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Background Computed tomography perfusion (CTP) predictions of infarct core play an important role in the determination of treatment eligibility in large‐vessel occlusion acute ischemic stroke. Prior studies have demonstrated that blood glucose can affect cerebral blood flow. Here, we examine the influence of acute and chronic hyperglycemia on CTP estimations of infarct core. Methods From our prospectively collected multicenter observational cohort, we identified patients with large‐vessel occlusion acute ischemic stroke who underwent CTP with RAPID (IschemaView, Stanford, CA) postprocessing, followed by endovascular therapy with substantial reperfusion (Thrombolysis in Cerebral Infarction 2b–3) within 90 minutes, and final infarct volume determination by magnetic resonance imaging 48 to 72 hours posttreatment. Core volume overestimations and underestimations were defined as a difference of at least 20 mL between CTP‐RAPID predicted infarct core and Diffusion Weighted Imaging (DWI) final infarct volume. Primary outcome was the association of presentation glucose and hemoglobin A1c (HgbA1c) with underestimation of core volume and was measured using multivariable logistic regression adjusted for comorbidities and presentation characteristics. Secondary outcomes included frequency of overestimation of infarct core. Results Among 256 patients meeting inclusion criteria, median age was 67 (interquartile range [IQR], 57–77) years, 51.6% were women, and 132 (51.6%) and 93 (36.3%) had elevated presentation glucose and elevated HgbA1c, respectively. Median CTP‐predicted core was 6 mL (IQR, 0–30 mL), median DWI final infarct volume was 14 mL (IQR, 6‐43 mL), and median difference was 12 mL (IQR, 5–35 mL). Twenty‐eight (10.9%) patients had infarct core overestimation and 68 (26.6%) had underestimation. Compared with those with no underestimation, patients with underestimation had elevated blood glucose (median, 119 [IQR, 103–155] versus 138 [IQR, 117–195] mg/dL; P = 0.002) and HgbA1c (median, 5.80% [IQR, 5.40–6.40] versus 6.40% [IQR, 5.50–7.90]; P = 0.009). In multivariable analysis, underestimation was independently associated with elevated glucose (adjusted odds ratio [OR], 2.10; P = 0.038) and HgbA1c (adjusted OR, 2.37; P = 0.012). Overestimation was associated with lower presentation blood glucose (median, 109 [IQR, 99–132] in overestimation versus 127 [IQR, 107–172] mg/dL in no overestimation; P = 0.003) and HgbA1c (5.6%[IQR 5.1–6.2] in overestimation versus 5.90%[IQR, 5.50–6.70] in no overestimation; P = 0.012). Conclusions Acute and chronic hyperglycemia were strongly associated with CTP underestimation in patients with large‐vessel occlusion acute ischemic stroke undergoing endovascular therapy. Glycemic state should be considered when interpreting CTP findings in patients with large‐vessel occlusion acute ischemic stroke.

Introduction Due to the variability in patient responses to clopidogrel, adjusting antiplatelet regimen based on platelet function testing has become a widespread practice to reduce thromboembolic complications in neurointervention. In the absence of standardized guideline, we aimed to explore the practice patterns related to clopidogrel resistance. Methods We conducted a survey targeting neurointerventionalists, comprising multiple‐choice questions and opportunities for free‐text responses when necessary. The survey was distributed via a professional society – the Society of Vascular and Interventional Neurology (SVIN) and two emailing lists – WovenEndoBridge and Neurointerventional Research Consortium. The data obtained from the responses were analyzed using descriptive statistics. Results A total of 133 neurointerventionalists representing 83 institutions within 24 countries responded to the survey. 62% of respondents tested for clopidogrel resistance prior to any neurovascular stent placements. 80% utilized VerifyNow point‐of‐care P2Y12 assay; other assays included multiplate analyzer, platelet function analyzer (PFA‐100), and CYP2C19 genotype assay. Respondents reported 25 different therapeutic thresholds, with the P2Y12 Reaction Units range between 60 and 180 most commonly used (16.4%). 61% reported they would switch to ticagrelor in the case of persistent resistance. On the other hand, when patients are supratherapeutic, 48% did not make any changes while 42% reduced clopidogrel dose. Finally, 93% felt that there was a lack of well‐established protocol for management of clopidogrel resistance. Conclusion Neurointerventional practice patterns around clopidogrel resistance remains heterogeneous. Our results underscore the need for evidence‐based guidance on anti‐thrombotic management during cerebrovascular stenting.

Background Traumatic direct carotid cavernous fistulas results in a direct communication between the internal carotid artery and the cavernous sinus. Covered stents are not frequently used in neuro‐endovascular procedures due to concerns primarily about occlusion of perforating vessels. There are however several factors in direct carotid cavernous fistulas that make it more amenable to covered stenting than other diseases treated endovascularly. Methods Wepresent 2 cases of occlusion of traumatic direct carotid cavernous fistulas utilizing the PK Papyrus stent. Results In our first case, this device was successfully used as a salvage technique afterfailure of conventional techniques and in the second case it was used as primary treatment. Conclusion The properties of the PK Papyrus covered stent are promising in overcoming the difficulties of other covered stents and warrants further investigation.

Background For acute proximal intracranial artery occlusions, contact aspiration may be more effective than stent‐retriever for first‐line reperfusion therapy. Due to the lack of data regarding medium vessel occlusion thrombectomy, we evaluated outcomes according to first‐line technique in a large, multicenter registry. Methods Imaging, procedural, and clinical outcomes of patients with acute proximal medium vessel occlusions (M2, A1, or P1) or distal medium vessel occlusions (M3, A2, P2, or further) treated at 37 sites in 10 countries were analyzed according to first‐line endovascular technique (stent‐retriever versus aspiration). Multivariable logistic regression and propensity‐score matching were used to estimate the odds of the primary outcome, expanded Thrombolysis in Cerebral Infarction score of 2b–3 (“successful recanalization”), as well as secondary outcomes (first‐pass effect, expanded Thrombolysis in Cerebral Infarction 2c‐3, intracerebral hemorrhage, and 90‐day modified Rankin scale, 90‐day mortality) between treatment groups. Results Of the 440 included patients (44.5% stent‐retriever versus 55.5% aspiration), those treated with stent‐retriever had lower baseline Alberta Stroke Program Early Computed Tomography Scale scores (median 8 versus 9; P

Cervical vertebral arteriovenous fistula is a rare entity that is typically managed with endovascular techniques. We describe 2 consecutive cases of spontaneous obliteration of high flow cervical vertebral arteriovenous fistulas following angiography. Our cases pose an interesting natural history course, and we review the role of angiography in the unusual phenomenon of spontaneous obliteration of vascular malformations. These 2 cases bring forward the possibility of conservative management in such lesions.

Introduction Chronic Subdural Hematoma (cSDH) is projected to be the most common neurosurgical disease in the US by the end of the decade. MMA embolization is a promising new treatment; however, its efficacy in patients with complex, septated cSDH remains uncertain. Methods From our prospectively maintained registry of patients with cSDH treated with MMA embolization (with or without concurrent surgical drainage), we identified patients with and without septations. Septations were defined as hyperdense septa between the inner and outer membranes on a lower‐density background. The primary outcome was recurrence of cSDH, which was defined as any radiographic evidence of increase in thickness and/or new acute hemorrhage. Secondary outcomes included reduction in cSDH thickness, midline shift and rate of reoperation. Results Among 84 patients with 100 cSDHs, median age was 70 [IQR 59‐77] with 26.2% females. 35 CSDHs (35%) had membranes identified on imaging. Evacuation with burr holes was performed in 45.2% and craniotomy in 16.7% of the total cohort. Baseline characteristics between the patients with no septations (no SEP) and those with septatations (SEP) were similar except for median age (no SEP vs SEP, 66 vs 74, p = 0.006). Recurrence rate was lower in the SEP group (no SEP vs SEP, 21.5 vs 2.9%, p = 0.017) even when adjusting for clinically relevant factors (OR 0.07, p = 0.017). Despite larger baseline thickness in the SEP groups, the mean absolute reduction in thickness was more pronounced (no SEP vs SEP, ‐4.6 vs ‐8.0 mm, p = 0.016) with similar midline shift change. Rate of reoperation did not differ (6.2 vs 2.9%, p = 0.65). Recurrence free survival was significantly improved in patients with septations even after adjustment for age and evacuation strategy (Figure 1, p = 0.04). Conclusions MMAE in traditionally higher risk septated cSDHs appears to be highly effective with an even larger reduction in volume and lower risk of recurrence than non‐septated hematomas. These findings support the mechanistic theory of MMAE as a devascularization procedure of membrane neovasculature and may aid in improved patient selection.

Introduction Venous sinus stenosis (VSS) stenting in medically refractory Idiopathic Intracranial Hypertension (IIH) patients has emerged as an effective treatment with low rates of failure and recurrence. However, the best treatment strategy following recurrence of symptoms in previously stented patients with initial response is unclear and frequently leads to shunt placement. We investigated the role of re‐stenting in patients with recurrence after prior successful stenting. Methods This is a retrospective review of a prospectively maintained IIH registry. Inclusion criteria included patients with confirmed IIH and angiographically demonstrable VSS who underwent interventions from 2012–2022. Patients were divided into those who underwent a single stenting procedure (Group S) and those who underwent placement of an additional stent due to recurrence of clinical symptoms and angiographic stenosis (Group R). All re‐stenting was performed in adjacent or remote regions of stenosis. Bivariate analyses were utilized to compare clinical outcomes. Results 86 patients were included with a median age of 33 [IQR 26‐39] and 94% were females. Group S (79/86) and Group R (7/86) had similar baseline characteristics. There was similar improvement in post‐stenting opening pressure (22.4±6.7 vs. 25.2±4.6 cm H2O, p = 0.35, Group S vs. Group R), change in opening pressure (11.6±10.4 vs. 5.3±12.2 cm H2O, p = 0.20, Group S vs. Group R) and resolution of tinnitus (91.8 vs. 80%, p = 0.28, Group S vs. Group R). Headache improvement was higher in Group S at 6 weeks, but similar at 6 months (92.8 vs. 60%, p = 0.02 and 88.2 vs. 80%, p = 0.59, Group S vs. Group R). Group S also had higher improvement in visual disturbances at 6 months (93.8 vs. 60%, p = 0.01, Group S vs. Group R), but similar improvement in papilledema (92.2 vs 100%, p = 0.68, Group S vs. Group R). None of the re‐stented patients required VPS rescue. Conclusions VSS re‐stenting in IIH patients with recurrence after initial stenting is feasible with similar efficacy in reducing intracranial pressure and symptoms.

Postoperative pseudomeningocele is a common complication of craniotomies for tumor resection. Intracranial hypertension can hinder dural repair and potentially lead to refractory or severe cases of pseudomeningocele. We present an unconventional use of venous sinus stenosis stenting to treat postcraniotomy pseudomeningocele driven by intracranial hypertension.

Introduction: Prevention of distal embolization during carotid artery stenting (CAS) is a key element of procedural technique and is standardly performed using distal protection devices (DPDs). Data in support of DPDs, however, are limited. Here, we present our experience of proximal occlusion using a balloon guide catheter (BGC) during CAS as the primary method of distal embolic protection. Methods: We conducted a retrospective review of patients undergoing CAS at our healthcare system between January of 2018 to March of 2021. Procedures were categorized by embolic protection strategy: DPD or BGC (with or without DPD). Emergent cases were defined as patients receiving CAS within

Background Because of the variability in patient responses to clopidogrel and to reduce the risk of thromboembolic complications, adjusting the antiplatelet regimen based on platelet function testing has become a widespread practice in neurointervention. We aimed to explore current patterns related to this practice. Methods We conducted a survey targeting neurointerventionalists, comprising multiple‐choice questions and opportunities for free‐text responses when necessary. The survey was distributed via a professional society distribution list (the Society of Vascular and Interventional Neurology) and 2 consortium emailing lists (WovenEndoBridge and Neurointerventional Research Consortia). The data obtained from the responses were analyzed using descriptive statistics. Results A total of 133 neurointerventionalists, representing 79 institutions within 27 countries, responded to the survey. A total of 62% of respondents tested for clopidogrel resistance before any neurovascular stent placements. A total of 80% used VerifyNow point‐of‐care P2Y12 assay; other assays included multiplate analyzer, platelet function analyzer, and CYP2C19 genotype assay. Respondents reported 25 different therapeutic thresholds, with the P2Y12 reaction unit range between 60 and 180 most commonly used (16.4%). A total of 61% reported they would switch to ticagrelor in the case of persistent resistance. On the other hand, when patients are supratherapeutic, 48% did not make any changes, whereas 42% reduced clopidogrel dose. Finally, 93% opined that a well‐established protocol for management of clopidogrel resistance was needed. Conclusions Neurointerventional practice patterns around clopidogrel resistance remain heterogeneous. Our results underscore the need for evidence‐based guidance on the management of clopidogrel resistance in neurointervention.