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Background and purpose: Flow diversion has established as standard treatment for intracranial aneurysms, the Surpass Streamline is the only FDA-approved braided cobalt/chromium alloy implant with 72-96 wires. We aimed to determine the safety and efficacy of the Surpass in a post-marketing large United States cohort. Materials and methods: This is a retrospective multicenter study of consecutive patients treated with the Surpass for intracranial aneurysms between 2018 and 2021. Baseline demographics, comorbidities, and aneurysm characteristics were collected. Efficacy endpoint included aneurysm occlusion on radiographic follow-up. Safety endpoints were major ipsilateral ischemic stroke or treatment-related death. Results: A total of 277 patients with 314 aneurysms were included. Median age was 60 years, 202 (73%) patients were females. Hypertension was the most common comorbidity in 156 (56%) patients. The most common location of the aneurysms was the anterior circulation in 89% (279/314). Mean aneurysm dome width was 5.77 ± 4.75 mm, neck width was 4.22 ± 3.83 mm, and dome/neck ratio was 1.63 ± 1.26. Small-sized aneurysms were 185 (59%). Single device was used in 94% of the patients, mean number of devices per patient was 1.06. At final follow-up, complete obliteration rate was 81% (194/239). Major stroke and death were encountered in 7 (3%) and 6 (2%) cases, respectively. Conclusion: This is the largest cohort study using a 72–96 wire flow diverter. The Surpass Streamline demonstrated a favorable safety and efficacy profile, making it a valuable option for treating not only large but also wide-necked small and medium-sized intracranial aneurysms. [ABSTRACT FROM AUTHOR]

Aneurysm boundary has been marked with a dashed line for visibility. c Contrast-enhanced CBCT MIP coronal reconstruction from right vertebral artery injection immediately after flow diversion construct placement. A contrast-enhanced CBCT showed extensive acute thrombosis of the aneurysm with preserved patency of the stent construct and of the origins of several pontine arteries seen previously (Fig. Introduction Successful flow diversion, with progressive aneurysm thrombosis while maintaining side branch patency, requires complete apposition of the implant to healthy vessel segments proximal and distal to an aneurysm [[1]]. [Extracted from the article]

Background Existing travel restrictions limit the mobility of proctors, significantly delaying clinical trials and the introduction of new neurointerventional devices. We aim to describe in detail technical and legal considerations regarding international teleproctoring, a tool that could waive the need for in-person supervision during procedures. Methods International teleproctoring was chosen to provide remote supervision during the first three intracranial aneurysm treatments with a new flow diverter (currently subject of a clinical trial) in the US. Real-time, high-resolution transmission software streamed audiovisual data to a proctor located in Canada. The software allowed the transmission of images in a de-identified, HIPAA-compliant manner. Results All three flow diverters were implanted as desired by operator and proctor and without complication. The proctor could swap between images from multiple sources and reported complete spatial and situational awareness, without any significant lag or delay in communication. Procedural times and radiologic dose were similar to those of uncomplicated, routine flow diversion cases at our institution. Conclusions International teleproctoring was successfully implemented in our clinical practice. Its first use provided important insights for establishing this tool in our field. With no clear horizon for lifting the current travel restrictions, teleproctoring has the potential to remove the need for proctor presence in the angiography suite, thereby allowing the field to advance through the continuation of trials and the introduction of new devices in clinical practice. In order for this tool to be used safely and effectively, highly reliable connection and highresolution equipment is necessary, and multiple legal nuances have to be considered. [ABSTRACT FROM AUTHOR]

Objective: To describe the results in patients treated with the Surpass Evolve (SE) device, the new generation of Surpass flow diverters. Methods: Twenty-five consecutive patients (20 women, average age 58 years), with anterior or posterior circulation aneurysms treated with SEs in two early-user centers, were included. Device properties and related technical properties, imaging and clinical follow-up data, and intraprocedural, early (<30 days) and delayed (>30 days) neurological complications, further divided into minor (silent/non-permanent) and major (permanent) complications, were recorded and analyzed. Results: Twenty-nine SEs were successfully implanted in all subjects to treat 26 aneurysms using an 0.027" microcatheter with an average of 1.2 stents per patient. No intraprocedural thromboembolic or hemorrhagic complications were seen. At clinical follow-up, 24/25 (96%) patients had a modified Rankin Score of 0-2. Mortality was 0%. Imaging follow-up, available in 22/25 (88%) patients (median follow-up time 4 months), showed a complete aneurysm occlusion in 13/23 (57%) imaged lesions. Minor, transitory neurological deficits were recorded in 5/25 (20%) patients. One (4%) major complication was seen in one patient (4%) with a left-sided hemispheric stroke on postprocedural day 4 due to an acute stent thrombosis. Conclusions: Preliminary experience in patients demonstrates a good performance of the SE. This newly designed implant maintains the engineering characteristics of Surpass flow diverters, including precise placement due to its lower foreshortening and a high mesh density, yet can be deployed through a significantly lower-profile delivery system. [ABSTRACT FROM AUTHOR]

Background Flow diverting stent (FDS) devices have revolutionized the treatment of large and complex brain aneurysms, but there is still room for improvement, particularly on the flow diversion properties and technical challenges associated with stent deployment. In this study we compared flow diversion properties between the new generation Surpass Evolve (Stryker) and the Pipeline Flex (Medtronic) devices by quantitatively evaluating intra-aneurysmal flow modification. Methods An in vitro experimental set-up was used, consisting of four patient-specific silicone models with internal carotid aneurysms and a circulating hemodynamic simulation system with pulsatile flow. The Evolve and Pipeline stents were deployed across the neck of each aneurysm model, in a randomized fashion, for a total of eight device deployments. A 60 frames/s digital subtraction angiography run was acquired before and after placement of each FDS. An optical flow-analysis method was used to measure intra-aneurysmal flow modification induced by the stent by calculating a mean aneurysm flow amplitude (MAFA) before and after stent placement and computing a ratio. Results Average MAFA ratio values calculated from pre- and post-stent placement were significantly lower after deployment of the Evolve (n=4, mean=0.62±0.09) compared with the Pipeline device (n=4, mean=0.71±0.06) (p=0.03). Conclusions Our in vitro results show that the Evolve stent had a superior flow diversion effect compared with the Pipeline stent, which--based on clinical evidence--suggest it may promote faster aneurysm occlusion rates in patients. [ABSTRACT FROM AUTHOR]

Endovascular thrombectomy revolutionized the treatment of acute ischemic stroke. Nevertheless, access to endovascular thrombectomy is limited in many parts of the world. Asia holds 60% of the world's population and its countries carry some of the highest stroke disease burden. To understand the availability of endovascular thrombectomy and intravenous thrombolysis in this region, we interviewed stroke neurologists and neuro-interventionists of 19 Asian countries, and found a large disparity in access to endovascular thrombectomy and intravenous thrombolysis between high- and low-income countries. Lack of neuro-interventionists, comprehensive stroke units, stroke triage systems and high treatment cost are the major obstacles to wider accessibility of endovascular thrombectomy, especially among developing countries. The potential solutions to provide equitable access to stroke revascularization therapy are discussed. [ABSTRACT FROM AUTHOR]

Further characterization with a computed tomography (CT) angiogram confirmed increased vascularity adjacent to the cortex and increased tortuosity of the distal right middle cerebral artery (MCA) branches. 1 Right MCA pure arterial malformation with ipsilateral perisylvian polymicrogyria in a 22-year-old woman with epilepsy. a Anteroposterior projection of a 3D reconstruction of the malformation using CT angiography. This imaging finding suggests that at the time of vessel maturation, a relative difference in blood flow to the MCA distributions existed, with reduced vessel caliber on the side of low flow in order to maintain a preset level of endothelial shear stress [[20]]. Also, at this institution like many others, dedicated vascular imaging is not performed as part of routine seizure imaging, making detection of related vascular abnormalities more difficult. [Extracted from the article]

Background Femoral access is the traditional approach for endovascular carotid artery stenting. Radial access is increasingly used as an alternative approach due to its known anatomical advantages in patients with unfavorable aortic arch morphology via the femoral approach and its excellent access site safety profile. Our objective was to analyze procedural success using radial access for carotid artery stenting as reported in the literature. Methods Three online databases were systematically searched following PRISMA guidelines for studies (n ≥ 20) using radial artery access for carotid artery stenting (1999-2018). Random-effects meta-analysis was used to pool the procedural success (successful stent placement with no requirement for crossover to femoral access), mortality, and complication rates associated with radial access. Results Seven eligible studies reported procedural success outcomes with a pooled meta-analysis rate of 90.8% (657/723; 95% CI 86.7% to 94.2%; I²=53.1%). Asymptomatic radial artery occlusion occurred in 5.9% (95% CI 4.1% to 8.0%; I²=0%) and forearm hematoma in 1.4% (95% CI 0.4% to 2.9%; I²=0%). Risk of minor stroke/transient ischemic attack was 1.9% (95% CI 0.6% to 3.8%; I²=42.3%) and major stroke was 1.0% (95% CI 0.4% to 1.8%; I²=0%). There were three deaths across the seven studies (0.6%; 95% CI 0.2% to 1.3%; I²=0%). The meta-analysis was limited by statistically significant heterogeneity for the primary outcome of procedural success. Conclusion Radial access for carotid artery stenting has a high procedural success rate with low rates of mortality, access site complications, and cerebrovascular complications. The potential benefits of this approach in patients with unfavorable aortic arch access should be explored in a prospective randomized trial. [ABSTRACT FROM AUTHOR]

Background Flow diverters are a breakthrough treatment for large and giant intracranial aneurysms but carry a risk of periprocedural death or major stroke. Pipeline Flex is a second-generation device that is thought to have lower complication rates because of improvements in the delivery system as well as increased operator experience. Our objective was to analyze the risk of periprocedural death or major complications using Pipeline Flex for unruptured intracranial aneurysms. Methods A systematic search of three databases was performed for studies of ≥10 treatments using Pipeline Flex for unruptured intracranial aneurysms (2014-2019) using PRISMA guidelines. Random effects meta-analysis was used to pool the rates of periprocedural (<30 days) death, major ischemic stroke, symptomatic intracranial hemorrhage, and minor stroke/transient ischemic attack. Results We included eight studies reporting 901 treatments in 879 patients. Periprocedural mortality (<30 days) was 0.8% (5/901; 95% CI 0.4% to 1.5%; I²=0%). Rate of major complications (death, major ischemic stroke, or symptomatic intracranial hemorrhage) was 1.8% (14/901; 95% CI 1.0% to 2.7%; I²=0%). Aneurysm size ≥10 mm was a statistically significant predictor of a major complication (OR 6.4; 95% CI 2.0 to 20.7; p=0.002). Risk of a major complication in aneurysms <10 mm was 0.9% (95% CI 0.3% to 1.7%; I²=0%). The meta-analysis was limited by the predominance of anterior circulation aneurysms. Conclusion Treatment of unruptured intracranial aneurysms using the Pipeline Flex flow diverter has a low periprocedural risk of death (0.8%) or major complication (1.8%). The risk of a major complication is significantly higher for large/giant aneurysms (4.4%) and is very low for aneurysms <10 mm (0.9%) [ABSTRACT FROM AUTHOR]

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 and Purpose: Neonatal hypoxic-ischemic injury of the brain and resultant encephalopathy (HIE) leads to major developmental impairments by school age. Conventional/anatomical MRI often fails to detect hippocampal injury in mild cases. We hypothesize that diffusion tensor imaging (DTI) has greater sensitivity for identifying subtle hippocampal injury.Methods: We retrospectively analyzed DTI data collected from a cohort of neonates with HIE and controls. Conventional MRI sequences were classified qualitatively according to severity using a modified Barkovich scale. Using multivariate linear regression, we compared hippocampal DTI scalars of HIE patients and controls. Spearman correlation was used to test the association of DTI scalars in the hippocampal and thalamic regions. A multiple regression analysis tested the association of the DTI scalars with short-term outcomes.Results: Fifty-five neonates with HIE (42% males) and 13 controls (54% males) were included. Hippocampal DTI scalars were similar between HIE and control groups, even when restricting the HIE group to those with moderate-to-severe injury (8 subjects). DTI scalars of the thalamus were significantly lower in the moderate-to-severely affected patients compared to controls (right fractional anisotropy [FA] .148 vs. .182, P = .01; left FA .147 vs. .181, P = .03). Hippocampal and thalamic DTI scalars were correlated (P < .001). Hippocampal DTI scalars were not associated with short-term outcomes.Conclusions: Quantitative DTI analysis of the hippocampus in neonates following HIE is a feasible technique to examine neuronal injury. Although DTI scalars were useful in identifying thalamic injury in our cohort, hippocampal DTI analysis did not provide additional information regarding hippocampal injury following HIE. [ABSTRACT FROM AUTHOR]

Background and Purpose: Hypoxic-ischemic injuries (HIIs) are a scarcely investigated but important cause of morbidity and mortality in children who suffered abusive head trauma (AHT). The purpose of this study is to determine: (a) prevalence, types, and clinical relevance of cytotoxic edema compatible with HII in nonpenetrating AHT, (b) their relationship to other classic neuroimaging findings of AHT, and (c) their correlation with clinical outcomes.Methods: Diffusion-weighted imaging sequences of magnetic resonance imagings performed on children under 5 years diagnosed with AHT were reviewed to detect the most common patterns of acute parenchymal damage. Patterns of cytotoxic edema were described, and HII-compatible ones divided in subtypes. Correlation between HII, fractures, and subdural hemorrhages (SDHs) and with clinical outcomes was determined using imaging and available follow-up data.Results: Out of 57 patients, 36.8% showed lesions compatible with HII. A predominantly asymmetric cortical distribution was observed in 66.7% of cases, while 33.3% had diffused both cortical and deep gray/white matter distribution injury. Traumatic axonal injuries and focal contusions were less common. There was no significant correlation between the presence of SDH (P = .6) or skull fractures (P = .53) and HII. HII was the most severe form of parenchymal damage in terms of in-hospital mortality and morbidity at follow-up.Conclusions: HII is the most common type of parenchymal damage in children victim of AHT, being present in 1/3 of patients with this condition, and correlates with more severe outcomes. Its presence is independent from other classic traumatic findings such as SDH and fractures. [ABSTRACT FROM AUTHOR]

Background Cerebral intraoperative DSA (IODSA) is a well-described, routinely performed procedure that allows the effectiveness of cerebrovascular interventions to be evaluated in the operating room. Spinal IODSA, on the other hand, is infrequently obtained and has received less attention. Objective To discuss the indications, technique, safety, and clinical impact of spinal IODSA. Materials and methods Twenty-three patients underwent 45 thoracic and/or lumbar spinal IODSA between 2005 and 2016, either immediately before surgery for lesion localization or after the intervention to evaluate its effectiveness. Indications included 21 vascular malformations and 2 diaphragmatic crus compression syndromes. A long femoral arterial sheath with its hub positioned on the lateral surface of the thigh was used to allow catheter manipulations in the prone position. Results All targeted intersegmental arteries (ISAs) were successfully catheterized. The course of surgery was changed in 6 instances (26.1%). In 4 cases of epidural or perimedullary arteriovenous fistulae (AVFs), a residual lesion required additional intervention. In one case of epidural AVF, initial IODSA revealed spontaneous resolution of the lesion, preventing unnecessary surgery. Finally, angiography performed in a case of diaphragmatic crus syndrome showed thrombosis of the ISA and non-visualization of the artery of Adamkiewicz. Recanalization was obtained by IA thrombolysis, with excellent clinical outcome. No intraprocedural or postprocedural complication was noted. Conclusions Spinal IODSA is a safe technique that offers an immediate assessment of the effectiveness of a spinovascular surgical procedure, notably epidural and perimedullary AVFs. Spinal IODSA was technically successful in all cases, influencing the surgical strategy in 6 of 23 patients, including one patient who benefited from intraoperative endovascular therapy. [ABSTRACT FROM AUTHOR]

Sacral dural arteriovenous fistulas (SDAVFs) are rare, constituting no more than 10% of all spinal dural fistulas. They are most commonly fed by the lateral sacral artery (LSA), a branch of the internal iliac artery (IIA). Catheterization of this vessel requires either a crossover at the aortic bifurcation in cases of right femoral access or retrograde catheterization from the ipsilateral common femoral artery. We present the case of a 79-year-old man with tethered cord syndrome and a symptomatic SDAVF fed by two feeders from the left LSA. Spinal diagnostic angiography was made exceptionally challenging by an aorto-bi-iliac endograft, and selective catheterization of the left IIA was not possible. The patient could not undergo surgery due to multiple comorbidities, therefore embolization was considered the best approach. The procedure was carried out through a transradial access (TRA) with Onyx and n-butyl cyanoacrylate. The SDAVF was successfully treated and the patient made a full neurological recovery. [ABSTRACT FROM AUTHOR]

Sacral dural arteriovenous fistulas (SDAVFs) are rare, constituting no more than 10% of all spinal dural fistulas. They are most commonly fed by the lateral sacral artery (LSA), a branch of the internal iliac artery (IIA). Catheterization of this vessel requires either a crossover at the aortic bifurcation in cases of right femoral access or retrograde catheterization from the ipsilateral common femoral artery. We present the case of a 79-year-old man with tethered cord syndrome and a symptomatic SDAVF fed by two feeders from the left LSA. Spinal diagnostic angiography was made exceptionally challenging by an aorto-bi-iliac endograft, and selective catheterization of the left IIA was not possible. The patient could not undergo surgery due to multiple comorbidities, therefore embolization was considered the best approach. The procedure was carried out through a transradial access (TRA) with Onyx and n-butyl cyanoacrylate. The SDAVF was successfully treated and the patient made a full neurological recovery. [ABSTRACT FROM AUTHOR]

Purpose: To assess the rate of jugular vein (JV) invasion by paragangliomas and imaging's ability to predict invasion. Methods: Imaging studies of patients with paragangliomas were evaluated for JV invasion. Rates of invasion by different paragangliomas and each modality's accuracy were determined. Results: JV invasion occurred in 11/11 glomus jugulares (GJs), 3/5 glomus vagales, and 2/8 carotid body tumors. Accuracy for magnetic resonance imaging (92.3%), computed tomography (92.3%), and digital subtraction angiography (94.1%) was comparable. Conclusions: JV invasion is characteristic of but not specific to GJs. All modalities show high accuracy in detecting invasion. [ABSTRACT FROM AUTHOR]

We present the case of a 15-year-old girl with a left T7 spinal epidural arteriovenous fistula (SEAVF), in whom bilateral and symmetric isolated T9 dorsospinal arteries (DAs) were incidentally documented, each providing a significant contribution to the anterior spinal artery. Recognizing the existence of isolated DAs of direct aortic origin is critical, both for the diagnostic evaluation and for the management of spinal vascular diseases. Notably, isolated DAs tend to branch off significant radiculomedullary arteries, which vascularize the normal spinal cord but have also been shown to supply spinal vascular malformations. [ABSTRACT FROM AUTHOR]

Purpose The aim of this study was to determine the level of support for the proposal to restrict ACGME-accredited fellowships to candidates who completed residencies accredited by the ACGME or the Royal College of Physicians and Surgeons of Canada. Perceptions of foreign-trained international medical graduates during and after fellowships were also assessed.Methods An e-mail survey was sent to the members of the organizations that represent academic chairpersons (the Society of Chairs of Academic Radiology Departments) and radiology residency and fellowship program directors (the Association of Program Directors in Radiology) and to the program directors of the largest American radiology subspecialty society (the American Society of Neuroradiology). Results were analyzed separately for each of the 3 societies interviewed and then as a composite report for all 3 societies.Results Approximately 60% of the respondents said that they have offered at least one fellowship or faculty position to foreign-trained applicants in the past 5 years. More than 70% of the respondents said that these doctors performed equally to or better than American-trained ones both clinically and academically. The majority of members of all 3 societies responding opposed enactment of the rule, with the American Society of Neuroradiology being the most disapproving. The main concerns of those supporting the new rule were the inhomogeneous and sometimes unknown levels of training of the foreign-trained doctors and the need to favor American graduates. Those opposed were mostly worried about diminishing the quality of fellowship candidates, programs being unable to fill their positions, and a decrease in academic-oriented people.Conclusions Most respondents opposed the proposed rule. The majority were supportive of foreign-trained physicians continuing their training in the United States. [ABSTRACT FROM AUTHOR]

A 52-year-old man with a history of factor V Leiden thrombophilia, persistent headaches and papilloedema presented with worsening vision and confusion. MRI and MR angiography of the brain at the time of this presentation showed findings concerning for transverse sinus thrombosis and an associated dural arteriovenous fistula. Dural venous sinus thrombosis can lead to the formation of a dural arteriovenous fistula, which must be considered in the differential diagnosis for intracranial hypertension in patients with thrombophilia. [ABSTRACT FROM AUTHOR]

A duplicated middle cerebral artery (dMCA) is a rare anatomical variant that can be associated with aneurysm formation and rupture. The dMCA arises from the terminal portion of the internal carotid artery, with the caudal trunk supplying the temporal lobe and the cranial trunk supplying the frontal lobe and the lenticulostriate perforators. Previous reported cases were all treated with open surgical clipping with or without cerebral revascularization to reconstruct the dMCA. We present a rare case of a young woman with a ruptured dMCA (subtype B) aneurysm. We have demonstrated the unique anatomical relationship among the dMCA, internal carotid artery, and the anterior choroidal artery. Understanding and preserving the dMCA anatomy is essential in such cases to prevent ischemic complications. This was achieved endovascularly by balloon remodeling and coil embolization of the aneurysm in this location. Highlights • A duplicated middle cerebral artery is a rare anatomical variant and can be associated with aneurysm formation and rupture. • The caudal duplicated MCA typically supplies the temporal lobe without contribution to perforating arteries. • Endovascular therapy with balloon remodeling and coil embolization is feasible to treat a ruptured duplicated MCA aneurysm. [ABSTRACT FROM AUTHOR]