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Endovascular treatment of cervical internal carotid artery (ICA) loop dissections in acute stroke interventions can be challenging. Flow diverters can effectively reconstruct vessel loops and treat the injured vessel and provide a safe conduit for intracranial catheterization.We retrospectively reviewed our neurointerventional database and identified all patients with ICA loop dissections treated with flow diverters in the acute setting between August 2016 and September 2020. Patient demographics, procedural data, imaging follow-up results, and clinical outcome information were collected.Seven patients with a mean age of 62 years (range: 43-85 years) who underwent reconstruction of an ICA (loop) dissection with flow diverters were included. Four ICA dissections were treated with the Surpass Streamline flow diverter and 3 with the Pipeline embolization device. All cases were technically successful. All stroke cases achieved intracranial flow ≥thrombolysis in cerebral infarction 2B. Observed intracranial hemorrhages were all asymptomatic. All cases showed patent flow diverter(s) with or without (carotid) stent(s) on follow-up imaging. Semielectively treated patients did not show a change from baseline modified Rankin scale related to the procedure. Patients with acute stroke had a modified Rankin scale ≤2 in 4 of 5 cases (80%) at 3 months. Two patients died due to medical issues unrelated to the procedures. No patient showed new or recurrent symptoms.Use of flow diverters, in some cases in conjunction with (carotid) stents, is an effective treatment option for cervical carotid artery (loop) dissections.

Preliminary experience with distal radial artery (dRA) access for diagnostic cerebral angiography and some neurointerventional procedures has proved to be promising with good technical results and a reliable safety profile. Vascular access via the dRA may further improve minimally invasive treatment of intracranial aneurysms. Between July 2019 and June 2020 we identified 11 patients (9 females) with a mean age of 63.5 years who underwent WEB device placement for treatment of their intracranial aneurysm via the dRA approach. The mean aneurysm size (largest diameter) was 6.7 mm. One patient required conversion to femoral access due to severe brachial artery fibromuscular dysplasia. Placement of the WEB device was successful in all other cases via dRA approach. In all but one case, a low profile triaxial catheter system with the 6F Benchmark guide catheter (Penumbra) and 5F Sofia distal access catheter (Microvention) were used. No access related complications were observed. The combination of the intrasaccular WEB device and dRA access represents an ideal approach which offers operators a low risk vascular access and high procedural success by maintaining the ability to precisely place and manipulate the device using low-profile catheter systems. At the same time, this approach offers patients the most minimally invasive experience currently available for treatment of intracranial aneurysms with quick postprocedural recovery, minimal restrictions and low risk for access site complications.

Partially thrombosed intracranial aneurysms (PTIA) represent a unique subset of intracranial aneurysms with an ill-defined natural history, posing challenges to standard management strategies. This study aims to assess the efficacy of flow diversion in the treatment of this pathology.A retrospective review of patients with flow-diverted PTIA at 6 cerebrovascular centers was performed. Clinical and radiographic data were collected from the medical records, with the primary outcome of aneurysmal occlusion and secondary outcomes of clinical status and complications.Fifty patients with 51 PTIA treated with flow diversion were included. Median age was 56.5 years. Thirty-three (64.7%) aneurysms were saccular and 16 (31.4%) were fusiform/dolichoectatic. The most common location was the internal carotid artery (54.9%) followed by the vertebral and basilar arteries (17.7% and 17.7%, respectively). Last imaging follow-up was performed at a median of 25.1 (interquartile range, 12.8-43) months. Complete occlusion at last radiographic follow-up was achieved in 37 (77.1%) aneurysms. Pretreatment aneurysm thrombosis of50% was associated with a significantly lower rate of complete aneurysm occlusion (58.8 vs. 87.1%, P = 0.026) with a trend toward better functional outcome (modified Rankin scale2) at last follow-up in patients with50% pretreatment aneurysm thrombosis (96.8 vs. 82.4; P = 0.08). Ischemic complications occurred in 5 (9.8%) patients, producing symptoms in 4 (7.8%) and resultant mortality in 2 (4.2%) patients.Flow diversion treatment of PTIA has adequate efficacy along with a reasonable safety profile. Aneurysms harboring large amounts of pretreatment thrombus were associated with lower rates of complete occlusion.

Severe hypertension is a major cause, among a long list of recognized causative factors of posterior reversible encephalopathy (PRES). We present an interesting case of a middle-aged patient with hypertension and asymmetric distribution of PRES due to tumor-related encasement and narrowing of the right internal carotid artery and relative sparing of the ipsilateral right cerebral hemisphere. White matter lesions from PRES were mostly seen in the contralateral left cerebral hemisphere and bilateral posterior fossa. It is theorized that organs or tissues distal to a chronically constricted vessel are protected from hypertensive changes (such as PRES) as the arterial stenosis reduces the transmission of hypertension-related effects, presumably due to a combination of hypoperfusion and alterations in compensatory changes in vessel autoregulation. While protected from the effects of hypertension, the patient is, however, at risk for border-zone infarction from hypoperfusion.We believe that this case report provides a better understanding of the mechanism underlying the etiology of PRES as primarily regulated by the important baroreceptors and autoregulation mechanism of the carotid artery. Keywords: Headache, Hypertension, Posterior reversible encephalopathy syndrome, PRES, Vessel stenosis, White matter

The purpose of this study was to evaluate safety and efficacy of the pipeline embolization device (PED) in different patient age groups with unruptured intracranial aneurysms (UIA). All patients with UIA treated with the PED between 2011 and 2017 were included. Based on their age, patients were trichotomized to: young (≤45 years), middle-aged (46 to65 years) and older (≥65 years) groups. Patient's vascular risk factors, presenting symptoms and mRS on admission were collected. Follow-up imaging was evaluated for presence/absence of aneurysm occlusion. Clinical outcome at discharge, 3-9 months and 12-18 months was also documented when available. A total of 260 patients harboring 307 aneurysms (young = 57, middle-age = 144 and older age group = 64). Most aneurysms were located in the anterior circulation (94.8%). Overall morbidity and mortality was 2.3% each (6/260). At 3-9 months near complete to complete aneurysm occlusion was 82.5% (47/57) in the young age group, 82.6% (100/121) in the middle age, and 70.2% (40/57) in the older age group. At 12-18-month, near complete to complete occlusion was 100% in the young age group (32/32), 91.4% (64/70) in the middle age, and 78.4% (29/37) in the older age group. After adjustment for potential confounders, older age patients less frequently achieved near complete to complete occlusion by 3 years than younger subjects (p = 0.009, HR 1.34 95%, CI 1.08-1.66). Our results indicate feasibility and safety of PED across different age groups. Further study is required to determine age-related factors relating to aneurysm occlusion after PED to improve outcome and patient counseling.

Mechanical thrombectomy to treat large vessel occlusions (LVO) causing a stroke is one of the most effective treatments in medicine, with a number needed to treat to improve clinical outcomes as low as 2.6. As the name implies, it is a mechanical solution to a blocked artery and modeling these mechanics preclinically for device design, regulatory clearance and high-fidelity physician training made clinical applications possible. In vitro simulation of LVO is extensively used to characterize device performance in representative vascular anatomies with physiologically accurate hemodynamics. Embolus analogues, validated against clots extracted from patients, provide a realistic simulated use experience. In vitro experimentation produces quantitative results such as particle analysis of distal emboli generated during the procedure, as well as pressure and flow throughout the experiment. Animal modeling, used mostly for regulatory review, allows estimation of device safety. Other than one recent development, nearly all animal modeling does not incorporate the desired target organ, the brain, but rather is performed in the extracranial circulation. Computational modeling of the procedure remains at the earliest stages but represents an enormous opportunity to rapidly characterize and iterate new thrombectomy concepts as well as optimize procedure workflow. No preclinical model is a perfect surrogate; however, models available can answer important questions during device development and have to date been successful in delivering efficacious and safe devices producing excellent clinical outcomes. This review reflects on the developments of preclinical modeling of mechanical thrombectomy with particular focus on clinical translation, as well as articulate existing gaps requiring additional research.

A 54-year-old male with metastatic melanoma, including a presumed brain metastasis underwent elective surgery when there was sudden onset of extensive bleeding upon resection. An emergent cerebral angiogram revealed a fusiform left posterior cerebral artery aneurysm. Malignant melanoma commonly metastasizes to the brain and has shown to assume a wide variety of appearances with involvement of almost any intracranial structures. The unexpected intraoperative finding required immediate action and strategic rethinking. The patient successfully underwent vessel sacrifice by means of coil embolization.

Biphenotypic sinonasal sarcomas were initially described in 2012 and introduced to the 4th edition of the World Health Organization (WHO) classification of head and neck tumors as a new disease entity. We present the first comprehensive case description combining radiologic, surgical and pathologic findings of a biphenotypic sinonasal sarcoma in a young patient who presented with nonspecific sinonasal obstructive symptoms, left orbital pain and proptosis. While there is no distinct radiologic imaging finding to differentiate biphenotypic sinonasal sarcomas from other sinonasal malignancies, immunohistochemistry and histopathology were able to show the characteristic combination of neural and myogenic differentiation of the tumor. Overall, the tumor is considered rare and slow growing with locally aggressive features but no tendency to metastasize. Biphenotypic sinonasal sarcomas are primarily treated with surgical resection. Postoperative radiation treatment is recommended with but not limited to positive or close surgical margins, high-grade pathologic tumor classification or imaging evidence of perineural spread. Primary radiation therapy, possibly combined with chemotherapy, is reserved for palliative treatment approaches or patients who refuse surgery. Keywords: Ethmoid sinus, Malignancy, Nasal cavity, Sinonasal sarcoma, Sinus

Introduction La diversion de flux est une technique efficace pour le traitement des anevrismes intracrâniens, avec des taux d’occlusion eleves au long terme. Toutefois, certains anevrismes ne vont jamais cicatriser et d’autres vont s’occlure de facon retardee. De nombreuses donnees precliniques montrent que la bonne apposition a la paroi est un facteur fondamental a l’occlusion anevrismale. Nous avons compare les taux d’occlusion a moyen terme avec ou sans angioplastie apres la pose d’un stent a diversion de flux. Methodes Entre octobre 2011 et septembre 2016, tous les patients traites a l’aide d’un stent Pipeline pour un anevrisme de la circulation anterieure ont ete inclus. Les criteres d’exclusion etaient l’absence de suivi angiographique (6–24 mois) et l’utilisation concomitante d’un autre type de stent. La presentation clinique, les informations techniques et le suivi etaient conserves dans une banque de donnees prospective. Resultats Au total, 144 anevrismes ont ete inclus, avec un taux d’angioplastie de 52 %. Les caracteristiques demographiques, anevrismales et le suivi angiographique moyen (12 mois) n’etaient pas differents entre les deux groupes. Le taux d’occlusion complete etait plus eleve dans le groupe angioplastie (89 %) que dans le groupe controle (71 %), p = 0,006. L’angioplastie n’a pas entraine de complication hemorragique ni n’etait associe a une utilisation plus frequente d’inhibiteurs de la GPIIb/IIIa (p = 0,2). Lors du suivi il n’y a pas eu d’augmentation de score mRs dans le groupe angioplastie. Conclusion La bonne apposition a la paroi arterielle est un facteur important pour l’occlusion arterielle precoce apres traitement par stent a diversion de flux.

The innominate artery, also known as the brachiocephalic artery, is the first vessel off the aortic arch and provides blood to the right arm, neck, and head. Occlusion of the innominate artery can be treated with endarterectomy, angioplasty, stenting, and bypass grafting. Bypass grafting describes a surgical procedure during which a bypass from the ascending aorta to the innominate artery is created. Our case depicts a patient post innominate artery bypass graft with a less commonly encountered postsurgical anatomy.