusion (class D, O9Kelly-Marotta grading scale). Adjunctive coiling (P = .06), on-label Pipeline Embolization Device use (P = .04), and multiple device constructs (P = .02) had higher rates of complete occlusion at 6 months. Aneurysm remnants were identified in 25 cases on long-term follow-up imaging (median, 16 months; interquartile range, 12–24 months). No patient with an aneurysm remnant after flow diversion presented with delayed rupture or other clinical sequelae, with a median clinical follow-up of 31 months (interquartile range, 23–33 months). CONCLUSIONS: Aneurysm remnants after flow diversion are infrequent with minimal clinical impact. When appropriate, the presence of overlapping devices and possibly adjunctive coiling may result in higher rates of complete occlusion.

Purpose: Carotid web (CaW) is an underrecognized cause of cryptogenic stroke in young patients. The optimal imaging for CaW is unknown. We aim to evaluate the diagnostic accuracy of diverse imaging modalities for the diagnosis of CaW.Methods: Retrospective analysis of institutional neurovascular database was performed to identify patients with multimodal (CT angiogram–CTA, digital subtraction angiogram–DSA, and/or ultrasound–US) imaging diagnosis of CaW or atherosclerosis. Baseline clinical demographics were recorded. Blinded image analysis was performed for each imaging modality by separate readers. Discrepancies were settled by consensus. Two-sided Cohen's Kappa (κ) coefficient was used to evaluate the inter-rater agreement for the etiological diagnosis between imaging modalities.Results: Thirty patients/60 carotids were evaluated by CTA and 55 carotids were included. Patients with symptomatic CaW (n = 20), compared to individuals with atherosclerosis (n = 10), were younger (49 ± 9 vs. 60 ± 8 years; p < 0.01), more commonly female (75% vs. 30%; p = 0.01), and less frequently presented vascular risk factors: Hypertension (40% vs. 100%; p < 0.01), hyperlipidemia (0% vs. 50%; p < 0.01), diabetes (10% vs. 40%; p = 0.05), and smoking (5% vs. 70%; p < 0.01). High inter-rater correlation strength existed for CTA (n = 55; κ = 0.88; p < 0.0001) and DSA (n = 28; κ = 0.86, p < 0.0001) readers for lesion diagnosis while US inter-rater agreement was lower (κ = 0.553; p = 0.001). Across modalities CTA and DSA shared very high strength of agreement (κ = 0.92; p < 0.0001), compared to a less pronounced agreement between US and CTA (κ = 0.553; p = 0.001). The strength of correlation between DSA-CTA was significantly more robust as compared to US-CTA (Z = 3.58; p = 0.0003).Conclusion: CTA and DSA demonstrated comparable and superior performance as compared to US in the diagnosis of CaW.

Percutaneous ablation is an emerging, minimally invasive therapy for patients with osseous metastases who have not responded or have contraindications to radiation therapy. Goals of therapy are pain relief, and in some cases, prevention of local tumor progression. Areas covered: The epidemiology, pathophysiology, natural history, and traditional management of metastatic bone disease are reviewed. Novel features of the Spinal Tumor Ablation with Radiofrequency (STAR) System (DFINE, San Jose, CA) that facilitate treatment of osseous metastases are described, including the bipolar electrode, extensible distal tip that can be curved up to 90°, and inclusion of thermocouples that enable real-time monitoring of the ablation zone volume. Lastly, research evaluating the safety and efficacy of using this device to treat musculoskeletal metastases is summarized. Expert commentary: Although evidence supporting the efficacy of RFA for the treatment of bone metastases is limited to case series, it is a reasonable therapy when other options have been exhausted, especially given the safety and minimal morbidity of the procedure. The STAR Tumor Ablation System has expanded the anatomic scope of bone metastases that can be safely and effectively treated with percutaneous ablation.

To determine the safety and effectiveness of radiofrequency ablation (RFA) to treat sacral metastases for pain palliation and local tumor control (LTC).An institutional tumor ablation registry was retrospectively reviewed for sacral RFA procedures performed between January 2012 and December 2015. Clinical history, pre-procedural imaging, and procedural details were reviewed to document indication for treatment, primary tumor histology, tumor volumes, presence of concurrent cementoplasty after RFA, and the occurrence of peri-procedural complications. Pain scores before and 4 weeks after the procedure were recorded. Post-procedure imaging was reviewed for imaging evidence of tumor progression. Long-term complications and duration of clinical follow-up were recorded.During the study period, 11 RFA procedures were performed to treat 16 sacral metastases. All procedures were for pain palliation. Four procedures (36 %; 4 out of 11) were also performed with the intention of achieving LTC in patients with oligometastatic disease. Concurrent cementoplasty was performed in 63 % of cases (7 out of 11). The median pain score decreased from 8 (interquartile range, 6-9.25) at baseline to 3 (interquartile range, 1.75-6.3) 1 month following RFA (P = 0.004). In the 4 patients with oligometastatic disease, LTC was achieved in 3 patients (75 %; 3 out of 4) after a median follow-up of 7.6 months (range, 3.6-11.9 months). No acute or long-term complications were documented during the overall median clinical follow-up of 4.7 months (range, 0.9-28.7 months).Radiofrequency ablation maybe a safe and potentially effective treatment for patients with painful sacral metastases and can achieve LTC in selected patients.

The video highlights a challenging case of bilateral vertebral artery dissection presenting with subarachnoid hemorrhage. The patient was found to have a critical flow-limiting stenosis in his dominant right vertebral artery and a ruptured pseudoaneurysm in his left vertebral artery. A single-stage endovascular treatment with stent reconstruction of the right vertebral artery and coil embolization sacrifice of the left side was performed. The case highlights the rationale for treatment and potential alternative strategies.The video can be found here: https://youtu.be/e0U_JE2jISw.

Introduction The Pipeline Embolization Device (PED) has greatly expanded the range of aneurysms amenable to endovascular treatment, including those with wide necks that incorporate branch vessels. Published occlusion rates of anterior circulation aneurysms treated with the PED typically exceed 85%1–7 with morbidity rates of less than 7%.7 8 Prompted by this success, the PED is being increasingly utilized for the off-label treatment of posterior circulation aneurysms with widely varying results.9 10 The purpose of this study was to examine the procedural, clinical, and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. Methods Retrospective review of the neurointerventional databases of three high-volume neurovascular centers was approved by respective institutional review boards to identify patients with vertebrobasilar aneurysms treated with the PED between 2012 and December 2016. Demographic, clinical, and angiographic data were collected from electronic medical records. Procedural details, including devices used and peri-procedural complications, were collected from operative reports. Preoperative digital subtraction angiography was reviewed to determine the morphological characteristics of treated aneurysms, including largest diameter in any dimension, location, shape, and incorporated branch vessels. Follow-up angiographic images were also reviewed for intra-PED stenosis and patency of branch vessels covered by the PED. Results During the study period, 27 patients with 29 vertebrobasilar aneurysms underwent 28 treatments with the PED. The patients were 37% (10/27) men and 63% (17/27) women with a mean age of 53.3 years (range, 32–75 years), 44% (12/27) of whom were previous or current smokers. 74% (20/27) of patients were asymptomatic at presentation. Six of the remaining patients presented with subarachnoid hemorrhage (SAH; 22%, 6/27) and one patient presented with stroke related to thrombosis of brainstem perforators incorporated into the aneurysm (3.7%, 1/27). Aneurysm locations included the basilar trunk (41%, 12/29), basilar tip (7%, 2/29), vertebral artery (VA) proximal to the posterior inferior cerebellar artery (PICA; 10%, 3/29), VA at the PICA origin (10%, 3/29), and post-PICA VA (17%, 5/29). There were 15 saccular aneurysms (50%) with a mean size of 8.1 mm (range, 1.7–38 mm), 13 fusiform aneurysms (47%) with mean size of 11.8 mm (range, 4.3–34 mm) and length of 11.4 mm (range, 3.4–33), and one 2.9 mm blister aneurysm. The overall procedural complication rate was 18% (5/28), and the neurologic morbidity and mortality rate was 11% (3/28). Excluding aneurysms in patients who died, angiographic follow up was available for 96% (26/27) of patients. Mean duration of follow up was 12 months (range, 3–59 months). At last angiographic follow up, 67% (18/27) of aneurysms were completely occluded and 81% (22/27) were completely or near-completely occluded. A total of 36 branch vessels in 21 patients were covered by at least one PED. At last angiographic follow up, 8% (3/36) of covered branch vessels were occluded, none of which were symptomatic. Conclusion Pipeline embolization of vertebrobasilar aneurysms is associated with a higher complication rate and lower occlusion rate compared with anterior circulation aneurysms, but may be a viable treatment option in select cases. Disclosures A. Wallace: None. M. Kamran: None. T. Madaelil: None. Y. Kayan: 2; C; Medtronic, Penumbra, MicroVention. A. Kansagra: None. J. Grossberg: None. J. Delgado Almandoz: 2; C; Medtronic, Penumbra, Microvention, Accriva Diagnostics. C. Moran: 2; C; Medtronic. A. Roy: None. D. Cross: None. B. Howard: None. C. Cawley: None. J. Dion: None. T. CreveCoeur: None. J. Osbun: 1; C; MicroVention.

Purpose Intracranial dural arteriovenous fistulas (dAVFs) constitute approximately 10%–15% of all intracranial vascular malformations. More rarely, these lesions can lead to intracranial hemorrhage. Early re-bleeding rates from unsecured, ruptured dAVFs have been reported as high as 50%. Therefore, early intervention is paramount. Our aim of this study was to investigate the angiographic and clinical outcomes of early endovascular intervention in this rare disease presentation. Methods A HIPPA compliant neuroendovascular procedural database was reviewed for all treated dAVFs from 1999 to 2017. Inclusion criteria for the study included: 1) hemorrhagic presentation and 2) early endovascular intervention defined as less than 48 hours from initial ictus. Clinical demographics, angiographic and procedural details (Anatomic location, Borden classification, route of embolization, material used during embolization, number of retreatments, and need for completion microsurgical ligation), as well as clinical and angiographic follow up outcomes (modified Rankin scale and occlusion status on last follow-up imaging) were recorded. Appropriate statistical analyses were performed on parametric and non-parametric variables as applicable (statistical significance, α=0.05). Results A total of 262 dAVFs were identified, of those only 18 patients met inclusion criteria. Overall, the majority of patients were male (12/18; 66%), with a median age of 56 years (IQR 46–68 years). Hemorrhagic presentations included isolated intraparenchymal hemorrhage (IPH) (8/18; 44%), isolated subarachnoid hemorrhage (SAH) (7/18; 39%), SAH with subdural hematoma/intraventricular hemorrhage (IVH) (2/18; 11%), and isolated IVH (1/18; 6%). Almost all the hemorrhagic dAVF were of the aggressive type (Borden type II/III, 17/18; 94%). Anatomically, the most common location was tentorial (8/18; 44%). The anterior fossa, torcula, superior sagittal sinus, and transverse/sigmoid sinus all proportionately were the next common location (2/18; 11%, each respective group). Foramen magnum and straight sinus were the least common locations (1/18; 6%, each respective group). Transarterial embolization was performed most commonly (15/18; 83%), followed by transvenous approach (3/18; 17%). nBCA glue or Onyx embolization was most commonly used (15/18; 83%) with coils used exclusively in all transvenous cases (3/18; 17%). At last clinical follow-up, two patients succumbed to complications related to initial hemorrhage with the majority of patients (14/16; 88%) achieving good clinical outcome (mRS=0–2). On imaging follow-up when residual dAVF or incomplete embolization was noted (5/12; 42%) all cases underwent endovascular retreatment. Overwhelmingly, endovascular re-treatment failed in the majority of the cases (3/5; 60%); requiring microsurgical ligation for completion therapy. In no instance was early or late re-bleeding observed on last clinical follow-up, median 5 months (IQR 2–19 months). Conclusion Early endovascular intervention for ruptured dAVFs is feasible and effectively secures these lesions with no re-bleeding. Attention must be paid to lesions, which are incompletely embolized/show residual filling, as microsurgical ligation is imperative for completion therapy. Disclosures T. Madaelil: None. J. Grossberg: None. M. Cawley: None. F. Tong: None. J. Dion: 5; C; Vice President, Scientific Affairs at MicroVention-Terumo. B. Howard: None.

Purpose Carotid web is an intimal variant of fibromuscular dysplasia that has been associated with recurrent ischemic strokes in the young. The accuracy of different diagnostic tests is unknown. The objective of the present study is to evaluate the diagnostic performance of different imaging modalities for the detection of carotid webs. Methods Using an institutional neurovascular database, we retrospectively identified consecutive patients diagnosed with carotid web and internal carotid artery atherosclerosis. Multimodality imaging including at minimum neck CT angiography (CTA) at baseline plus either Digital Subtraction Angiography (DSA) and/or carotid Ultrasound (US) was mandatory. CTA images were evaluated by two readers (neurointerventionist#1 and diagnostic neuroradiologist) in a consensus read for confirmation of diagnosis, and degree of stenosis based on NASCET criteria. DSA studies were evaluated by two blinded readers (neurointerventionists #2 and #3) to categorize the presence or absence of carotid web or atherosclerotic plaque in individual carotid arteries. US studies were evaluated by two blinded readers (two neurosonology-credentialed stroke neurologists) to characterize diagnosis (carotid web vs atherosclerosis vs normal), degree of certainty, and the degree of stenosis. In the setting of discrepancies, consensus read was obtained. The performance of DSA and of US was compared to CTA. Results Median age of the cohort was 57 years (IQR 46–61 years) with 36.4% (12/33) male gender. Overall comorbidities included 60.6% (20/33) hypertension, 33.3% (11/33) hyperlipidemia, 21.2% (7/33) diabetes mellitus, and 27.3% (9/33) smoking. Multimodal imaging was available for 33 carotid arteries. Twenty-eight carotids had CTA and DSA available for review. DSA readers identified correctly all normal vessels, but diagnosed carotid webs less frequently (43%, 12/28; DSA group vs 50%, 14/28; CTA group) and atherosclerosis more frequently (43%, 12/28; DSA group vs 36%, 10/28; CTA group) when compared to CTA. Inter-rater correlation for the two DSA readers (κ=0.86, p Conclusion CTA and DSA should be preferred imaging modalities to diagnose and characterize carotid webs. Disclosures T. Madaelil: None. R. Nogueira: None. J. Grossberg: None. A. Anderson: None. C. Barreira: None. D. Haussen: None.

BackgroundAneurysmal subarachnoid hemorrhage is a potentially devastating condition, and among the first priorities of treatment is aneurysm occlusion to prevent re-hemorrhage. An emerging strategy to treat patients whose aneurysms are not ideal for surgical or endovascular treatment is subtotal coiling followed by flow diversion in the recovery phase or ‘plug and pipe’. However, data regarding the safety and efficacy of this strategy are lacking.MethodsA retrospective cohort study was performed to evaluate the efficacy and safety of ‘plug and pipe’. All patients with a ruptured intracranial aneurysm intentionally, subtotally treated by coiling in the acute stage followed by flow diversion after recovery, were included. The primary outcome was re-hemorrhage. Secondary outcomes included aneurysm occlusion and functional status. Complications were reviewed.Results22 patients were included. No patient suffered a re-hemorrhage, either in the interval between coiling and flow diversion or in follow-up. The median interval between aneurysm rupture and flow diversion was 3.5 months. Roy–Raymond (R-R) class I or II occlusion was achieved in 91% of target aneurysms at the last imaging follow-up (15/22(68%) R-R 1 and 5/22(23%) R-R 2). Complications occurred in 2 (9%) patients, 1 of which was neurological.ConclusionsOverall, these data suggest that subtotal coiling of ruptured intracranial aneurysms followed by planned flow diversion is both safe and effective. Patients who may most benefit from ‘plug and pipe’ are those with aneurysms that confer high operative risk and those whose severity of medical illness increases the risk of microsurgical clip ligation.

Percutaneous image-guided ablation is an emerging minimally invasive therapy for patients with metastatic bone disease for whom radiation therapy is ineffective or contraindicated. The purpose of this study was to examine the safety and efficacy of percutaneous ablation in achieving pain palliation and local tumor control of osseous metastases from non-small cell lung cancer (NSCLC).A retrospective review was performed of 76 musculoskeletal metastases in 45 patients treated with percutaneous ablation. 63% (48/76) were treated with radiofrequency ablation (RFA), 35% (27/76) with cryoablation, and 1.3% (1/76) with microwave ablation (MWA). In 70% (53/76) of cases, associated cementoplasty was performed. Primary outcomes measured were pre- and post-procedure pain scores 4 weeks after treatment and local tumor control at 3-, 6-, and 12-month follow-up.Mean age of the cohort was 63.6 ± 9.5 years. Median tumor diameter was 3.60 cm (range 1.0-10.0 cm). Mean and median pain scores before treatment were 7.5 ± 2.3 and 8.0, respectively. Post-procedure, patients reported significantly decreased pain scores at 4 weeks (mean, 3.7 ± 3.5; median, 3.0; p 0.00001). Radiographic local tumor control rates were 83% (35/42) at 3 months, 77% (23/30) at 6 months, and 68% (17/25) at 12 months after treatment. The overall complication rate was 2.6% (2/76).Percutaneous tumor ablation is a well-tolerated, minimally invasive procedure associated with improving pain palliation and achieving local tumor control of osseous metastases from NSCLC.Level 4, case series.

BackgroundAbciximab is used to treat thromboembolic complications of neuroendovascular procedures, but outcomes of treatment are not well defined.ObjectiveTo examine the angiographic and clinical outcomes based on route of abciximab administration and degree of vessel recanalization.Materials and methodsA prospectively maintained database of neuroendovascular procedures performed between January 2004 and May 2015 was retrospectively reviewed to identify cases with thromboembolic complications treated with abciximab. In these cases, route of administration, degree of vessel recanalization, and presence or absence of infarction were determined. A meta-analysis of similar cases in the literature was also performed.ResultsAbciximab was administered in 0.24% (47 of 19 566) of procedures to treat thromboemboli in 59 vessels. Angiographic improvement was seen in 94% after IA therapy and 79% after IV therapy (p=0.133). In our meta-analysis of 391 treated patients, angiographic improvement was greater after IA (91.7%) than IV (77.4%) treatment (pConclusionsAbciximab produces a high rate of angiographic improvement and a low incidence of postprocedural infarct in neuroendovascular procedures complicated by thromboemboli. IA abciximab produces greater angiographic improvement than IV treatment. Postprocedural infarction is less common in patients with complete angiographic response than in those with partial or no response.

There are limited data on outcomes of mechanical thrombectomy for pediatric stroke using modern devices. In this study, we report two cases of pediatric acute ischemic stroke treated with mechanical thrombectomy, both with good angiographic result (TICI 3) and clinical outcome (no neurological deficits at 90 days). In addition, we conducted a literature review of all previously reported cases describing the use of modern thrombectomy devices. Including our two cases, the aggregate rate of partial or complete vessel recanalization was 100% (22/22), and the aggregate rate of favorable clinical outcome was 91% (20/22). This preliminary evidence suggests that mechanical thrombectomy with modern devices may be a safe and effective treatment option in pediatric patients with acute ischemic stroke.

The purpose of this study was to evaluate the safety, technical success rate, and diagnostic efficacy of drill-assisted axial and appendicular bone biopsies. During a 3-y period, 703 drill-assisted biopsies were performed. The cohort included 54.2% men, with a mean age of 57.6 y ± 17.1. Median lesion volume was 10.9 mL (interquartile range, 3.4–30.2 mL). Lesions were lytic (31.7%), sclerotic (21.2%), mixed lytic and sclerotic (27.7%), or normal radiographic bone quality (19.3%). No complications were reported. The technical biopsy success rate was 99.9%. Crush artifact was present in 5.8% of specimens submitted for surgical pathologic examination, and 2.1% of specimens were inadequate for histologic evaluation.

BackgroundRuptured intracranial dissecting aneurysms must be secured quickly to prevent re-hemorrhage. Endovascular sacrifice of the diseased segment is a well-established treatment method, however postoperative outcomes of symptomatic stroke and re-hemorrhage rates are not well reported, particularly for the perforator-rich distal vertebral artery or proximal posterior inferior cerebellar artery (PICA).MethodsWe retrospectively reviewed cases of ruptured distal vertebral artery or PICA dissecting aneurysms that underwent endovascular treatment. Diagnosis was based on the presence of subarachnoid hemorrhage on initial CT imaging and of a dissecting aneurysm on catheter angiography. Patients with vertebral artery aneurysms were selected for coil embolization of the diseased arterial segment based on the adequacy of flow to the basilar artery from the contralateral vertebral artery. Patients with PICA aneurysms were generally treated only if they were poor surgical candidates. Outcomes included symptomatic and asymptomatic procedure-related cerebral infarction, recurrent aneurysm rupture, angiographic aneurysm recurrence, and estimated modified Rankin Scale (mRS).ResultsDuring the study period, 12 patients with dissecting aneurysms involving the distal vertebral artery (n=10) or PICA (n=2) were treated with endovascular sacrifice. Two patients suffered an ischemic infarction, one of whom was symptomatic (8.3%). One patient (8.3%) died prior to hospital discharge. No aneurysm recurrence was identified on follow-up imaging. Ten patients (83%) made a good recovery (mRS ≤2). Median clinical and imaging follow-up periods were 41.7 months (range 0–126.4 months) and 14.3 months (range 0.03–88.6 months), respectively.ConclusionsIn patients with good collateral circulation, endovascular sacrifice may be the preferred treatment for acutely ruptured dissecting aneurysms involving the distal vertebral artery.

Background Thromboembolic complications sustained during neuroendovascular procedures can result in postoperative infarcts if not promptly recognized and treated. Treatment commonly involves glycoprotein IIb/IIIa inhibitors such as abciximab. We aimed to retrospectively review angiographic and clinical outcomes following abciximab administration for thromboembolic complications at our institution. Methods Neuroendovascular cases with thromboembolic complications treated with abciximab over a 132 month period were identified using a search of a comprehensive, prospectively maintained case log and all angiography records for the terms “abciximab” or “ReoPro.” Intraoperative intra-arterial (IA) administration typically involved slow infusion of 10 mg abciximab over 5 to 10 minutes. Intraoperative intravenous (IV) administration 0.25 mg/kg abciximab. Postoperative IV infusion typically involved 10 mcg/min infusion of abciximab. All relevant clinical notes and neuroimaging were reviewed. Results Of 19,566 neuroendovascular procedures performed during the review period, 48 (0.25%) involved abciximab administration for thromboembolic complications. 65% (31/48) involved IA administration, 21% (10/48) were IV only, and 15% (7/48) were combined IA and IV. Intraoperative treatment was supplemented with postoperative abciximab infusion in 13% (6/48) patients. Angiographic improvement was seen in 92% (44/48) cases, including 65% (31/48) with complete angiographic resolution (Figure 1). Only 8% (4/48) cases failed to improve angiographically. Angiographic outcomes were similar in patients who received IA, IV, or combined IA and IV administration of abciximab intraoperatively (p = 0.58), or patients who did or did not receive continuous IV infusion of abciximab postoperatively (p = 0.11). Postoperative infarction was seen in 20% (5/25), 44% (4/9), and 67% (4/6) following IA, IV, and combined IA and IV abxicimab, respectively (p = 0.06) (Figure 1). The rate of postoperative infarction was 33% (2/6) in patients who received continuous IV infusion of abciximab postoperatively and 32% (11/34) in those who did not (p = 1.00). Postoperative infarction developed in 8% (2/24) patients with complete angiographic improvement, compared to 69% (11/16) in patients with partial or no improvement (p Conclusion Abciximab administration is an effective method of treating thromboembolic complications of neuroendovascular procedures. Angiographic outcomes were not appreciably different between different routes of abciximab administration. Infarction was least common in patients treated with IA abciximab; the addition of postoperative abciximab infusion did not affect the rate of infarction. No or partial angiographic improvement was associated with significantly higher rates of postoperative infarction than complete angiographic improvement. Disclosures A. Kansagra: None. T. Madaelil: None. D. Cross: None. C. Moran: 2; C; Medtronic Neurovascular. 3; C; Medtronic Neurovascular. C. Derdeyn: None.

There is limited data on outcomes of mechanical thrombectomy for pediatric stroke using modern devices. In this study, we report two cases of pediatric acute ischemic stroke treated with mechanical thrombectomy, both with good angiographic result (TICI 3) and clinical outcome (no neurological deficits at 90 days). In addition, we conducted a literature review of all previously reported cases describing the use of modern thrombectomy devices. Including our two cases, the aggregate rate of partial or complete vessel recanalization was 100% (22/22), and the aggregate rate of favorable clinical outcome was 91% (20/22). This preliminary evidence suggests that mechanical thrombectomy with modern devices may be a safe and effective treatment option in pediatric patients with acute ischemic stroke. Disclosures T. Madaelil: None. A. Kansagra: None. C. Derdeyn: None. D. Cross: None. C. Moran: 2; C; Medtronic Neurovascular.

Background and purpose Flow diversion is an established technique to treat unruptured intracranial aneurysms not amenable to standard endovascular or microsurgical techniques. The suitability of flow diverting devices (FDD) to treat ruptured aneurysms is less clear. Materials and methods An in-depth search of multiple electronic publication databases was performed for reports describing ruptured intracranial aneurysms treated by flow diversion. Clinical and radiological characteristics, interventional details, and outcomes were pooled and analyzed in aggregate. Results The pooled cohort comprised of 126 patients with a mean age of 52.6 ± 12.5 years. Mean Hunt Hess/World Federation of Neurosurgical Societies grading scale at presentation was 2.2 ± 1.2. Treated aneurysms were located in the anterior circulation in 64% (81/126) cases and 36% (45/126) in the posterior circulation. Five distinct aneurysm morphologies were present, including dissecting (28%, 35/125), fusiform (9.6%, 12/125), giant (3.2%, 4/125), blister (37.6%, 47/125), and saccular (21.6%, 27/125) types. Favorable clinical outcome (defined as Modified Rankin Scale (mRS) = 0−2 or Glasgow Outcome Scale (GOS) = 4−5) was achieved in 81.5% (101/124) of treated patients. Unfavorable clinic outcome (defined by mRS = 3−6 or GOS = 1−3) occurred in 18.5% (23/124) of patients. Clinically significant hemorrhagic complications occurred in 5.5% (7/126) of cases, the majority of which were due to aneurysm re-rupture (4.8%; 6/126). Aneurysm size greater than 2cm was associated with a greater risk of re-rupture when compared to aneurysms smaller than 2 cm (p = 0.001). Aneurysm size greater than 7 mm was associated with more unfavorable clinical outcomes (p = 0.03). Conclusion For ruptured aneurysms not amenable to other treatment strategies, the use of flow diversion may allow for reasonably high rates of good clinical outcomes, particularly in small aneurysms. There was a risk of re-rupture in these aneurysms, especially those larger than 2 cm. Disclosures T. Madaelil: None. C. Moran: 2; C; Medtronic Neurovascular. D. Cross: None. A. Kansagra: None.