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Background Robust venous outflow (VO) profiles, measured by degree of venous opacification on pre-thrombectomy CT angiography (CTA) studies, are strongly correlated with favorable outcomes in patients with large vessel occlusion acute ischemic stroke treated by thrombectomy. However, VO measurements are laborious and require neuroimaging expertise. Objective To develop a semi-automated method to measure VO using CTA and CT perfusion imaging studies. Methods We developed a graphical interface using The Visualization Toolkit, allowing for voxel selection at the confluence and bilateral internal cerebral veins on CTA along with arterial input functions (AlFs) from both internal carotid arteries. We extracted concentration-time curves from the CT perfusion study at the corresponding locations associated with AIF and venous output function (VOF). Outcome analyses were primarily conducted by the Mann-Whitney U and Jonckheere-Terpstra tests. Results Segmentation at the pre-selected AIF and VOF locations was performed on a sample of 97 patients. 65 patients had favorable VO (VO+) and 32 patients had unfavorable VO (VO-). VO+ patients were found to have a significantly shorter VOF time to peak (8.26; 95% CI 7.07 to 10.34) than VO- patients (9.44; 95% CI 8.61 to 10.91), P=0.007. No significant difference was found in VOF curve width and the difference in time between AIF and VOF peaks. Conclusions Time to peak of VOF at the confluence of sinuses was significantly associated with manually scored venous outflow. Further studies should aim to understand better the association between arterial inflow and venous outflow, and capture quantitative metrics of venous outflow at other locations. [ABSTRACT FROM AUTHOR]

Background Venous sinus stenting (VSS) has emerged as a safe and effective treatment option for idiopathic intracranial hypertension. Many physicians routinely admit patients to the intensive care unit (ICU) for close monitoring, but little data exists on whether this is necessary. Methods Electronic medical records of consecutive patients who underwent VSS by the senior author from 2016 to 2022 at a single center were reviewed. Results 214 patients were included. The mean (SD) age was 35.5 (11.6) and 196 (91.6%) patients were female. A total of 166 (77.6%) patients underwent transverse sinus stenting alone; 9 (4.2%) underwent superior sagittal sinus (SSS) stenting alone, 37 (17.3) concomitant transverse and SSS stenting, and 2 (0.9%) underwent stenting at alternate sites. All patients were planned admission to the regular ward (27.6%) or day hospital (72.4%). Twenty (9.3%) patients were discharged to home the same day as the procedure and 182 (85%) patients were discharged the following day. Major periprocedural complications were identified in 2 (0.93%) patients and minor complications were identified in 16 (7.4%). Only one patient with a subdural hematoma identified in the post-anesthesia care unit (PACU) had care escalated to the ICU. No severe complications were identified after the PACU stay. During the next 48 hours after discharge, 4 (1.9%) patients returned to any emergency room to be evaluated without requiring readmission. Conclusion Routine ICU admission following uncomplicated VSS is unnecessary. Overnight admission to a low-acuity ward, or even same-day discharge in select patients, appears to be a safe and cost-effective strategy. [ABSTRACT FROM AUTHOR]

Background Dural sinus malformations (DSMs) associated with high flow arteriovenous shunts are a challenging disease in babies that can lead to severe neurological damage or death. We report our treatment strategy in seven consecutive DSMs. Methods We performed a retrospective analysis of seven consecutive patients from four centres, treated with transarterial embolization and anticoagulants. Results Mean clinical and imaging follow-up was 2.8 years (IQR1-3 1.8-5.3). At baseline, the median size of the dilated venous pouch (giant lake) was 35 mm (IQR1-3 24-41) that decreased to a normal or near normal venous collector diameter of median size 11.5 mm (IQR1-3 8.5-13.8). This was achieved after a median of two embolization sessions targeted on dural feeders (IQR1-3 1.5-2.5), leaving associated pial feeders untreated. There were no cerebral hemorrhagic complications during the anticoagulation treatment. Median percentage of shunt remaining after embolization was 30% (IQR1-3 12-30), which spontaneously decreased with anticoagulation and even after discontinuation of anticoagulation, in parallel with the reduction in diameter of the dilated sinus, up to healing (or near healing). At the last clinical assessment, the modified Rankin Scale score was 0 in four patients, 1 in one patient, and 3 in two patients. Conclusions Anticoagulants may help to potentiate transarterial embolization in DSMs in babies by decreasing venous dilatation and reducing the remaining arteriovenous shunt, particularly the pial feeders. We did not observe recurrence of arteriovenous shunts after treatment, especially during anticoagulation treatment. Further studies are needed to support our findings. [ABSTRACT FROM AUTHOR]

BackgroundDural arteriovenous fistulas (AVF) of the foramen magnum region (FMR) are technically challenging lesions to treat. Transvenous (TV), transarterial (TA), and surgical approaches have been described, but the optimum treatment strategy is not defined.ObjectiveTo report treatment strategies and outcomes for FMR-AVF at a single, high-volume referral center.MethodsA retrospective review from January 2010 to August 2020 identified patients with FMR-AVF at a single referral center. Angiographic features, treatment (observation, endovascular, surgical), and follow-up of angiographic and clinical results were recorded. The technical aspects of TV embolization are then presented in detail.Results29 FMR-AVF were identified in 28 patients. Of these, 24/29 (82.8%) were treated and 5/29 (17.2%) were observed. Treatment was endovascular in 21/24 (87.5%), combined (endovascular+surgical) in 2/24 (8.3%), and surgical in 1/24 (4.2%). Endovascular treatments were 76.2% TV, 14.3% TA, and 9.5% combined TV/TA. Sufficient follow-up data were available for 20/28 (71.4%) with mean follow-up of 16.8 months. No AVF recurrence was seen for TA/TV, combined endovascular/surgical, or surgical groups, and there was one recurrence (7.1%) in the TV group. Symptomatic improvement was seen in all groups: TV (71.4% complete, 28.6% partial), TA (66.7% complete, 33.3% no follow-up), TV+TA (100% partial), endovascular/surgical (100% complete), and surgical (100% partial). Minor non-neurologic complications included 1/14 (7.1%) in the TV group and 1/3 (33.3%) in the TA/TV group.ConclusionEndovascular treatment is safe and effective for most FMR-AVF. TV embolization has a high cure rate with few complications.

Venous sinus stenting (VSS) is a safe, effective, and increasingly popular treatment option for selected patients with idiopathic intracranial hypertension (IIH). Serious complications associated with VSS are rarely reported. Serious complications after VSS were identified retrospectively from multicenter databases. The cases are presented and management strategies are discussed. Six major acute and chronic complications after VSS were selected from a total of 811 VSS procedures and 1466 venograms for IIH. These included an acute subdural hematoma from venous extravasation, cases of both intraprocedural and delayed stent thrombosis, an ultimately fatal cerebellar hemorrhage resulting in acute obstructive hydrocephalus, venous microcatheter perforation during venography and manometry, and a patient who developed subarachnoid hemorrhage and subdural hematoma after cerebellar cortical vein perforation. The six cases are reviewed and learning points regarding complication avoidance and management are presented. We report on six rare, major complications after VSS for IIH. Familiarity with these potential complications and appropriate timely management may allow for good clinical outcomes.

Background Endovascular embolization is a feasible treatment for cranial dural arteriovenous fistulas (DAVFs). New embolic agents aim to improve the success of DAVF embolization. Objective To assess the safety, efficacy, and short-term outcome of the treatment of DAVFs using the new liquid embolic agent Squid. Methods The LIQUID study is a prospective, observational multicenter study on the treatment of highgrade (Cognard type ≥3) DAVFs with the embolic agent Squid. The primary outcome measures were safety (ie, morbidity and mortality), as well as the occlusion rate 90 to 180 days after treatment. Results In eight centers, 53 patients (mean age 59.8 years, 22.6% female) were treated in 55 treatment sessions. Of the DAVFs, 56.6% were Cognard type III, 41.5% type IV, and 18.9% were ruptured. Squid 18 was used in 83.6% and Squid 12 in 32.7% of the treatments. The overall rate of intraprocedural or postprocedural adverse events (AEs) was 18.2%. Procedure-related AEs resulting in permanent morbidity were observed in 3.6%. One patient (1.8%) died unrelated to the procedure due to pulmonary embolism. The final complete occlusion rate at 90 to 180 days was 93.2%. After a mean follow-up of 5.5 months, the modified Rankin Scale (mRS) score was stable or improved in 93.0%. In one of the patients, worsening of the mRS score was related to the procedure (1.8%). Conclusion Squid is a safe and effective liquid embolic agent for the treatment of high-grade DAVFs. [ABSTRACT FROM AUTHOR]

Background This study aims to explore factors that affect venous sinus pressures and associated gradients while awake and under general anesthesia (GA) both before and after venous sinus stenting (VSS) in patients with idiopathic intracranial hypertension (IIH). Methods A retrospective analysis was performed examining pressures and gradients in patients with IIH having undergone awake venography followed by VSS under GA. Results 174 patients were included. Compared with awake, GA superior sagittal sinus (SSS) pressures were 2.6 mmHg lower (p=0.01) resulting in a total cranial gradient reduction of 2.5 mmHg (p=0.002). The transverse- sigmoid gradient, the most commonly stented segment, did not differ under the two conditions (p=0.30). Regression analyses demonstrated that body mass index, gender, blood pressure, and end- tidal carbon dioxide content significantly affected venous pressures (all p<0.05). After stenting, mean total cranial gradients decreased by 13.2 mmHg while skull base gradients increased by 0.8 mmHg. Stenting resulted in an 84% mean reduction in the target gradient and a mean decrease in SSS pressures by 78% of the target gradient. When cardiopulmonary and anesthetic factors were optimized, GA had a limited effect on the target gradient in most patients (p=0.88). Conclusions This study is the largest series to date to report on cerebral venous pressure measurements and gradients recorded while awake and under GA both before and after VSS for IIH. In a well- controlled cardiorespiratory and anesthetic setting, GA venography may provide information that is not substantially inequivalent to that obtained while awake. [ABSTRACT FROM AUTHOR]

Background This prospective cohort study compared the outcomes of stenting and medical treatment for patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis (VSS). Methods In this single- center cohort study, patients with IIH and VSS were evaluated between January 2014 and December 2019 with follow- up periods of 1, 3, and 6 months. The patients received either stenting or medical treatment. The two groups underwent 1:1 matching using propensity score analysis, and the clinical outcomes were compared. Results Following 1:1 matching, 36 patients who underwent stenting and 36 who underwent medical treatment were matched. The median improvements in the papilledema Frisn grade were greater in the stenting group at 1 month (2 vs 0), 3 months (-3 vs -1), and 6 months (-3 vs -1) than in the medical treatment group. Patients who received stenting treatment had a significantly higher prevalence of complete resolution of their respective symptoms (headache, tinnitus, or visual disturbances) at 3 months (58.3% vs 13.9%, OR 8.68, 95% CI 2.74 to 27.52) and 6 months (80.6% vs 22.2%, OR 14.50, 95% CI 4.64 to 45.32) than those receiving medical treatment. Conclusions This matched- control study shows that stenting has a greater efficacy rate and rapid resolution of papilledema and its respective symptoms compared with medical treatment. [ABSTRACT FROM AUTHOR]

Background Evaluation of the transverse sinus stenosis (TSS) is essential for TSS- related diseases. Objective To investigate a new method for the quantitative assessment of TSS based on the correlation between TSS and trans- stenotic pressure gradient (TPG). Methods Patients with unilateral pulsatile tinnitus with or without idiopathic intracranial hypertension were retrospectively included. All patients underwent CT venography and venous manometry and were confirmed to have TSS. The cross- sectional diameter/area of TSS, the poststenotic and prestenotic segments, and the superior sagittal sinus (SSS) were measured. The degree of TSS was calculated by dividing the diameter/area of TSS by the diameter/area of the poststenotic segment (M1/M2), prestenotic segment (M3/M4), and SSS (M5/M6). Partial correlation analysis (controlling for the effect of age, sex, outflow laterality, and contralateral stenosis) was performed to evaluate the correlation between M1--M6 and the TPG. Receiver operating characteristic curve analysis of M1--M6 for diagnosing a significant TPG (≥8 mm Hg) was performed. Results Ninety- nine patients met the inclusion criteria. The partial correlation coefficients between M1--M6 and the TPG were 0.60, 0.61, 0.43, 0.48, 0.39, and 0.54, respectively. The areas under the curve (AUCs) of M1-- M6 for diagnosing a significant TPG were 0.81, 0.86, 0.68, 0.69, 0.64, and 0.72, respectively. The AUC of M2 was significantly larger than that of M3 (P=0.002), M4 (P<0.001), M5 (P=0.001), and M6 (P<0.001). Conclusions Quantitatively assessing TSS by taking the ratio of the cross- sectional area of TSS to that of the poststenotic segment might be a more efficient method for predicting the TPG. [ABSTRACT FROM AUTHOR]

Background Little is currently known about physician opinions and preferences on venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH), practice patterns, or clinical volumes. Methods A 19 question online survey was designed and distributed to physician members of the Society of Neurointerventional Surgery (SNIS). Results A total of 107 individual survey responses were obtained (14% of SNIS members). The majority of respondents (85%) indicated that they had performed at least one VSS procedure independently during their careers. Mean (SD) and median (range) career case volumes were 20.9 (33.8) and 10.0 (0.0-200.0), respectively. On a 1-10 scale, most respondents reported a high level of interest in treating IIH patients with VSS (median 8), a high level of comfort/expertise in treating IIH patients with VSS (median 9), and that VSS was effective in the long term reduction of symptoms and papilledema in IIH patients (median 8). Fifty-nine per cent of respondents reported increasing VSS volumes compared with previous years. A major complication during a VSS procedure, including two deaths, was reported by 11% of respondents. Conclusions This is the first study designed to understand the opinions and practices of neurointerventionists regarding VSS for IIH. Overall physician opinion on VSS was quite positive, supported by increasing procedural volumes reported by most over the past few years. However, only a small percentage of respondents had substantial experience with VSS and major complications were not rare. [ABSTRACT FROM AUTHOR]

Background The balloon-assisted sinus protection technique has been described as a sinus-preserving technique during transarterial embolization (TAE) of dural arteriovenous fistulas (DAVFs). However, some serious complications of this technique have been documented. Objective To describe our preliminary experience with a new technique called stent-assisted sinus protection (SSP). Methods We performed a retrospective analysis of seven consecutive patients with type I or IIa DAVFs of the lateral sinus treated by TAE with a closed-cell stent temporarily deployed in the sinus. Results Of the seven patients, four had type I DAVF, and three had type IIa DAVF. The patency of all involved sinuses and their tributaries (including the inferior anastomotic vein and the superior petrosal sinus) was preserved. At the end of the procedure, all stents were successfully retrieved with embolic particles trapped in their meshes. No procedural complications were noted. Clinical follow-up was satisfactory, with complete resolution or significant reduction of pulsatile tinnitus. Conclusions SSP appears to be feasible and probably safe. However, larger studies are needed to confirm these preliminary results. [ABSTRACT FROM AUTHOR]

Background Dural sinus diverticula are a rare vascular etiology of pulsatile tinnitus. Patients typically present with disabling symptoms and undergo an extensive workup for common causes of pulsatile tinnitus. Endovascular treatment has been shown to be effective in several case reports. We present the largest case series of eight patients treated with endovascular therapy using stent-assisted coiling and describe the unique details of intervention. Methods A retrospective chart review was performed on all patients who underwent endovascular dural sinus stenting. Results One-hundred-twenty patients underwent dural sinus stetnting from August 2012 to February 2020. Eight of these had symptomatic pulsatile tinnitus secondary to a dural sinus diverticulum and were successfully treated with stent-assisted coil embolization. No complications occurred. Conclusion Our case series demonstrates that endovascular dural sinus stent-assisted coil embolization for symptomatic dural sinus diverticula is a safe and effective treatment. [ABSTRACT FROM AUTHOR]

Background The dural vasculature plays a key role in several important conditions, including dural fistulas and subdural collections. While in vivo investigations of intrinsic dural arterial angioarchitecture are rare, no angiographic studies of dural venous drainage exist to our knowledge. Objective To describe methods by which dural venous drainage might be visualized with current angiographic equipment and technique, and to correlate our results with existing ex vivo literature. Methods Digital subtraction angiography and 3D angiography (rotational and Dyna CT) of dural neurovasculature were acquired in the context of subdural hematoma embolization and normal dura. Protocols for visualization of dural venous drainage were established, and findings correlated with ex vivo studies. Results Meningeal arteries supply both the skull and dura. Normal dural enhancement is accentuated by the presence of hypervascular membranes. Intrinsic meningeal veins/sinuses parallel outer layer arteries with well- known tram- tracking appearance. Dura adjacent to main arterial trunks drains via skull base foramina into the pterygopalatine venous plexus, or via emissary veins into the temporalis venous plexus. Dura near the sinuses drains into venous pouches adjacent to the sinus, before emptying into the sinus proper--possibly the same pouches implicated in the angioarchitecture of dural fistulas. Finally, posterior temporoparietal convexity dura, situated in a watershed- like region between middle and posterior meningeal territories, frequently empties into diploic and emissary veins of the skull. Wide variation in balance is expected between these three routes. Drainage patterns appear to correlate with venous embryologic investigations of Padget and ex vivo studies in adults. Conclusions Continued attention to dural venous drainage may prove useful in the diagnosis and management of dural- based vascular diseases. [ABSTRACT FROM AUTHOR]

Background Normative venous sinus diameters are not well established. This study seeks to compare two- dimensional digital subtraction cerebral angiographic (DSA) venous sinus calibers for patients with normal intracranial pressure (ICP) and with idiopathic intracranial hypertension (IIH). Methods Patients who underwent diagnostic cerebral angiography from 2016 to 2020 were retrospectively identified. Two independent reviewers measured venous sinus calibers from anteroposterior (AP) and lateral carotid injection delayed venous phase in patients from two groups (group 1: patients with normal ICP; group 2: patients with IIH) after receiving training in a standardized measurement protocol, with measurements obtained from the superior sagittal sinus (SSS) through the sigmoid sinuses (SS). Results 97 patients from group 1 and 30 patients from group 2 were included. Interrater reliability was greater than 0.75 for all measured sites. Both groups had similar anatomical subtypes with most being right transverse sinus (TS) dominant or codominant. In group 1, men had significantly larger SSS on lateral view (p<0.001) and dominant TS calibers on AP view (p=0.02) compared with women. Both dominant TS measurements and SSS measurements (lateral plane) were significantly smaller among group 2 compared with group 1 (p<0.001 and 0.02, respectively). Patients with IIH had significantly larger dominant SS measurements (p=0.01). Bifid SSS anatomy was present in 9% of patients with mean caudal width 31 mm (range 19--49 mm). Conclusions This study is the first to provide two- dimensional DSA dural venous sinus calibers in patients with and without IIH and to compare anatomical drainage types and calibers among groups. [ABSTRACT FROM AUTHOR]

Background Cerebral venous sinus stenting is an established treatment for patients with idiopathic intracranial hypertension (IIH), refractory to medical management and with stenotic venous sinus on conventional cerebral venography. Currently, there are no clear guidelines on optimal noninvasive imaging modality for routine post- stenting follow- up. We investigated diagnostic yield of CT venography (CTV) for evaluation of stent patency. Methods We reviewed our clinical database of patients with a diagnosis of IIH, who underwent stenting of stenotic transverse or transverse/sigmoid sinus junction. Patients who had follow- up CTVs after more than 30 days were included in the final study group. All CTVs were reviewed by two readers for in- stent thrombosis, extrinsic stent compression, juxta- stent stenosis, and new contralateral venous sinus stenosis. Inter- observer agreement and association of stent patency with clinical outcomes (headache and papilledema) were assessed. Results In all 36 included patients with 38 cerebral venograms for stenting, follow- up CTVs demonstrated adequate opacifications of the venous sinuses and stents for confident evaluation for in- stent thrombosis, extrinsic stent compression, juxta- stent stenosis, and new contralateral venous sinus stenosis, with interobserver agreement coefficient of 0.7, 1.0, 0.8, and 1.0 respectively. Association between abnormal CTV and higher rates of persistent headache and lower rates of headache improvement/resolution was statistically significant (P- value of 0.01). Conclusion CTV is a reliable noninvasive imaging modality for evaluation of cerebral venous sinuses and stent patency following treatment of idiopathic intracranial hypertension with venous sinus stenting and could be used as a routine follow- up study. [ABSTRACT FROM AUTHOR]

A teenager with a history of acute myeloid leukemia presented with headache, nausea and blurry vision over a 2 week period. The MRI of the brain was concerning for the presence of a myeloid sarcoma within the right sigmoid sinus. For evaluation of venous obstruction and the underlying lesion the patient underwent a cerebral angiogram and transvenous biopsy of the sigmoid sinus lesion using a stent retriever and aspiration catheter. The tissue extracted was consistent with myeloid sarcoma. This pathologic finding was consistent with the recurrence of leukemia and guided the targeted oncologic treatment. [ABSTRACT FROM AUTHOR]

background Venous sinus stenting is an effective treatment for papilledema associated with idiopathic intracranial hypertension (IIH). It is unclear whether unilateral transverse- sigmoid sinus (TSS) stenting adequately decompresses the contralateral TSS system in cases of bilateral transverse sinus stenosis. The objective of this study was to compare changes in bilateral TSS pressure gradients following unilateral TSS stenting in a series of patients with IIH. Methods Consecutive patients from a single institution who underwent venous sinus stenting for IIH with measurement of bilateral pressure gradients before and after stenting for IIH were enrolled. Pressure gradients in both TSS pre- and post- stenting were measured during the procedure. The TSS with the highest gradient was stented. Changes in TSS pressure gradients following stent placement were calculated for both TSS. Mean changes in pressure gradients of ipsilateral and contralateral TSS were calculated. results Sixteen patients with IIH who underwent TSS stenting were included. All were female. Mean age was 36.4 years. The right- sided TSS was the stented side in 12 (75.0%) patients. The mean pre- stent pressure gradient of the ipsilateral TSS was 19.3 mmHg (SD=10.8), which was reduced to a mean of 3.8 mmHg (3.4) following stent placement (P =<0.0001). On the contralateral (non- stented) side, the mean pre- stent gradient of 15.1 mmHg (7.5) was reduced to a mean of 7.8 mmHg (6.6) following stenting (P=0.006). Conclusions The use of a single stent provides some venous decompression of the contralateral non- stented stenosis in most cases of IIH treated with endovascular therapy. [ABSTRACT FROM AUTHOR]

background Transverse sinus (TS) stenting is a valid treatment alternative for patients with intracranial hypertension caused by underlying bilateral TS stenoses. Its mid- term patency has, however, not been well documented. Objective To assess the 6- month patency of TS stenting using subtracted CT venography (CTV). Methods A retrospective analysis of a prospectively collected database of patients undergoing TS stenting was performed. The cohort was a single- center, singleoperator series of 125 consecutive patients treated between 2008 and 2018. Mid- term follow- up 320- row detector CTV was available for review in 104 patients. results Follow- up CTV was obtained on average 6 months after stenting. Stents in all patients (100%) were patent. Subtracted reconstructions showed no intraluminal thrombus or neointimal hyperplasia. Native reconstructions confirmed the structural integrity of the stents. De novo stenosis proximal to the stent was noted in 10 cases (10%). A total of 10 patients (10%) received additional treatment due to recurrent symptoms. In univariate analysis, both high body mass index and stent size (>6 mm) were associated with development of de novo stenoses: OR 1.12 (95% CI 1.01 to 1.25, p=0.037) and OR 5.63 (95% CI 1.16 to 27.22, p=0.032), respectively. In multivariate analysis, only stent size (>6 mm) remained significant: OR 7.19 (95% CI 1.03 to 50.01, p=0.046). Conclusion TS stenting is an effective treatment for intracranial hypertension secondary to dural sinus stenosis in an appropriately selected patient population. A 320- row dynamic CTV is a high- quality non- invasive imaging method that can assess both the physical integrity of the stent and its patency. At mid- term followup, all imaged stents were patent. The occurrence of de novo stenoses proximal to the stent (10%) correlated with stent size (>6 mm). [ABSTRACT FROM AUTHOR]

Background Long term failure rates after venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) are poorly understood. Methods Retrospective analysis was performed on a prospectively-maintained single center database to identify patients with medically refractory IIH who underwent VSS. Patients with persistent or severe recurrent symptoms after VSS undergo lumbar puncture (LP), therefore LP serves as a marker for treatment failure. Results 81 patients underwent VSS with a mean follow-up of 10 months; 44 (54.3%) patients underwent LP after VSS due to persistent or recurrent symptoms at a mean of 12 months (median 7, range 2-43). There was a mean decrease in opening pressure (OP) on LP from pre- to post-VSS of 9.1 cm H2O (median 9.5). Overall, a total of 21 (25.9%) patients underwent further surgical intervention following VSS, including five who underwent repeat VSS (6.2% of total) and 18 who underwent cerebrospinal fluid shunting (22.2% of total). There was a non-significant (p=0.18) but overall increase in quality of life scores from pre-stenting (61.2) to last follow-up (71.2), and a significant decrease in Headache Impact Test-6 (HIT-6) scores (p=0.03) with mean pre-stenting and last follow-up scores of 62.7 and 55.8, respectively. Conclusions VSS is an effective treatment for venous sinus stenosis in IIH; however, this study found higher rates of symptomatic recurrence and need for further surgical intervention (26%) than previously reported in the literature. Recurrence of symptoms occurred at a median of 7 months, even though OP remained lower at follow-up LP, suggestive of a re-equilibration phenomenon. [ABSTRACT FROM AUTHOR]

Introduction Little is known about how changes in physiologic parameters affect venous sinus pressure measurements, waveforms, or gradients associated with sinus stenosis. Objective To evaluate the effect of changes in cardiovascular and respiratory physiologic parameters on venous sinus pressure and caliber measurements in patients with idiopathic intracranial hypertension (IIH) undergoing venous sinus stenting. Methods In a prospective, randomized pilot study, eight patients with IIH undergoing venous sinus stenting were randomized to one of two groups. Under general anesthesia, patients underwent venous manometry and waveform recordings twice in succession based on assigned physiologic groups immediately before stenting. The mean arterial pressure (MAP) group maintained normocapnia but modified MAPs in two arms to control for temporal confounding: group A1 (MAP 60-80 mm Hg then 100-110 mm Hg) and group A2 (MAP 100-110 mm Hg then 60-80 mm Hg). The end-tidal carbon dioxide (EtCO2) group maintained a high-normal MAP similar to standard neuroanesthesia goals and modified EtCO2: group B1 (EtCO2 24-26 mm Hg then 38-40 mm Hg) and B2 (EtCO2 28-40 mm Hg then 24-26 mm Hg). Results In group A, superior sagittal sinus (SSS) pressures (ranging from 8 to 76 mm Hg) and trans-stenotic pressure gradients (TSPGs) (ranging from 2 to 67 mm Hg) were seen at MAP of 100-110 mm Hg compared with SSS pressures (4-38 mm Hg) and TSPGs (3-31 mm Hg) at 60-80 mm Hg. In group B, SSS pressures and TSPGs were considerably higher at EtCO2 levels of 38-40 mm Hg (15-57 mm Hg and 3-44 mm Hg, respectively) than at 24-26 mm Hg (8-26 mm Hg and 1-8 mm Hg, respectively). Conclusions Despite the small sample size, this pilot study demonstrates a dramatic effect of both MAP and EtCO2 on venous sinus pressures obtained during venography. These findings underscore the importance of maintaining normal physiologic cardiovascular and respiratory parameters during venous sinus manometry. [ABSTRACT FROM AUTHOR]

Objective To determine the relationship between normal physiologic and pathologic venous sinus pressures in patients with idiopathic intracranial hypertension (IIH), which is poorly understood. Methods Retrospective analysis was performed to identify patients with medically refractory IIH who were evaluated by angiography and retrograde venography with venous manometry. Patients were further subdivided into groups based on anatomic factors. Results 104 patients met inclusion criteria for the study. In the absence of non-invasive venographic screening, 58% of patients in this series were found to have pressure gradients of ≥8 mm Hg; 93% were located near the transverse-sigmoid sinus junction. Opening pressure (OP) is strongly predictive of superior sagittal sinus (SSS) pressures (p<0.001) and also of the presence of a pressure gradient ≥8 mm Hg (p<0.001). Twenty-three percent of patients with an OP <25 had a pressure gradient ≥8 mm Hg compared with 77% of patients with an OP ≥35. Analysis of patients with OP ≤20 suggests that SSS pressures in patients without IIH should be less than 16-18 mm Hg with total cranial gradients <5 mm Hg. Across all patients, a pressure decrement of approximately 1 mm Hg occurs with progressively more caudal transition across anatomic points of measurement. Conclusions This study describes intracranial and extracranial venous pressure measurements and gradients in different subgroups of patients with IIH. OP is highly predictive of intracranial venous pressures and significant venous pressure gradients. [ABSTRACT FROM AUTHOR]

Objective Cranial nerve palsy (CNP) is rarely reported after endovascular intervention for cavernous sinus dural arteriovenous fistulas (CS DAVFs). Our aim was to evaluate the treatment outcomes of CS DAVFs, and the clinical course and risk factors of newly occurring CNPs, with a review of the literature. Methods 121 patients with 134 lesions treated in our institution were selected. They were retrospectively analyzed in terms of baseline characteristics, radiologic results, clinical outcome, and newly occurring CNPs after treatment. Angiographic and clinical follow-up data were available for 104 lesions (77.6%) and 130 lesions (97.0%), respectively. Results The angiographic results showed partial:complete obliterations in 13:91 (87.5%) at the final follow-up. Clinical outcomes were deteriorated or no change:improved or completely recovered (3:126 (96.9%)) at the final follow-up. New CNPs occurred in 24 patients (19.8%), including the sixth CNP alone or mixed in 23 patients (95.8%). 23 cases were completely recovered or improved (21 and 2 cases, respectively), and 19 (90.4%) of 21 were completely recovered within 6 months after treatment. In the multivariate analysis, pretreatment cranial nerve symptoms (OR=0.33; 95% CI 0.14 to 0.76; P=0.010) and complete obliteration immediately after treatment (OR=0.32; 95% CI 0.12 to 0.85; P=0.021) were significant preventive factors for new CNPs. Embolization in the posterior compartments of the CS (OR=5.15; 95% CI 1.71 to 15.47; P=0.004) was a significant risk factor. Conclusions Endovascular intervention was satisfactory in patients with CS DAVFs. The prognosis of newly occurring CNPs was favorable [ABSTRACT FROM AUTHOR]

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Background and objective Pulsatile tinnitus (PT) can be debilitating and lead to significant morbidity. Cerebral venous sinus lesions, such as venous sinus stenosis, diverticula, and high-riding jugular bulb, are uncommon causes of PT, for which there is no standard treatment. Endovascular interventions have shown promising results for PT secondary to idiopathic intracranial hypertension, and may be a valid therapeutic option for isolated venous PT. Methods We conducted a systematic literature review on the outcome and safety of endovascular treatment for patients with isolated, debilitating venous PT. The venous lesion characteristics, endovascular techniques, complications, and clinical outcomes were assessed. In addition, an illustrative case of endovascular stenting for PT caused by venous sinus stenosis was included. Results A total of 41 patients (90.2% female) from 26 papers were included. The median age was 46 years (IQR 23; range 25-72 years). Focal venous sinus stenosis (20 patients) and sinus diverticula (14 patients) were the most common culprit lesions. Endovascular treatment included venous sinus stenting in 35 patients, 11 of whom had adjuvant coil embolization, and coil embolization alone in six patients. Complete resolution of the tinnitus was achieved in 95.1% of patients. There was one complication of cerebellar infarct, and no procedure-related mortality. Conclusions In patients with debilitating PT secondary to venous sinus lesions, endovascular treatment by stenting and/or coil embolization appears to be safe and effective. Prospective randomized studies with objective outcome assessments are needed to confirm the treatment benefits. [ABSTRACT FROM AUTHOR]

Background Cavernous carotid artery aneurysms (CCAs) represent a unique subset of intracranial aneurysms due to their distinct natural history and the anatomy of the cavernous sinus. enlarging CCAs can cause elastic compression of the parent internal carotid artery (ICA). We suggest defining aneurysms that cause luminal stenosis of their parent vessels as 'matricidal aneurysms.' Though many patients are asymptomatic, presenting symptoms of CCAs include ophthalmoplegia with resulting diplopia, vision changes, pain, ptosis, facial numbness, and cavernous-carotid fistula. Less commonly, patients with CCAs can present with epistaxis, subarachnoid hemorrhage, and--in cases of matricidal aneurysms--ischemia due to stenosis. The proper management of stenosis caused by a matricidal CCA is not well established and may not be intuitive. Methods We present a multicenter retrospective case series of patients with matricidal CCAs. Results Forty patients with matricidal aneurysms presented with both asymptomatic and symptomatic stenosis. These patients were either treated with conservative medical management, coiling, flow diversion, or endovascular sacrifice of the parent artery. Planned treatment modalities were not executed in 11 cases (28% treatment failure rate). Presenting symptoms, patient outcomes, and follow-up data are presented for all cases. Conclusion Matricidal aneurysms require careful consideration and planning. The restricted anatomy of the cavernous sinus can make successful execution of endovascular interventions more difficult. Direct elastic compression of the parent artery does not respond to angioplasty and stenting in the same way atherosclerotic stenosis does. Because of this, planning for the possibility of parent vessel sacrifice is important. [ABSTRACT FROM AUTHOR]

Background and purpose We evaluated the inferior petrosal sinus (IPS) and adjacent cerebellopontine angle (CPA) cistern as a potential implantation site for a novel venous endovascular transdural csF shunt concept to treat communicating hydrocephalus. We analyzed the dimensions of the IPS, CPA cistern, and distances to adjacent neurovascular structures. Materials and methods gadolinium enhanced T1 weighted brain Mri datasets of 36 randomly selected patients, aged 20-80 years, were analyzed with threedimensional multiplanar reconstruction to measure iPs diameter and length, CPA cistern depth, and IPS proximity to the vertebrobasilar arteries and brainstem. Statistical analysis was used to assess gender, sidedness, and age dependence. Results Mean IPS diameter ranged from 2.27 mm to 3.31 mm at three axial levels, with >90% larger than 1.46 mm. CPA cistern adjacent to the IPS exhibited a mean depth of 3.86 mm to 7.39 mm between the dura and brainstem at corresponding axial levels. There was no side dependence except for a longer distance from the IPS to the basilar artery on the left compared with the right (9.72 vs 7.28, P<0.019). Linear regression analysis showed that the distance from the IPS to the brainstem was statistically significantly increased with age (P<0.0002) and was greater in men, with little side variation (P=0.524). Conclusion Our results demonstrate sufficient CSF CPA cisternal space adjacent to the IPS and support the feasibility of an endovascular catheter delivered transdural implantable shunt. Such a device could serve to mimic the function of the arachnoid granulation by establishing a regulated path for CSF flow from the intracranial subarachnoid space to the venous system and provide a treatment for communicating hydrocephalus. [ABSTRACT FROM AUTHOR]

Purpose The impact of venous sinus stenting (VSS) on vein of labbé (VOL) drainage is poorly understood. The purpose of the study is to examine the incidence and potential high risk factors of impaired VOL drainage among idiopathic intracranial hypertension (IIH) patients following VSS. Materials and methods institutional review board approved prospective evaluation of all iih patients who underwent VSS over a 5 year period (January 2012 to December 2017) at Weill cornell Medical center constituted the study population. Patient demographics, procedural details (laterality of stenting, balloon angioplasty, number of stents, and stent diameters), morphology of the VOL and changes in the flow in the VOL, type of sinus stenosis, and transverse sinus symmetry were evaluated. We used χ² analysis to evaluate impaired VOL drainage against other variables. Statistical significance was set at 0.05. Results 70 consecutive patients (67 women, 3 men) with a mean age of 31±9.8 years underwent VSS. stenosis was extrinsic in 63% (n=44) and intrinsic in 37% (n=26) of patients. Impaired drainage of the VOL was detected in 9/70 (13%) patients. Ipsilateral VOL was recognized as dominant in 20% (n=14), co-dominant in 51% (n=36), and non-dominant in 29% (n=20) of patients. Impaired VOL drainage was significantly associated with ipsilateral VOL dominance (P=0.001) and stent diameter of ≥9 mm (P=0.042). All patients demonstrated widely patent VOL on follow-up contrast enhanced Mr venography at 3 months and 24 months. Conclusion Impaired drainage of the ipsilateral VOL is a potential consequence of VSS with 13% incidence, and has significant association with ipsilateral superficial cortical venous drainage via dominant VOL and stent diameter of ≥9 mm. [ABSTRACT FROM AUTHOR]

Aims We report the cerebrospinal fluid opening pressure (CSF-OP) measurements obtained before and after venous sinus stenting (VSS) in 50 patients with idiopathic intracranial hypertension. Methods The CSF-OP was measured with a spinal tap 3 months before and 3 months after treatment. All data were prospectively collected and included patient demographics, weight (kg), body mass index (BMI), acetazolamide daily dosage (mg), procedural details, complications, venous sinus pressures (mm Hg), transstenotic pressure gradient (mm Hg), transverse sinus symmetry, and type of venous sinus stenosis. Results The average pretreatment CSF-OP was 37 cm H2O (range 25-77) and the average post- treatment CSF-OP was 20.2 cm H2O (range 10-36), with an average reduction of 16.8 cm H2O (P<0.01). The post-treatment CSF-OP was less than 25cm H2O in 40/50 patients. The average acetazolamide daily dose decreased from 950 mg to 300 mg at the time of 3-month follow-up (P<0.01). No patient required an increase in acetazolamide dose 3 months after VSS. The average weight before treatment was 95.4 kg with an average BMI of 35.41. There was an average increase in body weight of 1.1 kg at the 3-month follow-up with an average increase in BMI of 0.35 (P=0.03). Conclusions We provide evidence that there is a significant decrease in CSF-OP in patients with idiopathic intracranial hypertension 3 months after VSS, independent of acetazolamide usage or weight loss. [ABSTRACT FROM AUTHOR]

Introduction The relationship between degree of angiographic venous sinus stenosis and the transstenosis pressure gradient magnitude in idiopathic intracranial hypertension (IIH) is poorly understood. The present study aimed to assess the utility of angiography, venography, and non-invasive imaging (MRV or CTV) for the diagnosis and characterization of clinically significant VSS. Methods Retrospective analysis of a prospectively collected database was performed to identify patients with medically refractory IIH who were evaluated by angiography and venous manometry for the presence of VSS with associated clinically significant pressure gradient. Angiographic stenosis was measured by two independent raters using novel methodology. Results Thirty-seven patients met inclusion criteria for the study. In total, 70% of patients had clinically significant pressure gradients and were selected for stenting. The optimal percentage stenosis for detection of a significant pressure gradient was 34% stenosis on venous phase arteriography (sensitivity 0.81 and specificity 0.91) and 31% stenosis on venography (0.92 and 0.73). For every 10% increase in stenosis, an approximate increase in pressure gradient of 3.5 mmHg is seen. MRV/CTV had a calculated sensitivity of 0.42, and a negative predictive value of 22%. Conclusion The degree of stenosis predictive of a clinically significant pressure gradient (30-35%) in the venous sinuses is considerably lower than the arterial stenosis at which pathologic hemodynamic alterations occur. While highly predictive of a venous pressure gradient when a stenosis is identified, non-invasive imaging does not appear to be a suitable diagnostic evaluation for the purpose of ruling out clinically significant cerebral VSS. [ABSTRACT FROM AUTHOR]

Introduction Although venous sinus stenting (VSS) has emerged as a promising treatment option for patients with idiopathic intracranial hypertension (IIH) and associated venous sinus stenosis, there is considerable ambiguity regarding patient selection criteria, treatment protocols, and management strategies. Methods An extensive literature review was performed to identify all reports of VSS in patients with iiH using PubMed. Recommendations for the selection and treatment of patients with iiH with VSS are outlined as determined based on author opinion from supporting studies. Due to the lack of randomized trials and few published prospective studies, standard grading scales for recommendations and level of evidence are not fully applicable and therefore a revised grading scale has been provided for recommendations. results The literature review identified a total of eight systematic reviews or meta-analyses and 29 published patient series on VSS. Recommendations for patient selection for diagnostic catheter angiography, angiography procedural considerations, stenting procedural considerations, and retreatment are provided based on the literature. Recommendations that were considered strong included: performance of venous sinus manometry to assess candidacy for treatment prior to stenting; administration of antiplatelet agents prior to stenting and for a follow-up period of at least 3-6 months; performance of post-stenting manometry to confirm resolution of pressure gradient; and performance of repeat angiography and manometry on patients with recurrence of symptoms after resolution with stenting to evaluate for recurrent stenosis. Conclusion VSS for patients with iiH with venous sinus stenosis is now an established and effective treatment option. These recommendations have been provided, based on a summative review of the available published literature, to assist in standardizing care for patients with iiH undergoing VSS. [ABSTRACT FROM AUTHOR]

Paracavernous dural arteriovenous fistulas (pdAVFs) are extremely rare and can mimic carotid cavernous fistulas (CCFs) in both clinical presentation and imaging characteristics. Access to the venous pouch often presents the greatest challenge in the treatment of pdAVFs. Here we present a novel access technique utilizing an endoscopic endonasal transsphenoidal approach, where we directly puncture the venous pouch under both stereotactic guidance and endoscopic visualization, thereby completely embolizing a pdAVF with no alternate access (video 1). [ABSTRACT FROM AUTHOR]

Endovascular embolization is the mainstay for treatment of infantile dural sinus malformations.1 2 Distal access and flow control are limiting factors in controlled embolization.3-6 The Scepter mini catheter (Microvention, Aliso Viejo, California, USA) is a low-profile, dual-lumen balloon microcatheter designed to provide navigability in small-caliber, tortuous intracranial vessels. In this technical video, we demonstrate the staged embolization of a dural sinus malformation with multiple arteriovenous fistulae using the Scepter mini catheter (video 1). In the newborn patient, embolizations were performed through the parietal branches of the left and right middle meningeal arteries. The catheter easily navigated into the small feeding arteries. No neurological complications occurred due to the procedures. Post-embolization injections demonstrated significant flow reduction into the malformation. Three-month follow-up angiography illustrated resolution of the previously dilated left transverse sinus. Complete obliteration of the dural sinus malformation was achieved in the newborn patient. [ABSTRACT FROM AUTHOR]

Direct carotid cavernous fistulae (CCF) are often detected early and treated promptly resulting in a paucity of literature regarding its long-term evolution. We present a case of high flow post-traumatic direct CCF that was neglected for over 6 years and presented with a rare manifestation of primary intraventricular haemorrhage. Occlusions of the primary venous outlets likely resulted in engorgement of the deep venous system. The segmental anatomy of the shunting basal vein is critical to the clinical presentation and may range from basal ganglia or brainstem oedema/infarctions to uniquely, as in our case, isolated intraventricular haemorrhage secondary to variceal rupture. Treatment in such chronic cases requires a consideration of cerebral hyperperfusion syndrome necessitating deconstructive techniques with subsequent anticoagulation to avoid accelerated thrombosis of the venous varices. [ABSTRACT FROM AUTHOR]

Background: Pulsatile tinnitus (PT) can cause significant detriment to quality of life and may herald a life-threatening condition. Endovascular evaluation is the gold standard for the definitive diagnosis of PT and facilitates treatment. However, no large study has determined the distribution of causes and treatment outcomes of PT evaluated endovascularly., Methods: Consecutive patients evaluated at a multidisciplinary PT clinic from a single academic center were retrospectively reviewed. Patients with a suspected cerebrovascular etiology of PT based on clinical and/or non-invasive imaging, who were evaluated by endovascular techniques (arteriography, venography, manometry, and/or balloon test occlusion), were included in analysis. Baseline clinical features and treatment results by final etiology of PT were compared., Results: Of 552 patients referred for PT evaluation, 164 patients (29.7%) who underwent endovascular evaluation of PT were included. Mean (±SD) age at first clinical evaluation was 54.3±14.1 years (range 25-89 years); 111 patients (67.7%) were female. PT causes were 75.6% vascular and 24.4% non-vascular. Arteriovenous shunting lesions caused 20.7% of cases, venous etiologies 48.2%, and arterial etiologies 6.7%. Of patients with a shunting lesion treated with endovascular embolization, 96.9% had lasting significant improvement or resolution in PT. Endovascular stenting for venous sinus stenosis gave 84.6% of patients lasting improvement or resolution in PT. Arterial and non-vascular PT had fewer patients treated endovascularly and less improvement in PT symptoms., Conclusion: PT with a suspected vascular cause is most often attributable to venous etiologies. PT caused by arteriovenous shunting or venous sinus stenosis may be effectively treated endovascularly., Competing Interests: Competing interests: MRA: Board member: Mind Rhythm; Consultancy: Stryker, Neurovascular, Covidien, MicroVention, Comments: Pipeline proctor for Covidien and PHIL DSMB for MicroVention; Patents (planned, pending or issued): Cerebral venous sinus stent, Comments: provisional patent serial number 62/984,549. KHN: Consultancy: Stryker Neurovascular, Imperative Care. All other authors: No relevant competing interests., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction Venous outflow obstruction is recognized as a contributing factor in a subset of patients with idiopathic intracranial hypertension (IIH). little is known about venous sinus waveform morphology or how it changes after stenting. Methods Fifteen patients with iih underwent waveform recording during catheter venography and manometry. Ten patients (Group A) with venous sinus stenosis and pressure gradient ≥7 mm hg underwent waveform recording during awake venography and during stenting under general anesthesia. Five control iih patients (Group B) without a gradient underwent awake recording only. results group a patients underwent successful stenting with reduction of their gradient from 15.1±6.19 mm hg to 1.2±0.60 mm hg. This resulted in an amplitude reduction from 8.3 mm hg to 2.8 mm hg (P=0.02). Qualitative evaluation of the waveform yielded a number of novel findings. in Group A before stenting, the observed waveform progressed from an intracranial pressure (ICP)-dominated to central venous pressure (CVP)-dominated waveform. stenting abolished the high amplitude waveform and smoothed the transition from the intracranial to central venous measurement points. Group B displayed primarily CVP-influenced waveforms distal and proximal to the transverse-sigmoid junction along with respiratory variability of the waveform, absent in 8/10 group a patients. general anesthesia appeared to blunt the waveform in 5/10 group a patients. Conclusion The cerebral venous waveform appears to be influenced by both the ICP and CVP waveforms. as measurement moves proximally, the waveform progressively changes to mirror the CVP waveform. Venous sinus stenosis results in a high amplitude waveform which improves with treatment of the stenosis. [ABSTRACT FROM AUTHOR]

Background Dural venous sinus stenting has emerged as an effective and durable treatment for idiopathic intracranial hypertension (IIH). Improved visualization of the venous sinuses can improve stent placement. Methods We present two cases of IIH treated with venous sinus stenting in which retrograde three-dimensional rotational venography (3DRV) provided superior anatomical details of the venous sinuses for optimal sizing and positioning of stent. Results Comparison of pre-stent 3DRV with poststent contrast-enhanced flat panel detector CT allowed confirmation of stent placement and the result of stenosis dilation. Conclusion This 3DRV technique provides precise visualization of venous sinus stenosis prior to stenting without the need for arterial cerebral angiography during the treatment course. [ABSTRACT FROM AUTHOR]

Background Administration of ε-aminocaproic acid (εACA), as adjuvant therapy following incompletely embolized cranial dural arteriovenous (DAVFS) and direct carotid artery to cavernous sinus fistulae (CCFS), is a strategy to promote post-procedural thrombosis. However, the efficacy of εaca to treat incompletely obliterated DAVFS and CCFS has not been published. The purpose of this study was to determine if administration of εACA following incomplete embolization of cranial DAVFS or CCFS was associated with an increased likelihood of cure on follow-up imaging compared with patients not given adjuvant εACA. Methods Aa retrospective cohort study was performed. All patients who underwent treatment of a DAVF or CCF at our institution between 1998 and 2016 were reviewed (n=262). Patients with residual shunting following the first attempted endovascular embolization were included in the analysis (n=52). The study groups were those treated with εACA following incomplete obliteration of the fistula and those who were not. The primary outcome was obliteration of the fistula on initial follow-up imaging. Complication rates between cohorts were compared. Results 20 (38%) patients with incompletely obliterated fistulae were treated with adjuvant εaca. A trend towards an improved rate of complete obliteration on initial follow-up imaging was observed in the group treated with εACA (55% vs 34% in the group not treated with εACA, p=0.14). No difference in clinical outcomes or thromboembolic complications was observed between the groups. Conclusions In summary, these data suggest that administration of εaca is a safe adjuvant therapy in the management of cranial DAVFS and CCFS that are incompletely treated endovascularly. [ABSTRACT FROM AUTHOR]

Purpose To investigate the effects of detachable balloons in embolizing traumatic carotid cavernous fistulas (TCCFS) and the risk factors for recurrence after balloon embolization. Materials and methods 188 patients with TccFs were enrolled, and clinical, treatment, and follow-up data were analyzed for possible risk factors for recurrence after embolization. Results Among 188 patients, 182 (96.8%) had successful balloon embolization; 6 patients failed. One balloon was used in 94 cases and multiple (two or more) balloons were used in 62 patients. 26 patients had occlusion of the parent artery whereas the remainder had parent artery preservation. Periprocedural complications occurred in 3 patients (1.6%) including cerebral embolism in 1 and abducent nerve paralysis in the other 2. Immediately following embolization, headache appeared in 92 patients and was relieved after 3-5 days with medications. A total of 165 patients (87.8%) had follow-up (6 months to 16 years, mean 5 years). 23 (13.9%) patients with internal carotid artery preservation had recurrence 1-33 days (mean 11 days) after the first embolization and were retreated to complete occlusion. Factors affecting recurrence were multiple balloons and residual fistula (p<0.05). Logistic regression confirmed the independent factors affecting recurrence were multiple balloons (≥2 balloons, Or 7.80, 95% CI 2.28 to 26.73; p=0.001) and residual fistula immediately following embolization (Or 10.46, 95% CI 2.99 to 36.5; p=0.000). Conclusion The recurrence rate is high in the first month after embolization with detachable balloons, and multiple balloons and residual fistula are two independent factors affecting recurrence following balloon embolization. [ABSTRACT FROM AUTHOR]

Background Torcular dural sinus malformations (tDSMs) are described as slow flow dural arteriovenous fistulae with frequently poor outcomes in the neuroangiographic literature, but other etiologies have been proposed in the obstetric literature, where outcomes have been more favorable. Objective To review tDSMs reported in the literature of multiple specialties for features that support a common etiology, and to identify key prognostic factors, with an emphasis on tDSM trajectory highlighted in part I. Methods Analysis of imaging features and clinical outcome for 77 prenatal and 22 postnatal tDSMs reported in 37 papers from the literature. Results In addition to large venous lakes, 36% of prenatal and 96% of postnatal tDSMs had evidence of arterialization, where specifically assessed. For fetal cases, where there was an observable natural history, 97% underwent a spontaneous decrease--13% after an initial increase and only 1 case with subsequent enlargement after a decrease. Prenatal cases had 83% survival (62% with a favorable outcome) whereas postnatal cases had 59% survival (29% favorable). In addition to a postnatal diagnosis, unfavorable features included ventriculomegaly, parenchymal injury, arterialization, and need for intervention. Favorable features included decreasing tDSM size, presence of clot, and increasing clot percentage. Conclusions Neonatal and fetal tDSMs have overlapping imaging appearances, suggesting a common etiology, where neonatal tDSMs represent those rare fetal tDSMs that do not undergo spontaneous regression and have a propensity for worse outcomes. Decrease in tDSM size is a critical observation when managing a tDSM because it is generally irreversible and associated with a favorable outcome. A morphologically identical lesion to the tDSM has been reported in the fetal imaging literature, but the inability to directly demonstrate the angioarchitecture of these lesions has led to alternative etiologies being advanced for this population (eg, primary dural sinus dysplasia or thrombosis followed by dural sinus dilation).2-13 Some autopsy papers have also reported extraluminal localization of these fetal tDSMs.14 15 In distinction to the neuroangiographic literature, the outcome for these fetal tDSMs has been favorable in as many as 75-90% of cases.8 10 16 These differences in formulation and outcome cast doubt as to whether tDSMs seen in utero and postnatally represent the same entity. They also raise questions about how best to counsel late gestation pregnancies affected with a tDSM and how best to follow such pregnancies. In part I of this article,17we examined a local cohort of tDSM cases and found imaging commonalities across the fetal-neonatal age spectrum. For example, we described a fetal tDSM with directly visualized arteriovenous communications in utero, as well as postnatal tDSMs where AVFs were undetectable even with catheter angiography. We also showed that tDSM involution in our cohort was an irreversible process and one that may occur despite initial enlargement. In part II, we have conducted an analysis of the fragmented multidisciplinary literature on tDSMs to highlight prognostic factors identifiable from other cohorts and assess these in light of the prognosticators in our cohort. We have synthesized these data to offer a plausible model for tDSM evolution across fetal-neonatal life and provided a rational approach to following tDSM pregnancies and performing interventions when necessary. [ABSTRACT FROM AUTHOR]

Background Even for the most common dural sinus malformation (DSM), the torcular DSM (tDSM), generalizable statements about etiology and prognosis are difficult because neurosurgeons/neuroradiologists and obstetrical imagers have focused on different patient age groups, have reported different outcomes, and have offered differing pathophysiologic explanations. Objective To examine the imaging features and outcomes of a local cohort of tDSMs across fetal-neonatal life for commonalities. Methods Review of imaging and clinical outcome for a local cohort of 12 tDSM patients (9 fetal, 3 postnatal). results All 12 tDSMs had similar imaging characteristics, including enlargement of the torcular and intraluminal thrombus early on, later evolving to peripheral scar tissue after treatment or spontaneous regression. Spontaneous decrease in size of the tDSM was observed in 6 prenatal and 1 postnatal case, and this decrease appeared to be irreversible once it occurred. One of 9 prenatal tDSMs was demonstrated to have arteriovenous fistulae in utero, while 2 of 3 postnatal diagnoses had arteriovenous fisutlae. All 6 prenatal tDSM diagnoses followed to term and all 3 postnatal diagnoses had a grossly normal neurologic outcome after a median of 12 months of age. Conclusions Prenatal and postnatal tDSMs have overlapping imaging features suggesting a common etiology, and involution of a tDSM is a key imaging biomarker for a favorable outcome. While there is reason for concern with postnatally diagnosed tDSMs, good outcomes may still be achieved across the fetal-neonatal age spectrum of presentations. These findings are generalized in part II of this article. [ABSTRACT FROM AUTHOR]

Objective Venous sinus stenting (VSS) is a safe and effective treatment for idiopathic intracranial hypertension (IIH) with angiographic venous sinus stenosis. However, predictors of stent-adjacent stenosis (SAS) remain poorly defined. Methods We performed a retrospective review of 47 patients with IIH and intracranial venous stenosis who underwent VSS with pre- and post-stent venography. Patient characteristics, treatments and outcomes were reviewed. Changes in pressure gradient after VSS were classified according to pattern of gradient resolution into types I-III. Results Type I gradient resolution, in which mean venous pressure (MVP) in the transverse sinus (TS) decreases towards MVP in the sigmoid sinus (SS), occurred in 18 patients (38.3%). Type II gradient resolution pattern, in which SS MVP increases towards that in the TS, occurred in 7patients (14.9%). Type III pattern, in which MVP equilibrates to a middle value, occurred in 22patients (46.8%). SAS occurred in 0%, 28.6%, and 22.7% of patients in types I, II and III, respectively. Compared with patients with type I gradient resolution, SAS was more common in those with type II (p=0.0181) and type III (p=0.0306) patterns. Conclusions The pattern of change in the transstenosis venous pressure gradient may be predictive of SAS and is a useful tool for classifying the response of the venous obstruction to stenting. A type I pattern appears to represent the ideal response to VSS. Some patients with type II and III changes, particularly if they have other predictors of recurrent stenosis, may benefit from longer initial stent constructs. [ABSTRACT FROM AUTHOR]

Introduction Dural venous sinus stenosis (DVSS) may lead to increased intracranial pressure, sometimes requiring a stent if a high pressure gradient exists. Many neuroendovascular physicians use microcatheters to measure gradients, yet there are no studies comparing the accuracies and precisions of modern day microcatheters. We examined pressure recordings from five commonly used microcatheters in an experimental DVSS model. Methods Using a programmable pump, dynamic flow was established in a closed circuit mimicking the venous sinus waveform. Microcatheters with 150 cm effective lengths were connected proximally to pressure transducers. Mean recording pressures were compared with a high fidelity microcatheter (HFM) in several configurations including no stenosis, proximal to a focal stenosis, and distal to a focal stenosis in opposing orientations. results All microcatheters recorded lower pressures than the HFM. Three of the five microcatheters successfully met intracranial pressure monitoring device standards in all conditions, while one did not meet standards in any configuration. The performance of the final microcatheter was variable, with inaccuracies occurring in unrestricted flow. All microcatheters demonstrated relatively high precision, but with variable accuracies. The larger diameter microcatheters displayed the least damping and therefore the greatest accuracies. Of the three smaller microcatheters, dimensions did not predict performance, suggesting that microcatheter construction may also play a role in pressure accuracy. Conclusion The use of microcatheters to record dural venous sinus pressures must be done with an understanding of the inherent limitations and inaccuracies, especially if clinical decisions are made from the results. [ABSTRACT FROM AUTHOR]

Background Dural venous sinus thrombosis (DVST) is an increasingly recognized cause of a wide array of neurological symptoms, with outcomes that range from complete recovery to death. The condition of approximately 23% of patients with DVST will worsen after initial presentation, as a result of restricted venous outflow and venous hypertension, but early identification of this subset is challenging. A venous collateral scale (VCS) that grades alternative drainage routes may improve prediction of clinical deterioration. Objective To examine the ability of the VCS system to accurately identify patients with DVST who will experience clinical worsening, based on their imaging at presentation. Methods From our institutional database, we identified patients with DVST on dedicated venous imaging between January 2010 and July 2016. A VCS was created and calculated from venous imaging at presentation by two reviewers blinded to subsequent data. Results The 27 patients who met the inclusion criteria for this study had a median age of 42 years and 14 (52%) were female. Initial symptoms included headache without hemorrhage in 30% and focal deficit in 30%. Transverse sinus occlusion was present in 70% and superior sagittal sinus occlusion in 41%. VCS was 0 in 11%, 1 in 37%, and 2 in 52%. A lower VCS was significantly associated with clinical worsening both from time of initial symptom onset (77% vs 29%, VCS 0-1 vs 2, p<0.05) and during hospitalization (62% vs 0%, VCS 0-1 vs 2, p<0.01). In multivariate analysis, VCS but no other presenting features was significantly associated with in-hospital worsening (OR=2, p<0.01). Conclusions The type and quality of venous collaterals influence outcome in DVST. VCS helps to identify patients whose condition is likely to deteriorate and may need additional aggressive interventions. [ABSTRACT FROM AUTHOR]

Objective Safety and efficacy of superior sagittal sinus (SSS) stenting for non-thrombotic intracranial venous occlusive disease (VOD) is unknown. The aim of this retrospective cohort study is to evaluate outcomes after SSS stenting. Methods We evaluated an institutional database to identify patients who underwent SSS stenting. Radiographic and clinical outcomes were analyzed and a novel angiographic classification of the SSS was proposed. Results We identified 19 patients; 42% developed SSS stenosis after transverse sinus stenting. Pre-stent maximum mean venous pressure (MVP) in the SSS of 16.2 mm Hg decreased to 13.1 mm Hg after stenting (p=0.037). Preoperative trans-stenosis pressure gradient of 4.2 mm Hg decreased to 1.5 mm Hg after stenting (p<0.001). No intraprocedural complication or junctional SSS stenosis distal to the stent construct was noted. Improvement in headache, tinnitus, and visual obscurations was reported by 66.7%, 63.6%, and 50% of affected patients, respectively, at mean follow-up of 5.2 months. We divided the SSS into four anatomically equal segments, numbered S1-S4, from the torcula to frontal pole. SSS stenosis typically occurs in the S1 segment, and the anterior extent of SSS stents was deployed at the S1-S2 junction in all but one case. Conclusions SSS stenting is reasonably safe, may improve clinical symptoms, and significantly reduces maximum MVP and trans-stenosis pressure gradients in patients with VOD with SSS stenosis. The S1 segment is most commonly stenotic, and minimum pressure gradients for symptomatic SSS stenosis may be lower than for transverse or sigmoid stenosis. Additional studies and follow-up are necessary to better elucidate appropriate clinical indications and long-term efficacy of SSS stenting. [ABSTRACT FROM AUTHOR]