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Background: We aimed to determine the effects of endovascular coiling of unruptured intracranial aneurysms (UIAs) on cognition to inform treatment decisions. We present the first study using the Montreal Cognitive Assessment (MoCA) to determine neurocognitive changes after endovascular coiling., Methods: We prospectively collected data on all patients with UIAs undergoing endovascular coiling, primary or assisted. Patients completed the MoCA prior to intervention and 1 month and 6 months' post-procedure. A repeated measures linear mixed effects model was used to compare pre-procedure and post-procedure cognition., Results: Thirty-three patients with 33 aneurysms who underwent coiling from April 2017 to May 2020 were included (mean age 55.5, 81.8% female). All procedures used general anesthesia. There was no difference between baseline and post-procedure MoCA scores at any time interval (P>0.05). Mean MoCA scores at baseline, 1 month post-procedure, and 6 months' post-procedure were 25.4, 26.8, and 26.3 respectively. There was also no difference between pre- and post-procedure scores on any individual MoCA domain (visuospatial, naming, memory, attention, language, abstraction, delayed recall, and orientation) at any time interval (P>0.05). Seventeen patients had follow-up MRI or CT imaging, of which 11.8% showed radiographic changes or ischemia. 77.8% of patients with 6-month angiographic follow-up achieved class I, and 22.2% achieved class II Raymond-Roy Occlusion. Thirty-two out of 33 patients had follow-up mRS ≤2., Conclusion: Our study suggests that endovascular coiling does not diminish neurocognitive function. Patients with UIAs in our cohort also had baseline MoCA scores below the cut-off for mild cognitive impairment despite pre-procedure mRS and NIHSS of 0., Competing Interests: Competing interests: PK: consultant for Cerenovus, Stryker., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH)., Objective: To determine the safety and efficacy of MMA embolization., Methods: Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes., Results: A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities., Conclusion: MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Background: First-pass efficacy (FPE) is an established marker of technical and clinical efficacy among mechanical thrombectomy (MT) techniques. It is unclear what the optimal approach is in achieving FPE. We present a single-center experience comparing rates of FPE among 2 MT techniques and evaluate the potential predictors of FPE among other outcomes., Methods: A single-center retrospective analysis was carried out of patients with consecutive large-vessel occlusion strokes (LVOS) of anterior circulation from September 2015 to April 2019 who underwent MT and for whom data were available on the status of FPE. Four MT techniques were identified: ADAPT (a direct first-pass aspiration), SrADAPT (stent retriever with aspiration), SRBG (stent retriever with balloon guide catheter), and STRAP (stent retriever-aspiration and proximal flow arrest). The primary outcome was FPE and secondary outcomes included the rate of successful reperfusion., Results: Among 226 patients with LVOS of the anterior circulation who underwent MT, data were available for 164 on FPE for the 4 MT techniques. SRBG was the most prevalent technique. No significant difference was found in rates of FPE among the 4 MT techniques (P = 0.332). No independent predictors of FPE were identified on multivariable analysis. STRAP had the highest rate of successful reperfusion compared with the other techniques (P = 0.049) and was the only independent predictor of that outcome (P = 0.027)., Conclusions: Among patients with LVOS of the anterior circulation, the rate of FPE did not differ among the 4 MT techniques. There were no predictors of FPE among the studied variables. STRAP was the only predictor of successful reperfusion., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The safety and efficacy of flow diversion (FD) in the treatment of cerebral aneurysms have been reported by many studies. FD has enabled the treatment of complex aneurysms and aneurysms that were previously untreatable by conventional means. It has achieved high rates of obliteration with essentially no recanalization, and its indications have continued to expand, now including ruptured aneurysms, blister aneurysms, and dissecting aneurysms., Objective: To provide a review on the outcomes of studies covering the use of FD in the settings of ruptured, blister, and dissecting aneurysms. In addition, to discuss dual antiplatelet therapy (DAPT) used in preparation for FD deployment in these scenarios, including associated complications with DAPT use in the acute rupture setting., Methods: References for this topical review were identified by PubMed searches between January 2000 and January 2019. The search terms "aneurysm", "flow diverter", "stent", "pipeline", "ruptured", "blister", and "dissecting aneurysms" were used., Results: FD carries a higher complication rate in the acute rupture setting than for unruptured aneurysms. Patient selection is of paramount importance for achieving good functional and angiographic outcomes. DAPT still remains challenging, especially in ruptured aneurysms. Advancements in surface modification of flow diverters can reduce the risk of thromboembolism and perhaps lead to a safer antiplatelet regimen., Conclusion: In summary, FD shows promise to be an effective treatment for ruptured, blister, and dissecting aneurysms., (Copyright © 2019 by the Congress of Neurological Surgeons.)

We report an unusual case in which physiologic neck rotation impeded perfusion through the internal carotid artery. The patient had a history of prior radical neck surgery and radiation for malignancy. He presented withbow hunter's-like symptoms with transient loss of consciousness and right-sided weakness with left lateral neck rotation. A self-expanding peripheral stent was successfully used to treat the patient by preventing rotatory carotid compression. In select patients with prior neck surgery and radiation, carotid injections should be part of a dynamic cerebral angiogram if the vertebral arteries are unremarkable., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)