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Background Flow diversion (FD: flow diversion, flow diverter) is an endovascular treatment for many intracranial aneurysm types; however, limited reports have explored the use of FDs in bifurcation aneurysm management. We analyzed the safety and efficacy of FD for the management of intracranial bifurcation aneurysms. Methods A systematic review identified original research articles that used FD for treating intracranial bifurcation aneurysms. Articles with >4 patients that reported outcomes on the use of FDs for the management of bifurcation aneurysms along the anterior communicating artery (AComA), internal carotid artery terminus (ICAt), basilar apex (BA), or middle cerebral artery bifurcation (MCAb) were included. Meta-analysis was performed using a random effects model. Results 19 studies were included with 522 patients harboring 534 bifurcation aneurysms (mean size 9 mm, 78% unruptured). Complete aneurysmal occlusion rate was 68% (95% CI 58.7% to 76.1%, I²=67%) at mean angiographic follow-up of 16 months. Subgroup analysis of FD as a standalone treatment estimated a complete occlusion rate of 69% (95% CI 50% to 83%, I²=38%). The total complication rate was 22% (95% CI 16.7% to 28.6%, I²=51%), largely due to an ischemic complication rate of 16% (95% CI 10.8% to 21.9%, I²=55%). The etiologies of ischemic complications were largely due to jailed artery hypoperfusion (47%) and in- stent thrombosis (38%). 7% of patients suffered permanent symptomatic complications (95% CI 4.5% to 9.8%, I²=6%). Conclusion FD treatment of bifurcation aneurysms has a modest efficacy and relatively unfavorable safety profile. Proceduralists may consider reserving FD as a treatment option if no other surgical or endovascular therapy is deemed feasible. [ABSTRACT FROM AUTHOR]

Background To report the 3-year safety and effectiveness of the Surpass Streamline flow diverter in the SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms). Methods The Surpass Streamline flow diverter device was evaluated in a multicenter, prospective, single-arm, non-randomized interventional trial including patients with uncoilable or previously treated but failed aneurysms of the intracranial internal carotid artery. 3-year outcomes were tabulated with descriptive statistics and compared with 1-year outcomes. Results Of 180 patients in the modified intent-to-treat (mITT) cohort, 36-month clinical and angiographic follow-up was available in 134 and 117 cases, respectively. Effectiveness endpoint of complete aneurysm occlusion without clinically significant stenosis or retreatment was met in 71.8% (79/110, 95% CI 62.4% to 80.0%) of cases. Safety composite endpoint was 12.2% (22/180) over the 3-year period, with two major safety events (ipsilateral ischemic strokes) occurring between 12-36 months. Complete aneurysm occlusion was noted in 77.8% (91/117), and 99.1% (116/117) of the patients demonstrated adequate aneurysm occlusion (complete occlusion or neck residual). There were four cases (2.2%) of aneurysm rupture, all occurring within the first month of the index procedure. Target aneurysm retreatment rate was 2.8% (5/180). Conclusion The present findings support the long-term safety and effectiveness of the Surpass Streamline flow diverter device. [ABSTRACT FROM AUTHOR]

Background The Surpass flow diverter was developed to treat intracranial aneurysms not amenable to standard treatment. Indications for use allow placement in the internal carotid artery to the terminus, including the communicating artery segment. Methods The Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms (SCENT) trial is an international, multicenter, prospective, non-randomized trial comparing the outcomes of Surpass flow diverter treatment with historic control designed to evaluate the effectiveness and safety of Surpass for the treatment of wide neck (≥4 mm) large or giant intracranial aneurysms ≥10 mm. The primary effectiveness endpoint is the percentage of subjects with 100% aneurysm occlusion without significant stenosis of the parent artery and without retreatment of the target aneurysm at 12 months. The primary safety endpoint is the percentage of subjects experiencing neurologic death or major ipsilateral stroke at 12 months. We report the effectiveness and safety of flow diversion in the subgroup of posterior communicating artery (PComA) aneurysms. Results Of the 180 patients treated, 38 harbored a PComA aneurysm. Mean aneurysm size was 12.2 mm and mean neck width was 4.8 mm. The mean number of Surpass devices used was 1.1 per procedure, with 94.7% of aneurysms treated with one flow diverter. The 12 month primary effectiveness rate was 73.7% (28/38). At 36 months, 68.4% (26/38) of aneurysms remained completely occluded. The 12 month major ipsilateral stroke or neurological death rate was 10.5%. No patients with PComA occlusion after flow diverter placement (54.5%) had clinical sequelae. Conclusions SCENT demonstrated acceptable 12 month effectiveness of flow diversion in PComA aneurysms. Despite associated PComA occlusions in many cases, arterial occlusions were clinically silent. Trial registration number URL: https://www.clinicaltrials.gov. Unique identifier: NCT01716117. [ABSTRACT FROM AUTHOR]

Background Transradial access (TRA) for neurointervention is becoming increasingly popular as experience with the technique grows. Despite reasonable efficacy using femoral catheters off-label, conversion to femoral access occurs in approximately 8.6-10.3% of TRA cases, due to an inability of the catheter to track into the vessel of interest, lack of support, or radial artery spasm. Methods This is a multicenter, retrospective case series of patients undergoing neurointerventions using the Rist Radial Access System. We also present our institutional protocol for using the system. Results 152 patients were included in the cohort. The most common procedure was flow diversion (28.3%). The smallest radial diameter utilized was 1.9 mm, and 44.1% were performed without an intermediate catheter. A majority of cases (96.1%) were completed successfully; 3 (1.9%) required conversion to a different radial catheter, 2 (1.3%) required conversion to femoral access, and 1 (0.7%) was aborted. There was 1 (0.7%) minor access site complication and 4 (2.6%) neurological complications. Conclusions The Rist catheter is a safe and effective tool for a wide range of complex neurointerventions, with lower conversion rates than classically reported. [ABSTRACT FROM AUTHOR]

Introduction The low-profile Neuroform Atlas stent received FDA Humanitarian Device Exemption status (HDE) in January 2018 for stent-assisted coil embolization of wide-necked saccular aneurysms. We review and report our results with the Atlas stent in our institution within the first year after its HDE approval. Methods Our retrospective chart review identified patients treated with the Atlas stent. We analyzed the patient demographics, aneurysm characteristics, stent parameters and configuration, complications, angiographic, and clinical outcomes at discharge. Results From January to December 2018, 76 Atlas stents were deployed in 58 patients (average 1.3 stents/patient). Median patient age was 63.5 (IQR 56-71) years. Fifty-six (96.6%) patients had elective embolization of unruptured aneurysms, while two (3.4%) patients underwent embolization of a ruptured aneurysm within 2 weeks of subarachnoid hemorrhage. Forty (69.0%) patients were treated with a single stent, 15 (25.9%) with a Y-stent, and three (5.2%) with X-stent configuration. All stent deployments were technically successful. Most stents (82.9%) were the smallest 3mm diameter devices. Procedural complications included transient stent-associated thrombosis in three (5.2%) patients and aneurysm rupture in one (1.7%). None had distal embolization, associated cerebral infarction, or permanent neurological deficits. Immediate Raymond-Roy 1 occlusion was achieved in 41 (70.7%) patients. Median hospital length of stay for elective aneurysm embolization was 1 day. Excellent outcomes with median National Institute of Health Stroke Scale score 0 (IQR 0-0) and modified Rankin Score 0 (IQR 0-1) were seen for elective patients at discharge. Conclusion The Neuroform Atlas stent provided a reliable technical and safety profile for the treatment of intracranial wide-neck aneurysms. Further experience is needed to determine long-term durability and safety of this device. [ABSTRACT FROM AUTHOR]

Introduction Intracranial vertebral dissecting pseudoaneurysms are a rare, but increasingly recognized, cause of subarachnoid hemorrhage and ischemic stroke. The risks of aneurysm re-rupture and associated morbidity are high. The use of flow diverter stents for the treatment of these aneurysms has not been well studied. Objective To report our data and provide a summarized review of literature using flow diverter stents for the treatment of intracranial vertebral artery dissecting pseudoaneurysms. Methods We performed a retrospective analysis of flow diverter stents used for the treatment of intracranial vertebral artery dissecting pseudoaneurysms. Clinical, imaging, procedural, and follow-up data were collected. Results We identified eight vertebral dissecting pseudoaneurysms in seven patients (5 (71.4%) female; median age 47 years (IQR 46-52)) who had undergone treatment with flow diverter stents. In 4/7 patients (57.1%) the aneurysm had ruptured; however, only one was treated in the acute phase. Median size of the largest diameter of the aneurysm was 6.3 mm (IQR 4.2-8.8), and 7/8 aneurysms (87.5%) were treated with a single flow diverter device. Three aneurysms were concurrently coiled. Angiographic complete occlusion was seen in 6/8 (75%) aneurysms at a median follow-up of 14 months (IQR 7.7-20.2). Two patients had periprocedural strokes with transient neurologic deficits. All patients had a good clinical outcome (modified Rankin Scale score ≤2). There were no re-treatments or aneurysm ruptures during the follow-up period. Conclusions Our experience suggests that flow diverter stent treatment of intracranial vertebral artery dissecting pseudoaneurysms is safe, and associated with good occlusion rates and favorable clinical outcomes. [ABSTRACT FROM AUTHOR]

Background Mechanical thrombectomy using stentrievers is the standard of care for emergent large vessel occlusion stroke. Data on the use of stentrievers in smaller caliber vessels are sparse. Objective To present our initial experience with the Mindframe Capture LP device, which was designed for mechanical thrombectomy in small cerebral arteries. Methods A retrospective chart review was conducted of patients who underwent Mindframe device assisted emergent thrombectomy. Clinical, imaging, procedural and early follow-up data were obtained. Results Nine patients met inclusion criteria (5 men, median age 62 years). Median National Institute of Health Stroke Scale (NIHSS) score was 18 (IQR 9-22), and 6 patients received intravenous tissue plasminogen activator. Six patients had M2 segment occlusions, and 2 patients had distal M1 segment occlusions of the middle cerebral artery. One had distal basilar artery occlusion. Median vessel diameter at the thrombus was 1.7 mm (IQR 1.5-2.5). In all 9 patients the Mindframe device was used together with manual aspiration, with median groin puncture to recanalization time of 35 min (IQR 27-54), and median procedural time of 67 min (IQR 51-91). Final Thrombolysis in Cerebral Infarction score was 3 and 2b in 4 patients each (89% total), and 2a in 1 patient. No patient had any postprocedural complications or symptomatic intracerebral hemorrhage. Median postprocedure and discharge NIHSS were 4 and 1, respectively. Conclusions Our data suggest that the Mindframe device is safe and effective for rapid treatment of acute strokes involving small caliber intracranial vessels. Further study in a larger cohort is warranted. [ABSTRACT FROM AUTHOR]

Background Cerebrospinal fluid diversion through lumbar drainage catheters is a routine procedure that is used in a variety of clinical applications. Fracture of catheters during insertion or removal may result in retained foreign bodies that may lead to patient morbidity with potential legal ramifications. Fracture resistance is an important component of drain selection. Objective To analyze catheter integrity to determine which commercially available catheters are most robust and resistant to fracture. Methods Physical properties of the commercially available drainage catheters that can be advanced through a Touhy needle were assessed using laboratory equipment and reported. Five types of catheter were analyzed for break load, tensile strength, extension at break, and shear strength. Results and conclusions Of the five types of catheter, the Arrow catheter showed the greatest resistance to fracture. Of the drainage catheters, the Codman catheter showed the greatest resistance to fracture. [ABSTRACT FROM AUTHOR]

Background Flow diverters have been used predominantly for large anterior circulation aneurysms. Data on the safety and efficacy of this treatment for posterior circulation aneurysms are limited. Objective To present our posterior circulation flow diverter experience, outcomes and morbidity in comparison with recent studies. Methods A retrospective chart and imaging review of six patients with seven aneurysms in posterior circulation vessels, treated with flow diverter technology was carried out. A literature review was performed using standard online search tools. Results We included five saccular and two fusiform posterior circulation aneurysms. An average of two flow diverters was placed for each patient. Adjunctive coiling was used in three cases. Follow-up at an average of 14.5 months showed complete angiographic occlusion in 4 (57.1%) cases, including one patient with in-stent thrombosis and major brainstem stroke at 4.5 months, a week after self-discontinuing dual antiplatelet therapy. Two other patients developed small periprocedural strokes but had excellent recovery. One death occurred 18 months after the initial procedure. No aneurysm rupture or parenchymal hemorrhage was seen. Overall, 5 (71%) cases, all with saccular aneurysms, had good clinical outcome (modified Rankin score (mRS) 0-1). Fusiform basilar aneurysms had markedly worse outcomes (mRS 5 and 6). Our literature review yielded six other studies with 100 additional patients. Overall, good outcome was seen in 74.3%, with a 12.3% average mortality and 11% permanent neurologic deficit rate. Complete occlusion varied from 43% to 100%. Conclusions Flow diversion may be a possible treatment in carefully selected patients with high-risk atypical posterior circulation aneurysms, with poor natural history and no optimal treatment strategy. Symptomatic and fusiform large aneurysms appear to carry the highest risk. Further studies are necessary to assess the role of flow diversion in the posterior circulation. [ABSTRACT FROM AUTHOR]

Introduction Carotid artery sacrifice remains an important procedure for cerebral vascular disorders despite the development of new endovascular devices. Conventional carotid artery sacrifice with detachable coils alone often requires numerous coils to complete occlusion. Objective To describe the initial human experience with balloon-augmented Onyx and coil vessel sacrifice based on our previous experience with animals. Methods We performed a retrospective review of patients who underwent carotid artery sacrifice between 2008 and 2012 in accordance with local investigational review board approval. Two methods were used to occlude carotid arteries—namely, combined Onyx and coil embolization and traditional coil embolization. We compared the two methods for the cost of embolizate, time to occlude the vessels, and the number of coils. Results Eight consecutive patients (combined group n=3, traditional group n=5) were assessed. The median cost of embolic material was $6321 in the combined Onyx and coil embolization group and $29 996 in the traditional coil embolization group. The median time from first coil placement to achievement of vessel occlusion was 52 min in the Onyx group and 113 min in the coil embolization group. The median number of coils used was 4 in the Onyx group and 35 in the coil embolization group ( p<0.05). No symptomatic complications or recurrences were seen in the combined group. Conclusions Balloon-augmented Onyx endovascular ligation may reduce costs and fluoroscopy times during vessel sacrifice. Further studies in a larger number of patients are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Background Cerebral angiography remains the gold standard for the detection of mycotic aneurysms, and it has been estimated that ruptured mycotic aneurysms result in 5% of the neurological complications of patients with infective endocarditis (IE). Objective To determine the diagnostic yield of cerebral angiography in the above patient population and to assess patient factors that might suggest greater or lesser utility. Methods We retrospectively reviewed 168 patients who underwent cerebral angiography with a diagnosis of IE or infected left ventricular assist device at the Cleveland Clinic between January 2003 and March 2010 in accordance with institutional review board guidelines. Chart and imaging review was performed. Results 15/168 patients (8.9%) had mycotic aneurysms; 93.3% (14/15) of the patients with mycotic aneurysms presented with CNS hemorrhage and 66.7% (10/15) had acute ischemic findings. Of the 15 patients with mycotic aneurysms on angiography, seven underwent CT angiography and six underwent MR angiography, which showed mycotic aneurysms in three (42.9%) and two cases (one of which was questionable; 33.3%), respectively. Conclusions Patients with IE or similar sources of central bacterial emboli are prone to neurovascular complications. Approximately 9% of patients with IE at our institution who undergo cerebral angiography have mycotic aneurysms. Presentation with hemorrhage appears to be more predictive of aneurysm, as approximately 22% of patients with IE and hemorrhage were found to have an aneurysm compared with only 1% when hemorrhage was absent. Thus, patients with IE presenting with intracranial hemorrhage should undergo vascular imaging, preferably with cerebral angiography. [ABSTRACT FROM AUTHOR]

A patient was taken for emergent intra-arterial stroke therapy for an acute left middle cerebral artery stroke syndrome, with CT angiography showing a left internal carotid artery (ICA) occlusion. Through a 6 F Neuron MAX sheath, a 5 Max ACE Penumbra aspiration catheter was advanced to the thrombus and direct suction was performed through the ACE catheter and Neuron MAX sheath. Upon pull back, the thrombus became wedged in the Neuron MAX sheath and despite several attempts to aspirate the thrombus, no clot could be obtained. The Neuron MAX sheath was withdrawn to the left common carotid artery, and gently advanced to the origin of the external carotid artery (ECA). A glide wire was advanced and the thrombus dislodged into the ECA. Another pass with the 5 Max ACE was used to remove a remaining thrombus in the left ICA terminus, resulting in Thrombolysis in Cerebral Infarction (TICI) 3 flow. With improved devices for embolectomy, large and rigid emboli that exceed the inner diameter of large guide sheaths and balloon guide catheters can become lodged, and cannot be withdrawn through a catheter. While uncommon, strategies to overcome this are important to keep in mind during acute stroke intervention. [ABSTRACT FROM AUTHOR]

A patient was taken for emergent intra-arterial stroke therapy for an acute left middle cerebral artery stroke syndrome, with CT angiography showing a left internal carotid artery (ICA) occlusion. Through a 6 F Neuron MAX sheath, a 5 Max ACE Penumbra aspiration catheter was advanced to the thrombus and direct suction was performed through the ACE catheter and Neuron MAX sheath. Upon pull back, the thrombus became wedged in the Neuron MAX sheath and despite several attempts to aspirate the thrombus, no clot could be obtained. The Neuron MAX sheath was withdrawn to the left common carotid artery, and gently advanced to the origin of the external carotid artery (ECA). A glide wire was advanced and the thrombus dislodged into the ECA. Another pass with the 5 Max ACE was used to remove a remaining thrombus in the left ICA terminus, resulting in Thrombolysis in Cerebral Infarction (TICI) 3 flow. With improved devices for embolectomy, large and rigid emboli that exceed the inner diameter of large guide sheaths and balloon guide catheters can become lodged, and cannot be withdrawn through a catheter. While uncommon, strategies to overcome this are important to keep in mind during acute stroke intervention. [ABSTRACT FROM AUTHOR]

Background and purpose Symptomatic intracranial atherosclerosis has been associated with a high rate of recurrent stroke. The safety of treatment of more distal atheromatous lesions with angioplasty has not been systematically reported. Methods We retrospectively reviewed our institutional database for all patients treated with intracranial angioplasty and stenting from January 2008 to July 2009. A total of 108 patients were treated and five patients were treated with angioplasty for a symptomatic M2 middle cerebral artery stenosis with fluctuating neurological examinations. We report our experience with these patients. Results All five patients underwent technically successful treatment with a reduction of the stenosis to <50%. There were no periprocedural complications and all patients had cessation of their clinical fluctuations. Two patients were found to have symptomatic restenosis with one patient suffering a disabling stroke at 5 months and the second patient a transient ischemic attack at 4 months who was subsequently successfully re-treated with angioplasty and stent placement. Conclusions Angioplasty of M2 MCA lesions is technically feasible in our cohort of neurologically unstable patients, but the durability of this treatment will require more extensive study. [ABSTRACT FROM PUBLISHER]

Background: Significant controversy exists about the management of unruptured cerebral arteriovenous malformations (AVMs). Results from A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) suggested that intervention increases the risk of stroke/death compared with medical management. However, numerous study limitations raised concerns about the trial's generalizability., Objective: To assess the rate of stroke/death and functional outcomes in ARUBA-eligible patients from a multicenter database, the Neurovascular Quality Initiative-Quality Outcomes Database (NVQI-QOD)., Methods: We performed a retrospective analysis of prospectively collected data of ARUBA-eligible patients who underwent intervention at 18 participating centers. The primary endpoint was stroke/death from any cause. Secondary endpoints included neurologic, systemic, radiographic, and functional outcomes., Results: 173 ARUBA-eligible patients underwent intervention with median follow-up of 269 (25-722.5) days. Seventy-five patients received microsurgery±embolization, 37 received radiosurgery, and 61 received embolization. Baseline demographics, risk factors, and general AVM characteristics were similar between groups. A total of 15 (8.7%) patients experienced stroke/death with no significant difference in primary outcome between treatment modalities. Microsurgery±embolization was more likely to achieve AVM obliteration (P<0.001). Kaplan-Meier survival curves demonstrated no difference in overall death/stroke outcomes between the different treatment modalities' 5-year period (P=0.087). Additionally, when compared with the ARUBA interventional arm, our patients were significantly less likely to experience death/stroke (8.7% vs 30.7%; P<0.001) and functional impairment (mRS score ≥2 25.4% vs 46.2%; P<0.01)., Conclusion: Our results suggest that intervention for unruptured brain AVMs at comprehensive stroke centers across the United States is safe., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Introduction: Anatomic factors that predict outcomes following basal ganglia intracranial hemorrhage (bgICH) evacuation are poorly understood. Given the compact neuroanatomic organization of the basal ganglia, we hypothesized that bgICH spatial representation could predict postoperative functional outcomes., Methods: Patients undergoing minimally invasive surgical bgICH evacuation between 2013 and 2024 at one center were retrospectively reviewed. bgICH volumes were segmented and stereotactically localized using anatomic landmarks. Heat maps that identified bgICH spatial representation across functional outcome states were generated. Differential bgICH volume overlap with each heat map was calculated after subtracting out that patient's contribution to the map. Area under the receiver operating characteristic curve (AUC) was used to evaluate the diagnostic accuracy of differential volume overlap for poor functional outcome (modified Rankin Scale score of 4-6 within 1 year of surgery) and compared with that of the intracranial hemorrhage (ICH) score with a z test., Results: Forty-five patients were included (62% men, 7% Caucasian, median age 53 years). Thirty-two patients (71%) had poor functional outcome (median follow-up 4.1 months), which was associated with increased age (P=0.032), bgICH volume (P=0.005), intraventricular hemorrhage severity (P=0.032), National Institutes of Health Stroke Scale (P=0.006), and differential volume overlap (P<0.001). Anatomically, poor outcome was associated with bgICH extension into the anterior limb of the internal capsule (P=0.004), caudate (P=0.042), and temporal lobe (P=0.006). The AUC for differential volume overlap was 0.87 (95% CI: 0.76-0.97), which was higher than chance alone (P<0.001), but statistically similar to that (0.82 (0.71-0.97)) of the ICH score (P=0.545)., Conclusion: Stereotactic bgICH localization enabled functional outcome prognostication in patients undergoing minimally invasive surgical evacuation., Competing Interests: Competing interests: VRK is a consultant for Stryker and Integra. MB received teaching honoraria, is a consultant for Cerenovus and Integra, and is a member of the advisory board for Stryker., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Arteriovenous malformation (AVM)-associated aneurysms represent a high-risk feature predisposing them to rupture. Infratentorial AVMs have been shown to have a greater incidence of associated aneurysms, however the existing data is outdated and biased. The aim of our research was to compare the incidence of supratentorial vs infratentorial AVM-associated aneurysms., Methods: Patients were identified from our institutional AVM registry, which includes all patients with an intracranial AVM diagnosis since 2000, regardless of treatment. Records were reviewed for clinical details, AVM characteristics, nidus location (supratentorial or infratentorial), and presence of associated aneurysms. Statistical comparisons were made using Fisher's exact or Wilcoxon rank sum tests as appropriate. Multivariable logistic regression analysis determined independent predictors of AVM-associated aneurysms. As a secondary analysis, a systematic literature review was performed, where studies documenting the incidence of AVM-associated aneurysms stratified by location were of interest., Results: From 2000-2024, 706 patients with 720 AVMs were identified, of which 152 (21.1%) were infratentorial. Intracranial hemorrhage was the most common AVM presentation (42.1%). The incidence of associated aneurysms was greater in infratentorial AVMs compared with supratentorial cases (45.4% vs 20.1%; P<0.0001). Multivariable logistic regression demonstrated that infratentorial nidus location was the singular predictor of an associated aneurysm, odds ratio: 2.9 (P<0.0001). Systematic literature review identified eight studies satisfying inclusion criteria. Aggregate analysis indicated infratentorial AVMs were more likely to harbor an associated aneurysm (OR 1.7) and present as ruptured (OR 3.9), P<0.0001., Conclusions: In this modern consecutive patient series, infratentorial nidus location was a significant predictor of an associated aneurysm and hemorrhagic presentation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: CPK has received an educational grant from Penumbra. ASA receives research support and is a consultant for Penumbra. MB is a consultant for Rebound Therapeutics. DF receives research support from Penumbra. JM receives research support from Penumbra and is an investor and consultant for Rebound Therapeutics.

Background: Flow diverters have been used predominantly for large anterior circulation aneurysms. Data on the safety and efficacy of this treatment for posterior circulation aneurysms are limited., Objective: To present our posterior circulation flow diverter experience, outcomes and morbidity in comparison with recent studies., Methods: A retrospective chart and imaging review of six patients with seven aneurysms in posterior circulation vessels, treated with flow diverter technology was carried out. A literature review was performed using standard online search tools., Results: We included five saccular and two fusiform posterior circulation aneurysms. An average of two flow diverters was placed for each patient. Adjunctive coiling was used in three cases. Follow-up at an average of 14.5 months showed complete angiographic occlusion in 4 (57.1%) cases, including one patient with in-stent thrombosis and major brainstem stroke at 4.5 months, a week after self-discontinuing dual antiplatelet therapy. Two other patients developed small periprocedural strokes but had excellent recovery. One death occurred 18 months after the initial procedure. No aneurysm rupture or parenchymal hemorrhage was seen. Overall, 5 (71%) cases, all with saccular aneurysms, had good clinical outcome (modified Rankin score (mRS) 0-1). Fusiform basilar aneurysms had markedly worse outcomes (mRS 5 and 6). Our literature review yielded six other studies with 100 additional patients. Overall, good outcome was seen in 74.3%, with a 12.3% average mortality and 11% permanent neurologic deficit rate. Complete occlusion varied from 43% to 100%., Conclusions: Flow diversion may be a possible treatment in carefully selected patients with high-risk atypical posterior circulation aneurysms, with poor natural history and no optimal treatment strategy. Symptomatic and fusiform large aneurysms appear to carry the highest risk. Further studies are necessary to assess the role of flow diversion in the posterior circulation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: Carotid artery sacrifice remains an important procedure for cerebral vascular disorders despite the development of new endovascular devices. Conventional carotid artery sacrifice with detachable coils alone often requires numerous coils to complete occlusion., Objective: To describe the initial human experience with balloon-augmented Onyx and coil vessel sacrifice based on our previous experience with animals., Methods: We performed a retrospective review of patients who underwent carotid artery sacrifice between 2008 and 2012 in accordance with local investigational review board approval. Two methods were used to occlude carotid arteries-namely, combined Onyx and coil embolization and traditional coil embolization. We compared the two methods for the cost of embolizate, time to occlude the vessels, and the number of coils., Results: Eight consecutive patients (combined group n=3, traditional group n=5) were assessed. The median cost of embolic material was $6321 in the combined Onyx and coil embolization group and $29 996 in the traditional coil embolization group. The median time from first coil placement to achievement of vessel occlusion was 52 min in the Onyx group and 113 min in the coil embolization group. The median number of coils used was 4 in the Onyx group and 35 in the coil embolization group (p<0.05). No symptomatic complications or recurrences were seen in the combined group., Conclusions: Balloon-augmented Onyx endovascular ligation may reduce costs and fluoroscopy times during vessel sacrifice. Further studies in a larger number of patients are needed to confirm these findings., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

A patient was taken for emergent intra-arterial stroke therapy for an acute left middle cerebral artery stroke syndrome, with CT angiography showing a left internal carotid artery (ICA) occlusion. Through a 6 F Neuron MAX sheath, a 5 Max ACE Penumbra aspiration catheter was advanced to the thrombus and direct suction was performed through the ACE catheter and Neuron MAX sheath. Upon pull back, the thrombus became wedged in the Neuron MAX sheath and despite several attempts to aspirate the thrombus, no clot could be obtained. The Neuron MAX sheath was withdrawn to the left common carotid artery, and gently advanced to the origin of the external carotid artery (ECA). A glide wire was advanced and the thrombus dislodged into the ECA. Another pass with the 5 Max ACE was used to remove a remaining thrombus in the left ICA terminus, resulting in Thrombolysis in Cerebral Infarction (TICI) 3 flow. With improved devices for embolectomy, large and rigid emboli that exceed the inner diameter of large guide sheaths and balloon guide catheters can become lodged, and cannot be withdrawn through a catheter. While uncommon, strategies to overcome this are important to keep in mind during acute stroke intervention., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)