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Background Flow diversion has revolutionized the management of wide‐necked intracranial aneurysms (IAs). We aimed to assess the effectiveness and safety of the new generation 64‐wire Surpass Evolve for the treatment of unruptured small/medium‐sized IAs. Methods and Results This is a subanalysis from the SEASE (Safety and Effectiveness Assessment of the Surpass Evolve) registry, an observational cohort study including 15 academic institutions in North America and Europe between July 2020 and October 2022. Patients with wide‐necked saccular IAs, measuring

Background The presence of an incorporated branch as well as its anatomical relationship to the intracranial aneurysms (IAs) and the parent artery may affect the occlusion outcome following flow diversion. This study evaluated the safety and effectiveness of the cobalt‐chromium Surpass Evolve (Stryker), a 64‐wire flow diversion device for the treatment of IAs with incorporated branches. Methods This subanalysis uses data from the SEASE (Safety and Effectiveness Assessment of Surpass Evolve) registry to retrieve data related to IAs with incorporated branches. Those IAs were classified by a core lab into 4 categories based on their anatomical relationship to the parent artery and branch: (A) sidewall anatomic, (B) sidewall hemodynamic, (C) neck branch, and (D) dome branch. We compared the outcomes based on their incorporated branch's relation to the dome (A–C versus D). Results This study included 67 patients and IAs. Most IAs were in the posterior communicating artery (46.3%), with a median size of 4.35 mm. Age, sex, comorbidities, baseline functional‐status, and IA features were similar between the 2 groups. Among those, 53 (79.1%) had branches emerging from the dome, and 14 (20.9%) had branches originating from other locations (A = 7, B = 2, and C = 5). At a median imaging follow‐up of 10.5 months, complete occlusion was lower in IAs with a branch from the sac compared with those with the neck (60.8% versus 92.9%; P = 0.026), with an overall occlusion of 67.7%. Thromboembolic and hemorrhagic complications, as well as retreatment, were reported in 1.6% and 3.1% of cases, respectively, with no significant differences between groups. Conclusion Our analysis underscores the influence of branch origin on occlusion rates, with the neck‐originating branch demonstrating higher occlusion rates. These insights emphasize the role of anatomical considerations in treatment strategies, follow‐up timelines, and designing future clinical trials. Further studies are warranted to explore these variations across different flow diversion technologies.

Background Cerebral aneurysms are common, but there is no blood test for their diagnosis. Cerebral aneurysms are diagnosed incidentally or upon rupture. Current diagnostic tools either are invasive or place a large financial burden on the patient. Introduction of a blood test can reduce costs and allow for additional screening. Methods Markov decision analytic models were created for different case studies to simulate management within the US health care system. The model was run over 50 cycle‐years. Probabilities, costs, and outcomes were obtained from the literature and the National Inpatient Sample database. Quality‐adjusted life years were used to assess outcomes. Subgroup analysis was performed for different risk factors, patient groups, aneurysm size, and family members. Results A blood‐based diagnostic pathway is more cost effective in patients undergoing watchful waiting and as a screening tool in patients who may be at a higher risk. There was a 3‐fold reduction in death compared with the standard of care (15.71% versus 53.10%). The cost of using a blood test per additional quality‐adjusted life year gained was $34 515.13 among the watchful‐waiting cohort. The threshold price was $3951. Among patients with 1 family member with an aneurysm, we observed a 10‐fold reduction in death compared with the standard of care (0.21% versus 2.35%), with a threshold at $845.77. Among patients who smoke, we observed a 10‐fold reduction in death compared with the standard of care (0.27% versus 3.30%) with a threshold at $1054.24. Among patients with 2 family members with an aneurysm, there was a 10‐fold reduction in death compared with the standard of care (0.48% versus 5.85%) with a threshold at $1876.46. Conclusion Introduction of a blood‐based test for cerebral aneurysms would have a lifesaving effect within the US health care system while remaining cost effective.

Dural arteriovenous fistulas are contained within the dural leaflets, making them a unique arteriovenous shunt of the central nervous system. Those without cortical venous drainage may be found incidentally or in a workup of pulsatile tinnitus or ocular symptoms. These symptoms may also occur in the setting of cortical venous drainage, but additionally, seizures, neurological deficits, or even frank hemorrhage may occur because of disruption of normal parenchymal venous outflow and resultant venous hypertension. In the setting of debilitating symptomatology or cortical venous drainage, management is most often via endovascular therapy via transarterial or transvenous access to the fistulous site and subsequent obliteration. Surgical disconnection and radiosurgical obliteration are excellent alternative treatment options for appropriately selected lesions as well. In this article, background demographic and natural history data as well as treatment approaches are reviewed.

Introduction Ruptured aneurysmal SAH accounts up to 80% of nontraumatic SAH, with more than 80% located in the anterior circulation and a mortality rate upwards of 50%.1‐3 Endovascular treatment (EVT) of ruptured intracranial aneurysms (rIA) is increasingly being recognized as a standard treatment that may result in better early outcomes and independency when compared with open neurosurgical clipping in cases of appropriate equipoise.1,2,4–6 Despite this, EVT of intracranial aneurysms has its own risk of complications including intraoperative rupture and thromboembolic events.7 The complication rate is found to be higher in cases of rIA than that seen in cases of unruptured intracranial aneurysms.8 The use of somatosensory evoked potentials (SSEP) and electroencephalography (EEG) intraoperative neuromonitoring (IONM) have proven their efficacy in identifying iatrogenic neurological complications in vascular surgeries including carotid endarterectomy 9–11, EVT and microsurgical treatment of intracranial aneurysms. 11,12 rIA have their own unique challenges due to preoperative neurological deficits and perioperative vasospasm making it more difficult to identify new neurological deficits after the procedure. They are also associated with decreased vasoreactivity secondary to bleeding, and a higher rate of procedural complications that can alter the IONM signals.13,14 IONM in the form of SSEP and EEG can be utilized in anesthetized patients to indirectly monitor intraoperative cerebral perfusion as well as central and peripheral neuronal integrity.15,16 Changes in one or both modalities indicate a change in cerebral perfusion that can be related to EVT directly, for example, aneurysm perforation or coil herniation and embolism, or indirectly secondary to anesthesia and hemodynamic changes.17 (Figure1) Methods We reviewed the medical records of 323 patients who underwent EVT of ruptured aneurysms with IONM utilizing SSEP and EEG. We included all patients who had endovascular management of ruptured aneurysm and completed IONM records until the end of the procedure and excluded those with no IONM records or incomplete records. Patients were divided into 2 groups, one group with postprocedural neurological deficits (PPND) and one group without PPND. Results Total of 323 patients undergoing EVT, significant IONM changes were noted in 71 patients (21.98%) and 46 (14.24%) who experienced PPND. 22 out of 71 (30.98%) patients who had significant IONM changes experienced PPND. Univariable analysis demonstrated that persistent changes in SSEP and EEG were associated with PPND (p‐values:

Introduction Previous studies did not show a difference in terms of safety and efficacy among first‐line stent retriever (SR), contact aspiration (CA), or combined techniques for proximal large vessel occlusion strokes. However, the optimal reperfusion therapy in patients with primary distal medium vessel occlusion (DMVO) strokes is uncertain. We aimed to compare the clinical and procedural outcomes among first‐line SR, CA and combined techniques in patients with primary DMVO. Methods This is a retrospective analysis of a prospectively maintained database from 14 comprehensive stroke centers in the US and Europe. Patients were included if they had a primary DMVO stroke due to MCA‐M3/M4, ACA‐A1/A2‐3, or PCA‐P1/P2‐3 and underwent mechanical thrombectomy with first‐line SR, CA, or combined technique. The primary outcome was FPE defined as eTICI 2c/3 on the first pass. Secondary outcomes included mFPE defined as eTICI 2b/3 on the first pass, successful reperfusion defined as eTICI 2b/3 at the end of the procedure. Clinical outcomes included 90‐day mRS0‐1 and 90‐day mRS0‐2. Safety measures included procedural complications, symptomatic intracranial hemorrhage (sICH), and 90‐day mortality. The secondary analysis aimed to identify the procedural and clinical outcomes in 3 matched cohorts: (SR vs. CA), (SR vs. combined technique), and (CA vs. combined technique). Results A total of 365 patients were eligible for analysis; 38.1% were female, with a mean age of 69.3 years and a median NIHSS score of 11 [7‐18]. The first‐line SR group consisted of n=74 (20.3%), CA group n=142 (38.9%), and combined technique group n=149 (40.8%). Patients with first‐line SR or combined technique had a lower median NIHSS score, less frequent MCA‐M3 segment occlusion, and less usage of the rescue strategy compared to those with first‐line CA, P