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Introduction The NAPA study was a prospective, multicenter, single-arm IDE trial of the PulseRider device as an adjunctive treatment in conjunction with coil embolization of unruptured wide-neck bifurcation aneurysms which was electively discontinued for reasons not related to the safety or performance of the device. We report on the available enrollments in NAPA and their available follow up. Methods The PulseRider device was implanted in 18/21 enrollments. Available core-lab adjudicated data from the first 18 implants is presented. Of those, 5 have one year follow up data available. Of the 3 device implantation failures, the locations included basilar (1), carotid terminus (1), and ACOMM (1). Results For the 18 patients with PulseRider implanted as a coil-adjunct device, the mean age was 60.7± 8.9 yrs and 16 were female. The mean aneurysm diameter was 6.6± 2.2 mm, height 5.3±1.7 mm and neck 4.8 ±1.5 mm. Locations included the basilar apex (11), MCA bifurcation (4) and ACOMM (3). Thirteen of 18 were de novo aneurysms while the remainder (5) were treated in the setting of aneurysmal recurrence. The most common PulseRider placement was extra-aneurysmal (12/18), followed by intra-aneurysmal (4/18) and hybrid (2/18). Immediate angiographic occlusions were 66.6% RR-I, 16.7% RR-II, 16.7% RR-III. There were no device related adverse events. There were 3 (16.7%) procedure-related adverse events which did not result in neurological changes. Seven enrollments have 6 month follow up and all are RRI-II. Only 1 has one year angiographic follow up (RRI) adjudicated by the core lab, and 4 have clinical follow up (4/4 mRS 0–2). None of the target aneurysms have required retreatment. Conclusions The results of the discontinued NAPA provide high quality data on the occlusion rates and safety profile for the PulseRider device. Further one year angiographic and clinical follow up will be reported when available. Disclosures A. Spiotta: 1; C; Microvention. 2; C; Minnetronix, Penumbra, Cerenovus. 6; C; Cerenovus, Penumbra, Pulsar Vascular, Stryker, Microvention. K. Ebersole: None. J. Lena: None. R. Starke: 2; C; Medtronic Neurovascular, Penumbra, Cerenovus, Abbott. R. De Leacy: 6; C; Penumbra, Cerenovus, Siemens. A. Puri: 1; C; Stryker Neurovascular, Medtronic Neurovascular. 2; C; Stryker Neurovascular, Medtronic Neurovascular. D. Yavagal: 2; C; Medtronic Neurovascular, Rapid Medical, Steering Committee, Neuralanalytics. 6; C; Medtronic, Cerenovus/Johnson & Johnson, Rapid Medical, Neuralanalytics. B. Bohnstedt: 2; C; Penumbra, Stryker, Medtronic. L. Rangel-Castilla: None. A. Cheema: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University of Buffalo. 2; C; Medtronic, Neurotrauma Science, LLC. 4; C; RIST Neurovascular. K. de Macedo Rodrigues: None. J. Grossberg: None. B. Howard: None. C. Kellner: 1; C; Penumbra, Siemens Corp. G. Lanzino: None. S. Tateshima: 2; C; Cerenovus, Medtronic, Neurovasc, Stryker. 4; C; Neurovasc.

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.

Background Since its introduction in the early 90 s, endovascular treatment of cerebral aneurysms has had a steady upward trend and is the primary mode of treatment for most currently diagnosed cerebral aneurysms. Concurrently, the need for retreatment of cerebral aneurysms after prior endovascular treatment has also continued to grow, some of which can only be treated with microsurgical techniques. The factors that dictate outcomes in this group of patients are still not completely understood. Objective To study factors contributing to patient outcomes after microsurgical treatment of aneurysms with prior endovascular treatment. Methods Records were retrospectively reviewed for aneurysms treated after prior endovascular treatment. Demographics, treatment details and imaging were reviewed for all patients. A systematic review for these aneurysms was also conducted. Results A total of 86 aneurysms were identified from the retrospective review. Mean age at the time of initial treatment was 50±12.42 years. Most patients initially presented with subarachnoid hemorrhage prior to initial endovascular treatment, with only 10 (13.70%) patients presenting with incidentally discovered lesions. mRS at discharge after initial treatment was good (0–3) in 81.4% of cases. Functional outcomes at the last known follow-up revealed a mRS of 0–3 in 71 (83.5%) patients. Only the maximum diameter of aneurysm was found to be a significant predictor of surgical complications (Wald χ2=5.72, p=0.0168) with an odds ratio of 1.84 (95% CI: 1.10, 2.93) for a 5 mm increase in maximum diameter. Systematic review identified 37 studies that were used to pool data on 370 total patients. Although type of surgery was identified as a predictor of poor outcomes this was significantly confounded by Hunt and Hess grade in the systematic review. Conclusion Favorable outcomes can be obtained even for highly complex cerebral aneurysms that have failed endovascular treatment at high volume cerebrovascular centers. Initial presentation grade and aneurysm size are important predictors of final patient outcomes. Disclosures A. Roy: None. L. Phillips: None. B. Howard: None. D. Barrow: None. J. Grossberg: 1; C; GRA. 4; C; NTI.

Background and Purpose The Pipeline Embolization Device (PED; Covidien, Irvine, CA) is being increasingly utilized for off-label indications, but has not been widely utilized to treat posterior cerebral artery (PCA) aneurysms. Potential concerns regarding placement of the PED in the PCA include the relatively small parent vessel diameter and coverage of major branch vessels and P1 thalamic perforators. Herein, we report our experience using the PED for the treatment of PCA aneurysms. Materials and Methods Institutional review board approval was obtained to retrospectively review the neurointerventional databases of three high-volume neurovascular centers for PCA aneurysms treated with the PED between January 2012 and January 2016. Demographic information, clinical history, and outcomes were collected from electronic medical records. Procedural details and periprocedural complications were collected from operative reports. Preoperative digital subtraction angiography (DSA) was reviewed to determine aneurysm characteristics and anatomy of surrounding branch vessels. Follow up MR and DSA were reviewed for aneurysm occlusion, stenosis within the PED, and the status of branch vessels covered by the PED. Results The study included 10 PCA aneurysms in 9 patients (3 men, 6 women) with a mean age of 56 years (range, 18–74 years). There were 6 saccular aneurysms with a mean aneurysm size of 12.3 mm (range, 7–16 mm), and 4 fusiform aneurysms with mean size of 6.2 mm (range, 3.9–11.0 mm) and mean length of 18.8 mm (range, 5–45 mm). Eight aneurysms were treated with a single PED, and two aneurysms were treated with two PEDs. The PEDs ranged from 2.5–4.25 mm in diameter and 12–35 mm in length. Six of 10 PEDs were deployed entirely within the PCA. In two patients, the PED extended from the PCA into the basilar artery, covering the contralateral PCA and both superior cerebellar arteries. There were no deaths. There were two intraprocedural thromboembolic events (20%; 2/10), one of which resulted in symptomatic infarction (10%; 1/10), and one case of delayed PED thrombosis (10%; 1/10). Angiographic follow up was obtained for 9 of 10 aneurysms, including MRA for two patients, DSA for five patients, and DSA at 6 months and CTA at 24 months for one patient. The mean duration of angiographic follow up was 16.7 months (range, 2–33 months). Excluding the case of delayed parent vessel thrombosis, complete aneurysm occlusion was achieved in 75% (6/8) of cases at longest follow up during the study period. There were no instances of in-stent stenosis. All major branch vessels covered by a PED were patent at last angiographic follow. Conclusions PED embolization may be a viable treatment option for select PCA aneurysms that may be considered under appropriate clinical circumstances. Disclosures A. Wallace: None. J. Grossberg: None. J. Delgado Almandoz: None. M. Kamran: None. A. Roy: None. Y. Kayan: None. M. Austin: None. B. Howard: None. C. Moran: 2; C; Medtronic Neurovascular, Microvention. M. Cawley: None. D. Cross: None. J. Dion: None. A. Kansagra: None. J. Osbun: None.