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Collateral circulation is associated with improved functional outcome in patients with large vessel occlusion acute ischemic stroke (AIS) who undergo reperfusion therapy. Assessment of collateral flow can be time consuming, subjective, and difficult because of complex neurovasculature. This study assessed the ability of multiple artificial intelligence algorithms in determining collateral flow of patients with AIS.Two hundred patients with AIS between March 2019 and January 2020 were included in this retrospective study. Peak arterial computed tomography perfusion volumes were used to assess collateral scores. Neural networks were developed for dichotomized (≥50% or50%) and multiclass (0% filling, 0%-50% filling, 50%-100% filling, or 100% filling) collateral scoring. Maximum intensity projections from axial and anteroposterior (AP) views were synthesized for each bone subtracted three-dimensional volume and used as network inputs separately and together, along with three-dimensional data. Training:testing:validation splits of 60:30:10 and 20 iterations of Monte Carlo cross-validation were used. Network performance was assessed using 95% confidence intervals of accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).The axial and AP input combination provided the most accurate results for dichotomized classification: accuracy, 0.85 ± 0.01; sensitivity, 0.88 ± 0.02; specificity, 0.82 ± 0.03; PPV, 0.86 ± 0.02; and NPV, 0.83 ± 0.03. Similarly, the axial and AP input combination provided the best results for multiclass classification: accuracy, 0.80 ± 0.01; sensitivity, 0.64 ± 0.01; specificity, 0.85 ± 0.01; PPV, 0.65 ± 0.02; and NPV, 0.85 ± 0.01.This study reports one of the first artificial intelligence-based algorithms capable of accurately and efficiently assessing collateral flow of patients with AIS. This automated method for determining collateral filling could streamline clinical workflow, reduce bias, and aid in clinical decision making for determining reperfusion-eligible patients.

Background The ability of the patient specific 3D printed neurovascular phantoms to accurately replicate the anatomy and hemodynamics of the chronic neurovascular diseases has been demonstrated by many studies. Acute occurrences, however, may still require further development and investigation and therefore we studied acute ischemic stroke (AIS). The efficacy of endovascular procedures such as mechanical thrombectomy (MT) for the treatment of large vessel occlusion (LVO), can be improved by testing the performance of thrombectomy devices and techniques using patient specific 3D printed neurovascular models. Methods 3D printed phantoms were connected to a flow loop with physiologically relevant flow conditions, including input flow rate and fluid temperature. A simulated blood clot was introduced into the model and placed in the proximal Middle Cerebral Artery (MCA) region. Clot location, composition, length, and arterial angulation were varied and MTs were simulated using stent retrievers. Device placement relative to the clot and the outcome of the thrombectomy were recorded for each situation. Digital subtraction angiograms (DSA) were captured before and after LVO simulation. Recanalization outcome was evaluated using DSA as either ‘no recanalization’ or ‘recanalization’. Forty-two 3DP neurovascular phantom benchtop experiments were performed. Results Clot angulation within the MCA region had the most significant impact on the MT outcome, with a p-value of 0.016. Other factors such as clot location, clot composition, and clot length correlated weakly with the MT outcome. Conclusions This project allowed us to gain knowledge of how such characteristics influence thrombectomy success and can be used in making clinical decisions when planning the procedure and selecting specific thrombectomy tools and approaches.

Background The use of balloon guide catheters (BGCs) for proximal flow arrest during neurointerventional procedures has been limited owing to the incompatibility of BGCs with large-bore aspiration catheters and difficulty in device navigation. The objective of our study was to describe the use of the Walrus catheter (Q'Apel Medical, Fremont, California, USA), a new 8F BGC, with a variety of aspiration catheters and procedures requiring flow arrest. Methods Consecutive cases using Walrus BGCs for proximal flow arrest during mechanical thrombectomy for acute stroke cases were recorded. The procedure indication, vessel occlusion site, technique, first-pass effect (modified thrombolysis in cerebral infarction score of 2C or 3 after the first recanalization attempt), and complications were recorded and evaluated statistically. Results Our study included 57 patients who had undergone mechanical thrombectomy. In addition to mechanical thrombectomy, the Walrus BGC was used in conjunction with the following techniques: stent retrieval in 2 patients (3.5%), stent retrieval followed by aspiration (Solumbra technique) in 41 (71.9%), and aspiration followed by stent retrieval in 14 patients (24.6%). Eight different aspiration catheters were used in 56 of these 57 procedures. The first-pass effect (modified thrombolysis in cerebral infarction score of 2C and 3) was achieved in 36 (63.2%) of 57 procedures. Two patients (3.5%) had experienced intraoperative complications (symptomatic intracerebral hemorrhage) and one patient (1.8%) had died in-hospital. Conclusions Our results have demonstrated that the Walrus BGC is a highly navigable 8F guide catheter compatible with most available aspiration catheters. Owing to its compatibility with most available aspiration catheters and ease of use, the Walrus BGC is a valuable addition to the tools available for mechanical thrombectomy.

BackgroundThe perception of a steep learning curve associated with transradial access has resulted in its limited adoption in neurointervention despite the demonstrated benefits, including decreased access-site complications.ObjectiveTo compare learning curves of transradial versus transfemoral diagnostic cerebral angiograms obtained by five neurovascular fellows as primary operator.MethodsThe first 100–150 consecutive transradial and transfemoral angiographic scans performed by each fellow between July 2017 and March 2020 were identified. Mean fluoroscopy time per artery injected (angiographic efficiency) was calculated as a marker of technical proficiency and compared for every 25 consecutive procedures performed (eg, 1–25, 26–50, 51–75).ResultsWe identified 1242 diagnostic angiograms, 607 transradial and 635 transfemoral. The radial cohort was older (64.3 years vs 62.3 years, p=0.01) and demonstrated better angiographic efficiency (3.4 min/vessel vs 3.7 min/vessel, p=0.03). For three fellows without previous endovascular experience, proficiency was obtained between 25 and 50 transfemoral angiograms. One fellow achieved proficiency after performing 25–50 transradial angiograms; and the two other fellows, in ConclusionTechnical proficiency improved significantly over time for both access types, typically requiring between 25 and 50 diagnostic angiograms to achieve asymptomatic improvement in efficiency. Reduced access-site complications and decreased fluoroscopy time were benefits associated with transradial angiography.

Background Immediate and accurate detection of intracranial hemorrhages (ICHs) is essential to provide a good clinical outcome for patients with ICH. Artificial intelligence has the potential to provide this, but the assessment of these methods needs to be investigated in depth. This study aimed to assess the ability of Canon's AUTOStroke Solution ICH detection algorithm to accurately identify patients both with and without ICHs present. Methods Data from 200 ICH and 102 non-ICH patients who presented with stroke-like symptoms between August 2016 and December 2019 were collected retrospectively. Patients with ICH had at least one of the following hemorrhage types: intraparenchymal (n = 181), intraventricular (n = 45), subdural (n = 13), or subarachnoid (n = 19). Noncontrast computed tomography scans were analyzed for each patient using Canon's AUTOStroke Solution ICH algorithm to determine which slices contained hemorrhage. The algorithm's ability to detect ICHs was assessed using sensitivity, specificity, positive predictive value, and negative predictive value. Percentages of cases correctly identified as ICH positive and negative were additionally calculated. Results Automated analysis demonstrated the following metrics for identifying hemorrhage slices within all 200 patients with ICH (95% confidence intervals): sensitivity = 0.93 ± 0.03, specificity = 0.93 ± 0.01, positive predictive value = 0.85 ± 0.02, and negative predictive value = 0.98 ± 0.01. A total of 95% (245 of 258) of ICH volumes were correctly triaged, whereas 88.2% (90 of 102) of non-ICH cases were correctly classified as ICH negative. Conclusions Canon's AUTOStroke Solution ICH detection algorithm was able to accurately detect intraparenchymal, intraventricular, subdural, and subarachnoid hemorrhages in addition to accurately determine when an ICH was not present. Having this automated ICH detection method could drastically improve treatment times for patients with ICH.

Background The value of clot imaging in patients with emergent large vessel occlusion (ELVO) treated with thrombectomy is unknown. Methods We performed retrospective analysis of clot imaging (clot density, perviousness, length, diameter, distance to the internal carotid artery (ICA) terminus and angle of interaction (AOI) between clot and the aspiration catheter) of consecutive cases of middle cerebral artery (MCA) occlusion and its association with first pass effect (FPE, TICI 2c-3 after a first attempt). Results Patients ( n = 90 total) with FPE had shorter clot length (9.9 ± 4.5 mm vs. 11.7 ± 4.6 mm, P = 0.07), shorter distance from ICA terminus (11.0 ± 7.1 mm vs. 14.7 ± 9.8 mm, P = 0.048), higher perviousness (39.39 ± 29.5 vs 25.43 ± 17.6, P = 0.006) and larger AOI (153.6 ± 17.6 vs 140.3 ± 23.5, P = 0.004) compared to no-FPE patients. In multivariate analysis, distance from ICA terminus to clot ≤13.5 mm (odds ratio (OR) 11.05, 95% confidence interval (CI) 2.65–46.15, P = 0.001), clot length ≤9.9 mm (OR 7.34; 95% CI 1.8–29.96, P = 0.005), perviousness ≥ 19.9 (OR 2.54, 95% CI 0.84–7.6, P = 0.09) and AOI ≥ 137°^ (OR 6.8, 95% CI 1.55–29.8, P = 0.011) were independent predictors of FPE. The optimal cut off derived using Youden’s index was 6.5. The area under the curve of a score predictive of FPE success was 0.816 (0.728–0.904, P Conclusions Clot imaging predicts the likelihood of achieving FPE in patients with MCA ELVO treated with the aspiration-first approach.

Background Coiling of wide-necked aneurysms requires high-density packing of coils within the aneurysm, which necessitates adequate microcatheter access and navigability. The Comaneci device, introduced in the United States in 2019, is a retrievable stent that can be used as an adjunct to coiling of a wide-necked aneurysm without limiting flow. We present a case series and systematic review of use of this device. Methods All cases involving use of the device at our institute between May 1, 2019, and April 30, 2020, were reviewed. A comprehensive systematic review of the literature was conducted using PubMed and EMBASE and a review of eligible article bibliographies. Results Five patients underwent Comaneci-assisted wide-necked aneurysm coiling during the study period; 4 were treated via a radial artery approach, and 1 was treated via a femoral artery approach. Two patients presented with subarachnoid hemorrhage: 1 had a ruptured posterior inferior cerebellar artery aneurysm (Hunt-Hess 5, Fisher 4), and 1 had a ruptured middle cerebral artery aneurysm (Hunt-Hess 2, Fisher 1). Mean aneurysmal neck size was 4.4 ± 0.8mm; mean aspect ratio was 1.2 ± 0.3. Raymond-Roy 1 occlusion was achieved in all aneurysms except the posterior inferior cerebellar artery aneurysm. Systematic literature review identified 4 articles that found use of the Comaneci device to treat wide-necked aneurysms to be effective. Conclusions This device can be used with transfemoral and transradial approaches, allowing for continued flow through the parent vessel during the coiling procedure while providing a scaffold for dense coiling of the aneurysm and its neck.

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P P P P P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

Background and Purpose: The Tigertriever is a novel, radially adjustable, fully visible, stentriever that permits the operator to align radial expansion with target vessel diameters. This multicenter trial compared the Tigertriever’s effectiveness and safety compared with established stent retrievers. Methods: Single arm, prospective, multicenter trial comparing the Tigertriever to efficacy and safety performance goals derived from outcomes in 6 recent pivotal studies evaluating the Solitaire and Trevo stent-retriever devices with a lead-in and a main-study phase. Patients were enrolled if they had acute ischemic stroke with National Institutes of Health Stroke Scale score ≥8 due to large vessel occlusion within 8 hours of onset. The primary efficacy end point was successful reperfusion, defined as core laboratory-adjudicated modified Thrombolysis in Cerebral Ischemia score 2b-3 within 3 passes of the Tigertriever. The primary safety end point was a composite of 90-day all-cause mortality and symptomatic intracranial hemorrhage. Secondary efficacy end points included 3-month good clinical outcome (modified Rankin Scale score 0–2) and first-pass successful reperfusion. Results: Between May 2018 and March 2020, 160 patients (43 lead-in, 117 main phase) at 17 centers were enrolled and treated with the Tigertriever. The primary efficacy end point was achieved in 84.6% in the main-study phase group compared with the 63.4% performance goal and the 73.4% historical rate (noninferiority P P P =0.004; superiority P =0.57). Good clinical outcome was achieved in 58% at 90 days. Conclusions: The Tigertriever device was shown to be highly effective and safe compared with Trevo and Solitaire devices to remove thrombus in patients with large-vessel occlusive stroke eligible for mechanical thrombectomy. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03474549.

Rapid and accurate diagnosis of large vessel occlusions (LVOs) in acute ischemic stroke (AIS) patients using automated software could improve clinical workflow in determining thrombectomy in eligible patients. Artificial intelligence-based methods could accomplish this; however, their performance in various clinical scenarios, relative to clinical experts, must be thoroughly investigated. We aimed to assess the ability of Canon’s AUTOStroke Solution LVO application in properly detecting and locating LVOs in AIS patients. Data from 202 LVO and 101 non-LVO AIS patients who presented with stroke-like symptoms between March 2019 and February 2020 were collected retrospectively. LVO patients had either an internal carotid artery (ICA) ( n = 59), M1 middle cerebral artery (MCA) ( n = 82) or M2 MCA ( n = 61) occlusion. Computed tomography angiography (CTA) scans from each patient were pushed to the automation platform and analyzed. The algorithm’s ability to detect LVOs was assessed using accuracy, sensitivity and Matthews correlation coefficients (MCCs) for each occlusion type. The following results were calculated for each occlusion type in the study (accuracy, sensitivity, MCC): ICA = (0.95, 0.90, 0.89), M1 MCA = (0.89, 0.77, 0.78) and M2 MCA = (0.80, 0.51, 0.59). For the non-LVO cohort, 98% (99/101) of cases were correctly predicted as LVO negative. Processing time for each case was 69.8 ± 1.1 seconds (95% confidence interval). Canon’s AUTOStroke Solution LVO application was able to accurately identify ICA and M1 MCA occlusions in addition to almost perfectly assessing when an LVO was not present. M2 MCA occlusion detection needs further improvement based on the sensitivity results displayed by the LVO detection algorithm.

BackgroundRadial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates.MethodsAn international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature.ResultsOne hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%).ConclusionsUETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.

BackgroundThere are no reports that describe complete flow control using concurrent transient rapid ventricular pacing or intravenous (IV) adenosine and afferent arterial balloon flow arrest to aid transvenous embolization of cerebral arteriovenous malformations (AVM). We describe our experience with the use of this technique in patients undergoing transvenous AVM embolization.MethodsConsecutive patients in whom transvenous embolization was attempted at our institute between January 2017 and July 2019 were included. Anatomical AVM features, number of embolization stages, technique of concurrent transient rapid ventricular pacing and afferent arterial balloon flow arrest, complications, and clinical and radiological outcomes were recorded and tabulated.ResultsTransvenous AVM embolization was attempted in 12 patients but abandoned in two patients for technical reasons. Complete embolization was achieved in 10 patients, five of whom had infratentorial AVMs. All 10 had a single primary draining vein. Rapid ventricular pacing was used in nine cases; IV adenosine injection was used in one case to achieve cardiac standstill. Complete AVM nidus obliteration was achieved with excellent neurologic outcome in nine cases, with transvenous embolization alone in two cases, and with staged transarterial followed by transvenous embolization in the others. Two patients developed hemorrhagic complications intraprocedurally. One patient was managed conservatively and the other operatively with AVM excision and hematoma evacuation; both made an excellent recovery without any neurologic deficits at 3 months.ConclusionComplete flow control using concurrent transient rapid ventricular pacing with afferent arterial balloon flow arrest technique is safe and feasible for transvenous embolization of select AVMs.

Computed tomography perfusion (CTP) is crucial for acute ischemic stroke (AIS) patient diagnosis. To improve infarct prediction, enhanced image processing and automated parameter selection have been implemented in Vital Images’ new CTP+ software. We compared CTP+ with its previous version, commercially available software (RAPID and Sphere), and follow-up diffusion-weighted imaging (DWI). Data from 191 AIS patients between March 2019 and January 2020 was retrospectively collected and allocated into endovascular intervention ( n = 81) and conservative treatment ( n = 110) cohorts. Intervention patients were treated for large vessel occlusion, underwent mechanical thrombectomy, and achieved successful reperfusion of thrombolysis in cerebral infarction 2b/2c/3. Conservative treatment patients suffered large or small vessel occlusion and did not receive intravenous thrombolysis or mechanical thrombectomy. Infarct and penumbra were assessed using intervention and conservative treatment patients, respectively. Infarct and penumbra volumes were segmented from CTP+ and compared with 24-h DWI along with RAPID, Sphere, and Vitrea. Mean infarct differences (95% confidence intervals) and Spearman correlation coefficients (SCCs) between DWI and each CTP software product for intervention patients are: CTP+ = (5.8 ± 5.9 ml, 0.62), RAPID = (10.0 ± 5.2 ml, 0.73), Sphere = (3.0 ± 6.0 ml, 0.56), Vitrea = (7.2 ± 4.9 ml, 0.66). For conservative treatment patients, mean infarct differences and SCCs are: CTP+ = (–8.0 ± 5.4 ml, 0.64), RAPID = (–25.6 ± 11.5 ml, 0.60), Sphere = (–25.6 ± 8.0 ml, 0.66), Vitrea = (1.3 ± 4.0 ml, 0.72). CTP+ performed similarly to RAPID and Sphere in addition to its semi-automated predecessor, Vitrea, when assessing intervention patient infarct volumes. For conservative treatment patients, CTP+ outperformed RAPID and Sphere in assessing penumbra. Semi-automated Vitrea remains the most accurate in assessing penumbra, but CTP+ provides an improved workflow from its predecessor.

BACKGROUND AND PURPOSE: Clot perviousness in acute ischemic stroke is a potential CT imaging biomarker for mechanical thrombectomy efficacy. We investigated the association among perviousness, clot cellular composition, and first-pass effect. MATERIALS AND METHODS: In 40 mechanical thrombectomy–treated cases of acute ischemic stroke, we calculated perviousness as the difference in clot density on CT angiography and noncontrast CT. We assessed the proportion of fibrin/platelet aggregates, red blood cells, and white blood cells on clot histopathology. We tested for linear correlation between histologic components and perviousness, differences in components between “high” and “low” pervious clots defined by median perviousness, and differences in perviousness/composition between cases that did and did not achieve a first-pass effect. RESULTS: Perviousness significantly positively and negatively correlated with the percentage of fibrin/platelet aggregates (P = .001) and the percentage of red blood cells (P = .001), respectively. Higher pervious clots had significantly greater fibrin/platelet aggregate content (P = .042). Cases that achieved a first-pass effect (n = 14) had lower perviousness, though not significantly (P = .055). The percentage of red blood cells was significantly higher (P = .028) and the percentage of fibrin/platelet aggregates was significantly lower (P = .016) in cases with a first-pass effect. There was no association between clot density on NCCT and clot composition or first-pass effect. Receiver operating characteristic analysis indicated that clot composition was the best predictor of first-pass effect (area under receiver operating characteristic curve: percentage of fibrin/platelet aggregates = 0.731, percentage of red blood cells = 0.706, perviousness = 0.668). CONCLUSIONS: Clot perviousness on CT is associated with a higher percentage of fibrin/platelet aggregate content. Histologic data and, to a lesser degree, perviousness may have value in predicting first-pass outcome. Imaging metrics that more strongly reflect clot biology than perviousness may be needed to predict a first-pass effect with high accuracy.

Background Trends in mechanical thrombectomy have emphasized larger bore aspiration catheters that may be difficult to deploy from a radial access point due to size constraints or need to obtain sheathless access. As such, many neurointerventionists are reticent to attempt thrombectomy through transradial access (TRA) for fear of worse outcomes. Objective To explore whether mechanical thrombectomy could be achieved safely and effectively through the transradial route. Methods We retrospectively analyzed the records of patients undergoing mechanical thrombectomy at our academic institute between January 2018 and January 2019, which corresponded to a time when we began to transition to TRA for neurointerventions, including mechanical thrombectomy. We compared the procedural details and clinical outcomes of patients undergoing mechanical thrombectomy using TRA with those using transfemoral access (TFA). Results During the study period, 44 patients underwent mechanical thrombectomy with TRA and 129 with TFA. There was no statistically significant difference in door-to-access time, door-to-reperfusion time, or first-pass recanalization rate. There was no significant difference in modified Rankin Scale (mRS) score at discharge, mRS score at last follow-up, or length of stay. There were 7 access-site complications in the TFA group and none in the TRA group. One patient in the TRA group required crossover to TFA. Conclusion Mechanical thrombectomy can be performed safely and effectively from a TRA site without compromising recanalization times or rates. TRA has superior access-site complication profiles compared to TFA.

BackgroundRadial access has become popular among neurointerventionalists because it has favorable risk profiles compared with femoral access. Difficulties in accessing or navigating the radial artery have been viewed as a reason to convert to femoral access, but ulnar artery access may prevent complications associated with transfemoral procedures.ObjectiveTo evaluate the safety and feasibility of ulnar access for neurointerventions and diagnostic neuroangiographic procedures.MethodsConsecutive patients who underwent diagnostic angiography or neurointerventional procedures via ulnar access between July 1, 2019 and April 15, 2020 were included. Data recorded were demographics, procedure indication, devices, technique, and complications. Descriptive analysis was performed.ResultsUlnar artery access was obtained for 21 procedures in 18 patients (mean age 70.3±7.8 years; nine men). Procedures included 13 diagnostic angiograms and eight neurointerventions (3 left middle meningeal artery embolization, 1 of which was aborted; 2 carotid artery stenting; 2 angioplasty; 1 mechanical thrombectomy for in-stent thrombosis). A right-sided approach with ultrasound guidance was used for all cases except one. Indications included small caliber radial artery (n=9), radial artery occlusion (n=10), and radial artery preservation for potential bypass (n=2). A 5-French slender sheath was used for diagnostic angiography; a 6-French slender sheath was used for neurointerventions. No case required conversion to femoral access. Two patients had minor hematomas after the procedure; one other had ulnar artery occlusion on 30-day ultrasonography.ConclusionUlnar access is safe and feasible for diagnostic and interventional neuroangiographic procedures. It provides a useful alternative to radial access, potentially avoiding complications associated with femoral access.

BackgroundPatients with cerebral aneurysms treated with the Pipeline embolization device (PED) are maintained on dual antiplatelet therapy (DAPT) to prevent thromboembolic complications. Rates of minor, “nuisance” bleeding in these patients remain unknown. We sought to evaluate the frequency and factors associated with this bleeding and its effect on DAPT compliance.MethodsWe performed a multicenter retrospective cohort study on consecutive cases of intracranial aneurysms treated with PED. Patient characteristics, aneurysm characteristics, and bleeding complications were analyzed. Severity of bleeding was defined according to a previously published classification defining nuisance bleeding as easy bruising, bleeding from small cuts, petechia, and ecchymosis.Results245 PED aneurysm procedures on 243 patients were retrospectively collected from three academic centers over a 4.25-year period. Sixty-seven patients (27%) had nuisance bleeds. Patients with a higher risk of nuisance bleeding were older (59.1±3.4 vs . 54.7±2.2, P=0.032). Patients with nuisance bleeds were more likely to have their DAPT regimen changed or dose lowered (29% vs 8.3%, PConclusionsNuisance bleeding was a common complaint of PED-treated aneurysm patients maintained on DAPT. Increasing age and aneurysmal occlusion at 6 months were the only factors predictive of nuisance bleeds. Clinicians were more likely to adjust antiplatelet regimens or stop DAPT early given a nuisance bleed.

In acute ischemic stroke (AIS) patients, eligibility for endovascular intervention is commonly determined through computed tomography perfusion (CTP) analysis by quantifying ischemic tissue using perfusion parameter thresholds. However, thresholds are not uniform across all analysis methods due to dependencies on patient demographics and computational algorithms. This study aimed to investigate optimal perfusion thresholds for quantifying infarct and penumbra volumes using two post-processing CTP algorithms: Vitrea Bayesian and singular value decomposition plus (SVD+). We utilized 107 AIS patients (67 non-intervention patients and 40 successful reperfusion of thrombolysis in cerebral infarction (2b/3) patients). Infarct volumes were predicted for both post-processing algorithms through contralateral hemisphere comparisons using absolute time-to-peak (TTP) and relative regional cerebral blood volume (rCBV) thresholds ranging from +2.8 seconds to +9.3 seconds and –0.23 to –0.56 respectively. Optimal thresholds were determined by minimizing differences between predicted CTP and 24-hour fluid-attenuation inversion recovery magnetic resonance imaging infarct. Optimal thresholds were tested on 60 validation patients (30 intervention and 30 non-intervention) and compared using RAPID CTP software. Among the 67 non-intervention and 40 intervention patients, the following optimal thresholds were determined: intervention Bayesian: TTP = +4.8 seconds, rCBV = –0.29; intervention SVD+: TTP = +5.8 seconds, rCBV = –0.29; non-intervention Bayesian: TTP = +5.3 seconds, rCBV = –0.32; non-intervention SVD+: TTP = +6.3 seconds, rCBV = –0.26. When comparing SVD+ and Bayesian post-processing algorithms, optimal thresholds for TTP were significantly different for intervention and non-intervention patients. rCBV optimal thresholds were equal for intervention patients and significantly different for non-intervention patients. Comparison with commercially utilized software indicated similar performance.

BackgroundCT perfusion (CTP) infarct and penumbra estimations determine the eligibility of patients with acute ischemic stroke (AIS) for endovascular intervention. This study aimed to determine volumetric and spatial agreement of predicted RAPID, Vitrea, and Sphere CTP infarct with follow-up fluid attenuation inversion recovery (FLAIR) MRI infarct.Methods108 consecutive patients with AIS and large vessel occlusion were included in the study between April 2019 and January 2020 . Patients were divided into two groups: endovascular intervention (n=58) and conservative treatment (n=50). Intervention patients were treated with mechanical thrombectomy and achieved successful reperfusion (Thrombolysis in Cerebral Infarction 2b/2 c/3) while patients in the conservative treatment group did not receive mechanical thrombectomy or intravenous thrombolysis. Intervention and conservative treatment patients were included to assess infarct and penumbra estimations, respectively. It was assumed that in all patients treated conservatively, penumbra converted to infarct. CTP infarct and penumbra volumes were segmented from RAPID, Vitrea, and Sphere to assess volumetric and spatial agreement with follow-up FLAIR MRI.ResultsMean infarct differences (95% CIs) between each CTP software and FLAIR MRI for each cohort were: intervention cohort: RAPID=9.0±7.7 mL, Sphere=−0.2±8.7 mL, Vitrea=−7.9±8.9 mL; conservative treatment cohort: RAPID=−31.9±21.6 mL, Sphere=−26.8±17.4 mL, Vitrea=−15.3±13.7 mL. Overlap and Dice coefficients for predicted infarct were (overlap, Dice): intervention cohort: RAPID=(0.57, 0.44), Sphere=(0.68, 0.60), Vitrea=(0.70, 0.60); conservative treatment cohort: RAPID=(0.71, 0.56), Sphere=(0.73, 0.60), Vitrea=(0.72, 0.64).ConclusionsSphere proved the most accurate in patients who had intervention infarct assessment as Vitrea and RAPID overestimated and underestimated infarct, respectively. Vitrea proved the most accurate in penumbra assessment for patients treated conservatively although all software overestimated penumbra.

There is wide variation in the reported size of ruptured intracranial aneurysms and methods of size estimation. There is widespread belief that small aneurysms

Background Modern science and healthcare generate vast amounts of data, and, coupled with the increasingly inexpensive and accessible computing, a tremendous opportunity exists to use these data to improve care. A better understanding of data science and its relationship to neurosurgical practice will be increasingly important as we transition into this modern “big data” era. Methods A review of the literature was performed for key articles referencing big data for neurosurgical care or related topics. Results In the present report, we first defined the nature and scope of data science from a technical perspective. We then discussed its relationship to the modern neurosurgical practice, highlighting key references, which might form a useful introductory reading list. Conclusions Numerous challenges exist going forward; however, organized neurosurgery has an important role in fostering and facilitating these efforts to merge data science with neurosurgical practice.

BackgroundRecurrence of intracranial aneurysms after endovascular coiling is a serious clinical concern.ObjectiveWe hypothesized that recurrence is associated with aneurysm morphology and flow, as well as the coil intervention and the induced flow modifications.MethodsWe collected 52 primary-coiling aneurysm cases that were either occluded (n=34) or recurrent (n=18) at >1 year follow-up. We created aneurysm models from pre-coiling digital subtraction angiographic images, calculated aneurysm morphology, simulated pre-coiling hemodynamics, modeled coil deployment, and obtained post-coiling hemodynamics for each case. We performed univariable analysis on 26 morphologic, treatment-specific, and hemodynamic parameters to distinguish between recurrent and occluded groups, and multivariable analysis to identify independently significant parameters associated with recurrence. Univariable analysis was also performed on ruptured and unruptured aneurysm subcohorts separately to investigate if they shared specific significant parameters.ResultsRecurrence was associated with pre-coiling aneurysm morphologic and flow parameters including larger size (maximum dimension and volume), larger neck (diameter, area, and neck-to-parent-artery ratio), and higher flow momentum and kinetic energy. Recurrence was also associated with lower coil packing (packing density and uncoiled volume), higher post-treatment flow (velocity, momentum, and kinetic energy), lower post-treatment washout time, and higher post-treatment impingement force at the neck. Multivariable analysis identified two aneurysmal characteristics (neck diameter and pre-coiling flow kinetic energy), one coil packing parameter (uncoiled volume), and one post-treatment hemodynamic parameter (flow momentum) that were independently associated with recurrence. In ruptured aneurysms, recurrence was associated with larger neck (diameter and area), whereas in unruptured aneurysms, recurrence was associated with larger size (maximum dimension and volume). In both subcohorts, recurrence was associated with higher post-coiling flow momentum and kinetic energy.ConclusionRecurrence at >1 year after coil treatment is associated with intrinsic aneurysm characteristics, coiling itself, and flow changes induced by coiling. Larger aneurysm size and neck, less coil packing, and higher intra-aneurysmal flow before and after coiling predict recurrence.

Background Controversy exists regarding the optimum number of flow diverters for the treatment of intracranial aneurysms. We explored the effect of the number of Pipeline embolization devices (PEDs; Medtronic, Dublin, Ireland) deployed on rates of aneurysm occlusion and complications. Methods Consecutive patients who underwent saccular intracranial aneurysm treatment solely with the PED were included in this retrospective study. Computed tomographic, magnetic resonance, or digital subtraction angiographic images at 6 and 12 months and last follow-up (>12 months) were reviewed for aneurysm occlusion. Complication and retreatment rates were recorded and analyzed statistically. Results The study included 141 aneurysm treatments in 119 patients. A single PED was deployed in 105 cases, two PEDs in 31 cases, and three PEDs in 5 cases (total = 182 devices). Six-month angiographic data were available for 103 patients. Occlusion rates were 67.1% for single-PED cases and 90.0% for cases with > 1 PED (p = 0.028). The 12-month occlusion rate (follow-up available for 132) for single-PED cases was 74.7% compared to 91.7% for multiple-PED cases (p = 0.04). On multivariate analysis, number of PEDs was an independent predictor of aneurysm occlusion at 12 months (odds ratio 6.3, 95% confidence interval 1.8–22.8, p = 0.005). Thromboembolic complication rates were the same in the single- and multiple-PED treatment groups (2.8%). The retreatment rate was higher in patients treated with a single PED (16.2% vs. 0%, p = 0.01). Conclusions Deployment of > 1 Pipeline embolization device was associated with higher intracranial aneurysm occlusion and lower retreatment rates. No significant difference was found in complication rates.

Various studies have suggested that age ≥80 years is associated with a higher rate of complications after carotid artery stenting (CAS). The Buffalo Risk Assessment Scale (BRASS) predicts complications in symptomatic patients undergoing CAS. Application of the BRASS has shown the ability to improve patient selection. We used the BRASS system to evaluate whether the higher rate of complications associated with CAS in the elderly is related to vascular anatomy.A retrospective review of CAS was performed at our institution over 7 years. Demographic information, anatomic characteristics, BRASS categorization, and outcome measures were compared between elderly (≥80 years) and younger patients (80 years).The study included 447 patients: 335 patients (75%)80 years and 112 patients (25%) ≥80 years. There were significantly more elderly patients in the high-risk BRASS category (P0.01), and more young patients in the low-risk BRASS category (P = 0.04). The complication rates in the 2 groups were similar. Older patients were more likely to harbor complex vascular anatomy: they had significantly higher rates of types II and III aortic arches (P = 0.01 and P0.01, respectively), higher percentage of tortuous carotid vessels (P0.01), and higher rates of hostile anatomy for deployment of distal embolic protection devices (P = 0.02).Complex vascular anatomy, rather than age, is the key factor behind the higher CAS-associated complication rate in the elderly. Complications can be avoided through proper patient selection and stratifying patients based on anatomic characteristics, which can be achieved through the BRASS scoring system.

Introduction Embolization of the middle meningeal artery (MMA) has emerged as a minimally invasive means of managing subdural hematoma. The purpose of this study was to systematically review the literature on the safety and effectiveness of this treatment and to share our clinical experience. Methods This review was registered with PROSPERO. PubMed, CINAHL, EMBASE, and the Cochrane Library were searched using MeSH (Medical Subject Headings) terms for MMA embolization and chronic subdural hematoma (CSDH) from January 2000 to November 2018. All articles in the English language literature describing MMA embolization for CSDH were included, irrespective of study design. Consecutive patients who underwent MMA embolization at our hospital between January 2017 and June 2018 comprised our clinical experience. Results Fifteen studies with 193 procedures were included in the review. Ninety-five cases (49.2%) involved primary MMA embolization; 88 embolizations (45.6%) for recurrent CSDH and 10 (5.2%) for prophylaxis after surgical evacuation were performed. Recurrence after MMA embolization requiring further treatment occurred in 7 cases (3.6%). All other patients had symptomatic relief with no further recurrence. No procedure-related complications were reported. Polyvinyl alcohol was the most commonly used material. Our series included 8 patients treated with Onyx. All had symptom relief and significant reduction in hematoma size; no recurrences or procedure-related complications were observed. Conclusions MMA embolization of CSDH is safe and effective for CSDH treatment based on a documented recurrence rate of 3.6% and lack of reported complications.

Background and Purpose: The modified Thrombolysis in Cerebral Infarct (mTICI) score is used to grade angiographic outcome after endovascular thrombectomy. We sought to identify factors that decrease the accuracy of intraprocedural mTICI. Methods: We performed a 2-center retrospective cohort study comparing operator (n=6) mTICI scores to consensus scores from blinded adjudicators. Groups were also assessed by dichotomizing mTICI scores to 0–2a versus 2b–3. Results: One hundred thirty endovascular thrombectomy procedures were included. Operators and adjudicators had a pairwise agreement in 96 cases (73.8%). Krippendorff α was 0.712. Multivariate analysis showed endovascular thrombectomy overnight (odds ratio [OR]=3.84 [95% CI, 1.22–12.1]), lacking frontal (OR, 5.66 [95 CI, 1.36–23.6]), or occipital (OR, 7.18 [95 CI, 2.12–24.3]) region reperfusion, and higher operator mTICI scores (OR, 2.16 [95 CI, 1.16–4.01]) were predictive of incorrectly scoring mTICI intraprocedurally. With dichotomized mTICI scores, increasing number of passes was associated with increased risk of operator error (OR, 1.93 [95 CI, 1.22–3.05]). Conclusions: In our study, mTICI disagreement between operator and adjudicators was observed in 26.2% of cases. Interventions that took place between 22:30 and 4:00, featured frontal or occipital region nonperfusion, higher operator mTICI scores, and increased number of passes had higher odds of intraprocedural mTICI inaccuracy.

Introduction Artificial intelligence (AI) can automate the detection and triage of Intracerebral Hemorrhage (ICH). Early Minimally invasive Removal of IntraCerebral Hemorrhage (ENRICH) is a RCT evaluating the efficacy of minimally invasive surgery (MIS) for ICH. AI ENRICH is a prospective trial operating within and in parallel to the ENRICH trial that utilizes an AI application, Viz RECRUIT ICH Volume, to identify and segment ICH to quickly identify potentially eligible subjects. Methods Non-contrast CT scans performed at 5 participating US hospitals were evaluated specifically for a parenchymal hemorrhage by Viz RECRUIT ICH Volume. Participating health care professionals downloaded a phone application that allowed users to be notified for any hemorrhage ≥ 5 mL. Time metrics included the onset of CT scan, phone alert, and user recognition of that alert. Results Over a combined period of 374 days, 24,137 CT scans were evaluated by the Viz ICH VOLUME application. Of these, 817 CT scans were determined to contain an ICH yielding a total of 154 patients that met ENRICH criteria for trial inclusion (30-80 mL). The median time from CT scan to cell phone notification was 2.6 minutes. The median time from cell phone notification to the user viewing the CT scan was 2.95 minutes. Conclusions Viz ICH VOLUME can screen large numbers of CT scans and send alerts within minutes to medical professionals searching for clinical trial candidates in time-sensitive environments. Studies relying on radiographic selection criteria may benefit from automated screening. Disclosures B. Jankowitz: 2; C; Stryker, Medtronic. J. Davies: None. J. Day: None. S. Chowdhry: None. C. Schirmer: None. N. Levkovitz: 5; C; Viz.ai. O. Bibas: 5; C; Viz.ai. E. Blanc: 5; C; Viz.ai. G. Pradilla: None.

Introduction The Woven Endobridge (WEB) device is a barrel-shaped nitinol mesh deployed within the aneurysmal sac. The absence of metallic mesh in the vessel lumen obviates the need for potent antiplatelet therapy, which makes this devices interesting for acutely ruptured aneurysms not amenable to clipping or coiling. Methods We performed a comprehensive systematic search of Pubmed, MEDLINE and EMBASE databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Keywords combined with Boolean operators to increase search sensitivity and specificity (‘woven endobridge device’ AND ‘ruptured’) were used. Results Five studies were included, totalizing 276 ruptured aneurysms. Overall, 222 (80.4%) were wide-neck and 236 (85.5%) were located in the anterior circulation. Grade of SAH based on Hunt and Hess scale was reported in four studies with 64 (25.7%) of patients presenting with a poor grade (Hunt and Hess 4-5). Intraoperative and post-operative complications occurred in 7.2% (95% CI, 3.8-13.4) and 4.3% (95% CI, 1.9-9.2) respectively. The rate of rebleeding after treatment was 0%. The rates of adequate occlusion and retreatment at last follow-up were 86.5% (95% CI, 75.6-93) and 5.9% (95% CI, 3.2-10.6), respectively. The rate of favorable outcome was 71% (95% CI, 64-77) and mortality was 19.4% (95% CI, 14.3-25.7). The United-States multicenter study reported use of intraoperative single-antiplatelet therapy (SAPT) in 13.1% and dual-antiplatelet therapy (DAPT) in 2.2%, while 18.7% were discharged under DAPT. The remaining 4 European studies reported no use of antiplatelets during the procedure unless stenting was needed. Two studies reported no use of antiplatelet regimen during follow-up, while 2 studies reported use of SAPT for 4-6 weeks. Conclusions Treatment of acutely ruptured aneurysms with WEB device results in high rates of adequate occlusion, with low perioperative complications, no rebleeding and low recurrence. This device is promising for wide-necked ruptured aneurysms that are not amenable to clipping or coiling, considering its lower need for antiplatelet regimen either during procedure or follow-up. Disclosures A. Monteiro: None. A. Lazar: None. M. Waqas: None. H. Rai: None. A. Baig: None. R. Dossani: None. F. Almayman: None. J. Cappuzzo: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University at Buffalo. K. Snyder: 2; C; Canon Medical Systems Corporation, Penumbra Inc., Medtronic, and Jacobs Institute. E. Levy: 2; C; Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed;. 4; C; NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical;. A. Siddiqui: 2; C; Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Imperative Care, Inc. Integra LifeSciences C. 4; C; Adona Medical, Inc, Amnis Therapeutics, (Purchased by Boston Scientific October 2017), Blink TBI Inc., Buffalo Technology Partners Inc., Cerebrotech Medical Systems, Inc., Cognition Medical, Endostrea.

Introduction Ischemic stroke secondary to acute extracranial internal carotid artery (EC-ICA) occlusion accounts for approximately 20% of all stroke cases. Pure EC-ICA lesions account for only a minority of cases as a larger subgroup of people who experience these occlusions, concomitantly develop an intracranial anterior circulation large vessel occlusion (ACLVO), i.e. a tandem lesions. Endovascular management includes acute carotid artery stenting (CAS) with or without balloon angioplasty for pure EC-ICA occlusions and concurrent mechanical thrombectomy (MT) for tandem lesions. In lieu of the scarcity of randomized data and abundance of observational studies, we intend to perform a systematic review and pooled analysis of the data over the past decade to evaluate clinical outcomes, safety and feasibility of endovascular management of acute EC-ICA strokes. Methods Systematic search of the Pubmed, MEDLINE, and EMBASE databases was conducted based on Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. We performed a systematic review of all acute EC-ICA stroke papers (including tandem lesions) published between January 2010 and December 2020. A pooled analysis of the extracted data was performed. Results Data from 1153 patients from 22 studies were pooled and analyzed. Mean age after pooling was 66.9 years, mean NIHSS at admission was 15.9,% IV tPA use before endovascular intervention was seen 56.1% of studies. 82.8% of subjects had a tandem lesion involving both Extracranial and intracranial part of ICA and only 17.2% had a pure and isolated EC-ICA lesion. Angioplasty + stenting (both) was done in 77.6% of cases. Pooling was also done for any and all approaches taken in case of a tandem lesion i.e. anterograde or retrograde. Anterograde approach was taken in 61.7% of cases whereby CAS was performed first followed by MT. Outcome measures were reported as successful recanalization (TICI ≥ 2B) in 80.0% of cases, with good outcome (90-day mRS Conclusion Our systematic review for endovascular treatment of EC-ICA strokes found a high rate of good outcomes and an impressive rate for recanalization, with low mortality rates. Since these results are from observational, retrospective studies, more rigorous randomized trials are required to establish the best approach. Disclosures A. Baig: None. M. Waqas: None. S. Khan: None. A. Monteiro: None. H. Rai: None. R. Dossani: None. J. Cappuzzo: None. F. Almayman: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University at Buffalo. K. Snyder: 2; C; Canon Medical Systems Corporation, Penumbra Inc., Medtronic, and Jacobs Institute. E. Levy: 2; C; Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed;. 4; C; NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical;. A. Siddiqui: 2; C; Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Imperative Care, Inc. Integra LifeSciences C. 4; C; Adona Medical, Inc, Amnis Therapeutics, (Purchased by Boston Scientific October 2017), Blink TBI Inc., Buffalo Technology Partners Inc., Cerebrotech Medical Systems, Inc., Cognition Medical, Endostrea.

Introduction The Flow Redirection Endoluminal Device (FRED; MicroVention) is a dual-layered flow diverter used for the treatment of intracranial aneurysms. The objective of this systematic review was to compile device-related safety and effectiveness data. Methods The literature from January 1, 2013 to April 30, 2021 was searched for studies describing use of the FRED for intracranial aneurysm treatment irrespective of aneurysm location and morphology. The review included anterior and posterior circulation ruptured and unruptured saccular, fusiform or dissection, and blister aneurysms. MeSH terms related to “flow re-direction endoluminal device” and “FRED for aneurysms” were used. Data related to indication, complications, and rates of aneurysm occlusion were retrieved and analyzed. Results Twenty-two studies with 1729 intracranial aneurysms were included in this review. Overall reported morbidity was 3.9% (range 0–20%). Overall procedure-related mortality was 1.4% (range 0–6%). Complication rates fell into 5 categories: technical (3.6%), ischemic (3.8%), thrombotic or stenotic (6%), hemorrhagic (1.5%), and non-neurological (0.8%). The aneurysm occlusion rate between 0 and 3 months (reported in 11 studies) was 47.8%. The occlusion rate between 4 and 6 months (reported in 14 studies) was 73.8%. Occlusion rates continued to increase to 75.1% at 7–12 months (reported in 10 studies) and 86.6% for follow-up beyond 1 year (reported in 10 studies). Conclusion This review indicated that the FRED is a safe and effective for the treatment of intracranial aneurysms. Future studies should directly compare the FRED with other flow diverters for a better understanding of comparative safety and effectiveness among the different devices.

Objective The current mainstay treatment for juvenile nasopharyngeal angiofibromas (JNAs) is surgical resection, but embolization of primary feeding arteries through endovascular transarterial and direct tumoral puncture embolizations with various agents has been described. We describe a single institutional experience with JNA embolization utilizing Onyx (Medtronic, Dublin, Ireland). Methods A retrospective records review was performed to identify patients who underwent embolization for devascularization of Fisch grades II-IVa JNA (tumor extension beyond the sphenopalatine region) before surgical resection between 2010 and 2019. Fluoroscopy time, grade, intraoperative blood loss, and clinical follow-up data were compiled. Tumor devascularization percentage was calculated using ImageJ software (public domain, BSD-2) by measuring the ratio of preoperative and postoperative embolization tracing. Results Five consecutive patients (ages 12-16 years [average 14 years]; all male) with JNAs underwent preoperative transarterial embolizations performed under general anesthesia. All patients presented with epistaxis; two also presented with headaches. Fisch grades were II in two patients, IIIa in two, and IVa in one. The patient with the grade IVa lesion underwent direct transtumoral puncture and Onyx embolization. The mean percentage of all tumor devascularizations postembolization was 86.0±9.7%.Complete resection 24-48 hours postembolization was obtained for grades II and IIIa lesions with

BackgroundThe effectiveness of transradial stroke thrombectomy has been limited by guide catheter size and lack of good balloon options. In this study we describe our technique for the use of a sheathless 8-French balloon guide catheter (Walrus) through radial access and present our initial clinical experience.MethodsThis was a retrospective case series of consecutive patients who underwent mechanical thrombectomy for large vessel occlusion using the sheathless catheter over a period of 3 months. Clinical characteristics, procedural details, reperfusion success (modified Thrombolysis in Cerebral Infarction (mTICI) 2b–3 grade), first-pass effect (FPE; mTICI reperfusion grade 2c or 3 with a single pass), access site complications and clinical improvement at discharge were recorded. A descriptive analysis was performed.ResultsAmong the 10 patients in the series, median age was 77 years (IQR 75–79) and three were women. All patients had a baseline modified Rankin Scale score ≤2. Median admission National Institutes of Health Stroke Scale (NIHSS) score was 12.5 (IQR 9–16). Four patients received intravenous alteplase before mechanical thrombectomy. Eight patients had M1 occlusion and two had proximal M2 occlusion. The median radial artery diameter was 2.5 mm (IQR 2.5–2.7). Successful reperfusion was achieved in all patients. FPE was achieved in six patients. No access site-related complications or post-procedural intracranial hemorrhages occurred. All patients had improvement in NIHSS score at discharge.ConclusionsThe use of this sheathless catheter for transradial access was safe and feasible. The technique can potentially improve the outcomes of transradial access for stroke intervention.

Transfemoral access has long been the main access site for cerebral angiography and neurointerventional procedures. Radial access is accepted as an alternative to the traditional transfemoral approach. Ulnar access may be undertaken if the radial artery is occluded or small caliber, or when radial artery preservation is needed. The safety and feasibility of ulnar access for neuroangiographic procedures has been demonstrated.1-3 In this operative video, we demonstrate ulnar artery access in a patient in whom radial artery preservation was desired. We further elaborate on the technical nuances of this access. This nontraditional access site offers the same advantages as radial access, avoiding the need to switch to femoral artery access. A preoperative Allen's test is not necessary. Ultrasound imaging is used to aid in the identification and successful puncture of the ulnar artery. A medial to lateral approach for ulnar artery puncture is advised to avoid injury to the ulnar nerve. Careful application of wrist closure bands avoids hematoma accumulation. The patient gave informed consent for the procedure and video recording. Institutional review board approval was deemed unnecessary. Video. © University at Buffalo, May 2021. Used with permission.

Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. Antiplatelet therapy is the mainstay for symptomatic ICAD treatment. Endovascular management with submaximal angioplasty and/or intracranial stenting is reserved for patients with repeated ischemic events despite optimal medical therapy. We demonstrate intracranial angioplasty and stenting technique, technique indications, and sizing of stent and target vessel diameter. Stenting and angioplasty have been described in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis and Wingspan Stent System Post Market Surveillance trials.(1,2) Submaximal angioplasty has also been described.(3) This patient, who had been on dual antiplatelet therapy for several months, initially presented with occlusion of the left middle cerebral artery M2 inferior division and underwent mechanical thrombectomy with successful reperfusion. Postoperatively, the patient's symptoms did not improve. Medical management was optimized with heparin infusion. However, repeat stroke study demonstrated M2 inferior division reocclusion. A decision was made to proceed with intracranial angioplasty and stenting. P2Y12 levels were therapeutic. Under moderate conscious sedation, submaximal angioplasty of up to 80% of the normal M2 caliber was attempted. However, we observed persistent high-grade stenosis of the M2 inferior division. The major risk of crossing the lesion for angioplasty is vessel perforation. To safely perform this maneuver, we used a J-configured Synchro-2 microwire (Stryker). Because of the patient's recent thrombectomy, we also had prior tactile feedback about how much resistance was encountered while crossing the occlusion. We then deployed a balloon-mounted intracranial stent for optimal radial force across the stenotic area to restore perfusion. Postoperative computed tomography perfusion showed resolution of the previously noticed perfusion deficit. The patient gave informed consent for the procedures and video recording. Institutional review board approval was deemed unnecessary. Video. ©University at Buffalo Neurosurgery, September 2020. With permission.

Digital subtraction angiography (DSA) is the main imaging modality used to assess reperfusion during mechanical thrombectomy (MT) when treating large vessel occlusion (LVO) ischemic strokes. To improve this visual and subjective assessment, hybrid models combining angiographic parametric imaging (API) with deep learning tools have been proposed. These models use convolutional neural networks (CNN) with single view individual API maps, thus restricting use of complementary information from multiple views and maps resulting in loss of relevant clinical information. This study investigates use of ensemble networks to combine hemodynamic information from multiple bi-plane API maps to assess level of reperfusion. Three-hundred-eighty-three anteroposterior (AP) and lateral view DSAs were retrospectively collected from patients who underwent MTs of anterior circulation LVOs. API peak height (PH) and area under time density curve (AUC) maps were generated. CNNs were developed to classify maps as adequate/inadequate reperfusion as labeled by two neuro-interventionalists. Outputs from individual networks were combined by weighting each output, using a grid search algorithm. Ensembled, AP-AUC, AP-PH, lateral-AUC, and lateral-PH networks achieved accuracies of 83.0% (95% confidence-interval: 81.2%-84.8%), 74.4% (72.0%-76.7%), 74.2% (72.8%-75.7%), 74.9% (72.2%-77.7%), and 76.9% (74.4%-79.5%); area under receiver operating characteristic curves of 0.86 (0.84-0.88), 0.81 (0.79-0.83), 0.83 (0.81-0.84), 0.82 (0.8-0.84), and 0.84 (0.82-0.87); and Matthews correlation coefficients of 0.66 (0.63-0.70), 0.48 (0.43-0.53), 0.49 (0.46-0.52), 0.51 (0.45-0.56), and 0.54 (0.49-0.59) respectively. Ensembled network performance was significantly better than individual networks (McNemar's p-value

Chronic subdural hematoma (cSDH) is a common neurosurgical pathology that usually occurs in the seventh decade of life. Patients can present with mental status changes, focal neurologic deficits, seizures, headaches, or may be asymptomatic. Recurrence is common. In order to address this problem with the treatment of cSDH, many studies exist that compare the effectiveness of various treatment modalities. Two recently developed treatment options of cSDH include middle meningeal artery (MMA) embolization and use of self-irrigating catheter systems. To our knowledge there have been no reported cases of combining the use of these new treatments. What follows is a case report of a 72-year-old patient with recurrent cSDH following MMA embolization who underwent minimally invasive surgical drainage of his hematoma using an IRRAflow catheter (IRRAS, San Diego, CA, USA).

Introduction: Artificial intelligence (AI) can automate the detection and triage of ICH. ENRICH is a RCT evaluating the efficacy of MIS for ICH. AI ENRICH is a prospective trial operating within and in parallel to the ENRICH trial that utilizes an AI application, Viz RECRUIT and ICH VOLUME to identify and segment ICH to quickly identify potentially eligible subjects. Methods: Non-contrast CT scans performed at 5 participating US hospitals were evaluated specifically for a parenchymal hemorrhage by Viz ICH VOLUME. Participating health care professionals downloaded a phone application that allowed one to be notified for any hemorrhage ≥ 5 mL. Time metrics included the onset of CT scan, phone alert, and user recognition of that alert. Results: Over a combined period of 220 days, 8714 CT scans were evaluated by the Viz ICH VOLUME application. Of these, 257 CT scans were determined to contain an ICH yielding a total of 45 patients that met ENRICH criteria for trial inclusion (30-80 mL). The median time from CT scan to cell phone notification was 2:52 minutes (IQR=0.002) . The median time from cell phone notification to the user viewing the CT scan was 3:00 minutes (IQR=55.5 minutes), which was altered by a few significant delays in recognizing the alert (e.g. coordination of alerts and call schedules). After segregating the 4 weeks after ENRICH restarted on 7/14/20 into 2 week blocks, recognition of an alert within 5 minutes increased from 9% to 61.5% at the first site and 36% to 61.5% at second site - demonstrating the ability of alerts to improve site engagement and active screening for new subjects. Conclusions: In conclusion, Viz ICH VOLUME can screen large numbers of CT scans and send alerts within minutes to medical professionals. Studies relying on radiographic selection criteria may benefit from automated screening, although participating health care providers need to make use of the technology in order to maximize benefit.

Purpose Computed tomography perfusion (CTP) is used to diagnose ischemic strokes through contralateral hemisphere comparisons of various perfusion parameters. Various perfusion parameter thresholds have been utilized to segment infarct tissue due to differences in CTP software and patient baseline hemodynamics. This study utilized a convolutional neural network (CNN) to eliminate the need for non-universal parameter thresholds to segment infarct tissue. Methods CTP data from 63 ischemic stroke patients was retrospectively collected and perfusion parameter maps were generated using Vitrea CTP software. Infarct ground truth labels were segmented from diffusion-weighted imaging (DWI) and CTP and DWI volumes were registered. A U-net based CNN was trained and tested five separate times using each CTP parameter (cerebral blood flow (CBF), cerebral blood volume (CBV), time-to-peak (TTP), mean-transit-time (MTT), delay time). 8,352 infarct slices were utilized with a 60:30:10 training:testing:validation split and Monte Carlo cross-validation was conducted using 20 iterations. Infarct volumes were reconstructed following segmentation from each CTP slice. Infarct spatial and volumetric agreement was compared between each CTP parameter and DWI. Results Spatial agreement metrics (Dice coefficient, positive predictive value) for each CTP parameter in predicting infarct volumes are: CBF=(0.67, 0.76), CBV=(0.44, 0.62), TTP=(0.60, 0.67), MTT=(0.58, 0.62), delay time=(0.57, 0.60). 95% confidence intervals for volume differences with DWI infarct are: CBF=14.3±11.5 mL, CBV=29.6±21.2 mL, TTP=7.7±15.2 mL, MTT=-10.7±18.6 mL, delay time=-5.7±23.6 mL. Conclusions CBF is the most accurate CTP parameter in segmenting infarct tissue. Segmentation of infarct using a CNN has the potential to eliminate non-universal CTP contralateral hemisphere comparison thresholds.

BACKGROUND: Intra-procedural assessment of reperfusion during mechanical thrombectomy (MT) for emergent large vessel occlusion (LVO) stroke, is traditionally based on subjective evaluation of digital subtraction angiographs (DSA). However, semi-quantitative diagnostic tools which encode hemodynamic properties in DSAs, such as angiographic parametric imaging (API), exist and may be used for evaluation of reperfusion during MT. The objective of this study was to use data-driven approaches, such as convolutional neural networks (CNN) with API maps to automatically assess reperfusion in neuro-vasculature during MT procedures based on the modified thrombolysis in cerebral infarction (mTICI) scale. METHODS: DSAs from patients undergoing MTs of anterior circulation LVOs, were collected, temporally cropped to isolate late arterial and capillary phases and quantified using API peak height (PH) maps. PH maps were normalized to reduce injection variability. A CNN was developed, trained, and tested to classify PH maps into 2 outcomes (mTICI0,1,2a / mTICI2b,2c,3) or 3 outcomes (mTICI0,1,2a / mTICI2b / mTICI2c,3) respectively. Ensembled networks were used to combine information from multiple views (anteroposterior and lateral). RESULTS: The study included 383 DSAs. For the 2-outcome classification, average accuracy was 81.0% (95% CI: 79.0%−82.9%) and, area under the receiver operating characteristic curve (AUROC) was 0.86 (0.84–0.88). For the 3-outcome classification, average accuracy was 64.0% (62.0–66.0), AUROCs were 0.85 (0.83–0.87), 0.74 (0.71–0.77) and, 0.78 (0.76–0.81) for the mTICI0,1,2a, mTICI2b, and mTICI2c,3 classes respectively. CONCLUSIONS: This study demonstrated the feasibility of using hemodynamic information in API maps with data-driven models to autonomously assess intra-procedural reperfusion during MT.

Purpose: To assess acute ischemic stroke (AIS) severity, infarct is segmented using computed tomography perfusion (CTP) software, such as RAPID, Sphere, and Vitrea, relying on contralateral hemisphere thresholds. Since this approach is potentially patient dependent, we investigated whether convolutional neural networks (CNNs) could achieve better performances without the need for contralateral hemisphere thresholds. Approach: CTP and diffusion-weighted imaging (DWI) data were retrospectively collected for 63 AIS patients. Cerebral blood flow (CBF), cerebral blood volume (CBV), time-to-peak, mean-transit-time (MTT), and delay time maps were generated using Vitrea CTP software. U-net shaped CNNs were developed, trained, and tested for 26 different input CTP parameter combinations. Infarct labels were segmented from DWI volumes registered with CTP volumes. Infarct volumes were reconstructed from two-dimensional CTP infarct segmentations. To remove erroneous segmentations, conditional random field (CRF) postprocessing was applied and compared with prior results. Spatial and volumetric infarct agreement was assessed between DWI and CTP (CNNs and commercial software) using median infarct difference, median absolute error, dice coefficient, positive predictive value. Results: The most accurate combination of parameters for CNN segmenting infarct using CRF postprocessing was CBF, CBV, and MTT (4.83 mL, 10.14 mL, 0.66, 0.73). Commercial software results are: RAPID = (2.25 mL, 21.48 mL, 0.63, 0.70), Sphere = (7.57 mL, 17.74 mL, 0.64, 0.70), Vitrea = (6.79 mL, 15.28 mL, 0.63, 0.72). Conclusions: Use of CNNs with multiple input perfusion parameters has shown to be accurate in segmenting infarcts and has the ability to improve clinical workflow by eliminating the need for contralateral hemisphere comparisons.

BackgroundFew studies have compared technical success and effectiveness of transradial access (TRA) versus transfemoral access (TFA) for mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We compared the two approaches for technical success, effectiveness, and outcomes.MethodsWe retrospectively compared TRA with TFA for AIS MT at our institute. We additionally performed a systematic review and meta-analysis of studies describing the use of TRA alone or in comparison with TFA for MT. Primary outcomes included rate of successful reperfusion (thrombolysis in cerebral infarction (TICI)>2b), number of passes, access-site complications, and 3- month mortality and favorable functional outcomes (modified Rankin Scale (mRS) score 0–2).ResultsA total of 222 consecutive patients (TRA=93, TFA=129) were included in our case series. The rate of successful reperfusion was significantly higher for the TFA cohort (91.4% vs 79.6%, P=0.01) with lower mean number of passes (1.8±1.2 vs 2.4±1.6, P=0.014). Three-month mortality in the TFA group was lower (22.1% vs 40.9% for the TRA cohort (P=0.004), with a higher rate of favorable functional outcomes (51.3% vs 34.1%, P=0.015). A meta-analysis of 10 studies showed significant heterogeneity in rates of successful reperfusion (57.1% to 95.6%, heterogeneity=67.55%, P=0.001). None of the previous comparative studies reported 3-month mortality and functional outcomes.ConclusionsThis case series demonstrate a higher successful reperfusion rate, fewer passes, lower 3-month mortality, and improved 3-month functional outcomes with TFA. The systematic review highlights the inadequacy of existing evidence. Prospective comparative studies are needed before a ‘radial-first’ approach can be adopted for stroke intervention.

Objectives Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. Materials and Methods This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. Results Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09–3.5. All studies but 1 reported that EVT was cost-effective. Conclusions Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.

Medial sphenoid wing meningiomas constitute up to 10% of all intracranial meningiomas.(1) These meningiomas have a tendency to engulf the internal carotid artery (ICA), its termination, and the middle cerebral artery. These arteries and the optic apparatus are at a particularly high risk of injury during the microsurgical resection of these tumors. ICA injuries are potentially devastating and challenging to manage. In this technical video, we demonstrate the management of inadvertent ICA terminus injury during the microsurgical resection of the medial sphenoid. Rapid vascular control was obtained with temporary clips on the ICA and anterior cerebral artery (ACA). Tamponade with a felt and primary repair of the arterial tear were attempted without success. We then created a tamponade around the tear with the help of a Hemashield strip (Meadox Medicals, Oakland, New Jersey), which was secured with a 90-degree-angled clip. Temporary clips were removed, and microsurgical dissection was completed. The Hemashield strip was removed at the end of the procedure. This maneuver resulted in complete hemostasis. Vascular patency was confirmed using Doppler imaging and intraoperative indocyanine green angiography. Postoperatively, the patient had transient right-sided weakness, which resolved 2 d later. The patient was discharged without any neurological deficit. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Video ©University at Buffalo, April 2020. Published with permission.

Introduction Middle meningeal artery (MMA) embolization for the treatment of subacute/chronic subdural hematoma (cSDH) is an emerging therapy for minimally invasive treatment of subdural blood products. Trans radial access (TRA) may offer certain benefits to this patient population who are often on blood thinners with multiple comorbid medical issues. Methods 46 consecutive patients between 2018 and January of 2020 undergoing trans radial access for MMA embolization with Onyx were analyzed from a single center prospectively maintained database. Patient demographics, comorbidities, ambulatory times, subdural resorption status, and guide catheter type were recorded. We specifically looked at conversion to femoral access and complication rates from access for this series. Multivariate analysis with SPSS version 25 was utilized. Results 46 patients were included in this study. The average age was 71.7± 14 years. TRA was successful for MMA embolization in 44 patients (95%). There were no access site complications. The mean cSDH size was 14 ±5 mm. 5 patients had recurrent cSDH prior to undergoing MMA embolization (10.8%). 4 patients (8.7%) had adjuvant MMA embolization performed within 24 hrs of burr hole evacuation. Symptomatic improvement was seen in 88.6% of patients (39/44). Mean length of stay was 4 ±3 days, all patients previously ambulatory were ambulated immediately post procedure. 3 patients were appropriate for same day discharge. Mean followup was 8 weeks ± 4. 86.4% of patients had either resolution or partial resolution of the cSDH at mean follow-up. Univariate analysis revealed use of antiplatelet agents was associated with failed resorption of cSDH (83.3% vs 23%, P=0.009). Charlson comorbidity index, gender, age, and treatment approach (adjuvant vs primary) were not associated with failed resorption status. 48% of patients had a Charlson Comorbidity index >5. 91% of TRA embolizations were performed with a 6F 071 guide catheter. Conclusion MMA embolization with Onyx for cSDH appears to result in symptomatic and radiographic relief in the majority of patients. Trans radial access via 6F 071 guide catheter in this population with numerous comorbidities offers a safe and effective strategy for early ambulation and procedural success. Disclosures G. Rajah: None. M. Waqas: None. R. Dossani: None. A. Gong: None. K. Rho: None. S. Housley: None. H. Rai: None. F. Chin: None. M. Tso: None. E. Levy: None. A. Siddiqui: None. K. Snyder: None. J. Davies: None.

Background Diagnostic cerebral angiography (DSA) and neurointerventions have traditionally been performed via transfemoral access (TFA). The perception of a steep learning curve associated with transradial access (TRA) has limited adoption in neurointervention. This study compares the learning curves of transradial vs. transfemoral DSA in a cohort of neurointerventional fellows. Methods The first 150 consecutive radial and femoral DSA were identified for each fellow from a prospective neurointerventional registry from July 2017 to March 2020. Total fluoroscopy time and number of intracranial arteries injected were recorded. Mean fluoroscopy time per intracranial artery injected (termed angiographic efficiency) was calculated and was used as a surrogate measure of technical proficiency. Mean angiographic efficiencies were compared across partitions of 25 consecutive DSAs (e.g. 1–25, 26–50, 51–75, etc.). Results There were 607 radial DSA and 635 femoral DSA identified among 5 fellows. The overall angiographic efficiencies were not significantly different based on access site (radial mean 3.2 min, femoral mean 3.7 min, p>0.05). For 3 fellows without prior endovascular experience, technical proficiency was obtained between 25–50 femoral DSA procedures. Among these same fellows, one fellow achieved technical proficiency after 25–50 radial DSA procedures, while the other 2 fellows had flattened learning curves. There were 2 fellows that had no significant learning curve for either access type, but both had extensive experience with endovascular procedures prior to starting fellowship. Two patients (2/1342 = 0.1%) experienced transient neurologic symptoms post-procedure. Among 635 femoral DSA, there were 22 (3.5%) minor adverse events (14 small groin hematomas not requiring transfusion, 1 pseudoaneurysm, 7 non-flow-limiting dissections). Among 607 radial DSA, there were 3 (0.5%) minor adverse events (2 small forearm hematomas, 1 intraluminal wire removed with radial cut-down), which was significantly less than femoral DSA minor adverse events (p=0.0001). Radial to femoral conversion rate was 1.2% (7/607, 2 radial spasm, 2 unsuccessful radial artery access, 3 aberrant right subclavian artery). Femoral to radial conversion rate was 0.3% (2/635). From March 2019 to February 2020, the proportion of DSA performed via transradial access increased from 36% to 78% at our institution. Conclusion This study demonstrates the learning curves for both TRA and TFA diagnostic cerebral angiograms. Proficiency improves significantly with either type of access, typically requiring between 25–50 procedures. TRA DSA have significantly less access site complications than TFA DSA. Disclosures M. Tso: None. G. Rajah: None. R. Dossani: None. M. Meyer: None. M. McPheeters: None. K. Vakharia: None. M. Waqas: None. K. Snyder: None. E. Levy: None. A. Siddiqui: None. J. Davies: None.

Introduction The NAPA study was a prospective, multicenter, single-arm IDE trial of the PulseRider device as an adjunctive treatment in conjunction with coil embolization of unruptured wide-neck bifurcation aneurysms which was electively discontinued for reasons not related to the safety or performance of the device. We report on the available enrollments in NAPA and their available follow up. Methods The PulseRider device was implanted in 18/21 enrollments. Available core-lab adjudicated data from the first 18 implants is presented. Of those, 5 have one year follow up data available. Of the 3 device implantation failures, the locations included basilar (1), carotid terminus (1), and ACOMM (1). Results For the 18 patients with PulseRider implanted as a coil-adjunct device, the mean age was 60.7± 8.9 yrs and 16 were female. The mean aneurysm diameter was 6.6± 2.2 mm, height 5.3±1.7 mm and neck 4.8 ±1.5 mm. Locations included the basilar apex (11), MCA bifurcation (4) and ACOMM (3). Thirteen of 18 were de novo aneurysms while the remainder (5) were treated in the setting of aneurysmal recurrence. The most common PulseRider placement was extra-aneurysmal (12/18), followed by intra-aneurysmal (4/18) and hybrid (2/18). Immediate angiographic occlusions were 66.6% RR-I, 16.7% RR-II, 16.7% RR-III. There were no device related adverse events. There were 3 (16.7%) procedure-related adverse events which did not result in neurological changes. Seven enrollments have 6 month follow up and all are RRI-II. Only 1 has one year angiographic follow up (RRI) adjudicated by the core lab, and 4 have clinical follow up (4/4 mRS 0–2). None of the target aneurysms have required retreatment. Conclusions The results of the discontinued NAPA provide high quality data on the occlusion rates and safety profile for the PulseRider device. Further one year angiographic and clinical follow up will be reported when available. Disclosures A. Spiotta: 1; C; Microvention. 2; C; Minnetronix, Penumbra, Cerenovus. 6; C; Cerenovus, Penumbra, Pulsar Vascular, Stryker, Microvention. K. Ebersole: None. J. Lena: None. R. Starke: 2; C; Medtronic Neurovascular, Penumbra, Cerenovus, Abbott. R. De Leacy: 6; C; Penumbra, Cerenovus, Siemens. A. Puri: 1; C; Stryker Neurovascular, Medtronic Neurovascular. 2; C; Stryker Neurovascular, Medtronic Neurovascular. D. Yavagal: 2; C; Medtronic Neurovascular, Rapid Medical, Steering Committee, Neuralanalytics. 6; C; Medtronic, Cerenovus/Johnson & Johnson, Rapid Medical, Neuralanalytics. B. Bohnstedt: 2; C; Penumbra, Stryker, Medtronic. L. Rangel-Castilla: None. A. Cheema: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University of Buffalo. 2; C; Medtronic, Neurotrauma Science, LLC. 4; C; RIST Neurovascular. K. de Macedo Rodrigues: None. J. Grossberg: None. B. Howard: None. C. Kellner: 1; C; Penumbra, Siemens Corp. G. Lanzino: None. S. Tateshima: 2; C; Cerenovus, Medtronic, Neurovasc, Stryker. 4; C; Neurovasc.