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Background: Surface modification of flow diverters (FDs) has been explored as a solution for reducing thrombotic risk of these devices, without necessarily using dual antiplatelet therapy (DAPT). If effective, this could pose a promising alternative for treatment of ruptured aneurysms not amenable to other modalities., Methods: We performed a comprehensive search of PubMed, MEDLINE, and Embase databases following Preferred Reporting Items for Systematic reviews and Meta-analyzes guidelines. We included articles reporting use of surface-modified FDs for treatment of ruptured aneurysms. Demographics, subarachnoid hemorrhage (SAH) severity, aneurysm characteristics, devices used, periprocedural complications, angiographic outcomes, and mortality were extracted for sample size-based weighted analysis., Results: Six studies comprising 59 patients with 64 aneurysms were included. Mean patient age was 56.6 ± 6.3 years and 60.6% (95% confidence interval [CI], 46.7-72.9%) were women. The anterior circulation was the location in 60.4% (95%CI, 45.5-73.5%) of aneurysms; 41.8% of the aneurysms were saccular (95%CI, 29.3-55.4%), 16.7% were fusiform (95%CI, 8.3-30.8%), 29.9% were dissecting (95%CI, 12.8-55.4%), 24.4% were blood-blister (95%CI, 15.2-36.7%), and 5.7% were mycotic (95%CI, 2-15.1%). Poor SAH grade was reported in 46.9% (95%CI, 33.3-60.9%). Adjunctive coiling was used in 33.2% (95%CI, 12.4-63.6%). Periprocedural thromboembolic and hemorrhagic complications occurred in 20% (95%CI, 7.1-45.1%) and 8.8% (95%CI, 3.7-19.5%), respectively. Complete occlusion was achieved in 76.4% (95%CI, 58.1-88.3%); no retreatments during follow-up were reported. Overall mortality was 15.1% (95%CI, 7.7-27.6%). There were no differences between single antiplatelet therapy (SAPT) and DAPT regimens with respect to periprocedural thromboembolic complications ( P  = 0.09), hemorrhagic ( P  = 0.834) complications, and mortality ( P  = 0.312)., Conclusion: Surface-modified FD treatment of ruptured aneurysms resulted in high rates of thromboembolic complications and acceptable rates of hemorrhagic complications. A considerable proportion of aneurysms were nonsaccular. Rates of complete occlusion were high and retreatment were low. Importantly, no statistically significant difference was found between SAPT and DAPT with respect to complications and mortality., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: AM, AK, BD, CCK, SMB, MW, SBH—None. JMC—Consulting Fees: Cerenovus, J&J Medical Device Companies; Integra Lifesciences, Corp.; MIVI Neuroscience, Inc.; Penumbra, Inc.; Stryker, Corp. Support for attending meetings and/or travel: Stryker, Corp.; Penumbra, Inc. JMD—Consulting fees; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events; support for attending meetings and/or travel: Medtronic. Patents planned, issued, or pending: QAS.ai. Participation on a Data Safety Monitoring Board or Advisory Board: NIH NIHDS Strokenet. Stock or stock options: Synchron, Cerebrotech, QAS.ai. KVS—Consulting Fees: Boston Scientific, Canon Medical Systems USA, Inc., MicroVention, Medtronic, Stryker Neurovascular. Payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational event: Canon Medical Systems USA Inc. Stock or stock options: Boston Scientific, Access Closure Inc, Niagara Gorge Medical. EIL—Shareholder/Ownership Interest: NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care, Rebound Therapeutics, StimMed, Three Rivers Medical; Patent: Bone Scalpel; Honorarium for Training & Lectures: Medtronic, Penumbra, Microvention, Integra, Consultant: Clarion, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, StimMed, Misionix, Mosiac; Chief Medical Officer: Haniva Technology; National PI: Medtronic- Steering Committees for SWIFT Prime and SWIFT Direct Trials; Site PI Study: Microvention (CONFIDENCE Study) Medtronic (STRATIS Study-Sub 1); Advisory Board: Stryker (AIS Clinical Advisory Board), NeXtGen Biologics, MEDX, Cognition Medical; Endostream Medical, IRRAS AB (Consultant/Advisory Board, Medical Legal Review: Dr Levy renders medical/legal opinions as an expert witness;); Leadership or fiduciary roles in other board society, committee, or advocacy group, paid and unpaid: CNS, ABNS, UBNS. AHS—Consulting fees: Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Cerevatech Medical, Inc., Cordis, Corindus, Inc., Endostream Medical, Ltd, Imperative Care, InspireMD, Ltd, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Peijia Medical, Penumbra, Q’Apel Medical, Inc., Rapid Medical, Serenity Medical, Inc., Silk Road Medical, StimMed, LLC, Stryker Neurovascular, Three Rivers Medical, Inc., VasSol, Viz.ai, Inc. Leadership or fiduciary role in other board, society, committee or advocacy group: Secretary—Board of the Society of NeuroInterventional Surgery 2020–2021, Chair—Cerebrovascular Section of the AANS/CNS 2020–2021. Stock or stock options: Adona Medical, Inc., Amnis Therapeutics, Bend, IT Technologies, Ltd, BlinkTBI, Inc, Cerebrotech Medical Systems, Inc., Cerevatech Medical, Inc., Cognition Medical, CVAID Ltd, E8, Inc., Endostream Medical, Ltd, Galaxy Therapeutics, Inc., Imperative; Care, Inc., InspireMD, Ltd, Instylla, Inc., International Medical Distribution Partners, Launch NY, Inc.; Neurolutions, Inc., NeuroRadial Technologies, Inc., NeuroTechnology Investors, Neurovascular Diagnostics, Inc., Peijia; Medical, PerFlow Medical, Ltd, Q’Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (Purchased 2019 by Integra Lifesciences, Corp), Rist Neurovascular, Inc. (Purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, Sim & Cure, SongBird Therapy, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Three Rivers Medical, Inc., Truvic Medical, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, VICIS, Inc., Viseon, Inc. Other financial or non-financial interests: National PI/Steering Committees: Cerenovus EXCELLENT and ARISE II Trial; Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFT DIRECT Trials; MicroVention FRED Trial & CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial, MIVI neuroscience EVAQ Trial; Rapid Medical SUCCESS Trial; InspireMD C-GUARDIANS IDE Pivotal Trial.

Advanced salvage techniques are an essential tool in the armamentarium of any experienced endovascular surgeon. In this video, we show a patient presenting with rerupture of an anterior communicating artery (ACoA) aneurysm that had been treated with balloon-assisted coiling several months earlier in a ruptured setting. Premature coil detachment occurred during an attempt to coil a new bleb that the aneurysm had developed, and a sequence of salvage maneuvers was performed. An initial attempt to implant that coil failed, and retrieval with a snare unfortunately caused coil fragmentation and occlusion of the anterior cerebral artery (ACA). Further salvage maneuvers required inducing flow-arrest with a balloon-guide catheter, use of a stent-retriever to recanalize the ACA A2 segment, and aspiration to capture a small fragment of coil that was seen at the tip of the balloon guide catheter., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MW, SBH, AM—nothing to disclose. JMC-Consulting Fees: Cerenovus, J&J Medical Device Companies; Integra Lifesciences, Corp.; MIVI Neuroscience, Inc.; Penumbra, Inc.; Stryker, Corp.; AHS—Consulting fees: Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Cerevatech Medical, Inc., Cordis, Corindus, Inc., Endostream Medical, Ltd, Imperative Care, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Penumbra, Q’Apel Medical, Inc., Rapid Medical, Serenity Medical, Inc., Silk Road Medical, StimMed, LLC, Stryker Neurovascular, Three Rivers Medical, Inc., VasSol, Viz.ai, Inc., W.L. Gore & Associates. Leadership or fiduciary role in other board, society, committee or advocacy group: Secretary of the Board of the Society of NeuroInterventional Surgery, Chair of the Cerebrovascular Section of the AANS/CNS. Stock or stock options: Adona Medical, Inc., Amnis Therapeutics, Bend IT Technologies, Ltd, BlinkTBI, Inc, Buffalo Technology Partners, Inc., Cardinal Consultants, LLC, Cerebrotech Medical Systems, Inc, Cerevatech Medical, Inc., Cognition Medical, CVAID Ltd, E8, Inc., Endostream Medical, Ltd, Imperative Care, Inc., Instylla, Inc., International Medical Distribution Partners, Launch NY, Inc., NeuroRadial Technologies, Inc., Neurotechnology Investors, Neurovascular Diagnostics, Inc., PerFlow Medical, Ltd, Q’Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (Purchased 2019 by Integra Lifesciences, Corp), Rist Neurovascular, Inc. (Purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, Adona Medical, Inc., Amnis Therapeutics, Bend IT Technologies, Ltd, BlinkTBI, Inc, Buffalo Technology Partners, Inc., Cardinal Consultants, LLC, Cerebrotech Medical Systems, Inc, Cerevatech Medical, Inc., Cognition Medical, CVAID Ltd, E8, Inc., Endostream Medical, Ltd, Imperative Care, Inc., Instylla, Inc., International Medical Distribution Partners, Launch NY, Inc., NeuroRadial Technologies, Inc., Neurotechnology Investors, Neurovascular Diagnostics, Inc., PerFlow Medical, Ltd, Q’Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (Purchased 2019 by Integra Lifesciences, Corp), Rist Neurovascular, Inc. (Purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, SongBird Therapy, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Three Rivers Medical, Inc., Truvic Medical, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, VICIS, Inc., Viseon, Inc. Other financial or non-financial interests: National PI/Steering Committees: Cerenovus EXCELLENT and ARISE II Trial; Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFT DIRECT Trials; MicroVention FRED Trial & CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial, MIVI neuroscience EVAQ Trial; Rapid Medical SUCCESS Trial; InspireMD C-GUARDIANS IDE Pivotal Trial.EIL--Shareholder/Ownership Interest: NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care, Rebound Therapeutics, StimMed, Three Rivers Medical; Patent: Bone Scalpel; Honorarium for Training & Lectures: Medtronic, Penumbra, MicroVention, Integra, Consultant: Clarion, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, StimMed, Misionix, Mosiac; Chief Medical Officer: Haniva Technology; National PI: Medtronic- Steering Committees for SWIFT Prime and SWIFT Direct Trials; Site PI Study: MicroVention (CONFIDENCE Study) Medtronic (STRATIS Study-Sub 1); Advisory Board: Stryker (AIS Clinical Advisory Board), NeXtGen Biologics, MEDX, Cognition Medical; Endostream Medical, IRRAS AB (Consultant/Advisory Board, Medical Legal Review: render medical/legal opinions as an expert witness; leadership or fiduciary roles in other board society, committee or advocacy group, paid and unpaid: CNS, ABNS, UBNS; Support for attending meetings and/or travel: Stryker, Corp.; Penumbra, Inc.Video ©University at Buffalo Neurosurgery, Inc. April 2022. With permission.

Objective: Flow diverter devices have revolutionized the treatment of intracranial aneurysms (IAs) since their approval in 2011 and have continued to evolve. The devices have been widely adopted across institutions and centers over the past decade; however, long-term follow-up after treatment with the Pipeline embolization device (PED) is not well described in the literature. The authors' institution was among the first to begin using PEDs, allowing them to report their series of patients treated with flow diverters ≥ 10 years ago. In this study, the authors aimed to evaluate the long-term angiographic and clinical outcomes of these patients and review lessons learned along the way., Methods: The authors performed a retrospective review of their institution's IA database from January 2007 to July 2012. All patients with IAs treated with a PED prior to July 2012 were included. Clinical and angiographic characteristics were extracted. Available angiographic follow-up at 1, 3, 5, and 10 years was reported., Results: A total of 83 patients with 92 aneurysms treated with a PED ≥ 10 years ago were identified and included in the study. The mean aneurysm dome diameter was 9.2 (SD 5.7) mm, the mean aneurysm height was 10.4 (SD 6.8) mm, and the mean neck width was 4.1 (SD 2.4) mm. Only 1 (1.1%) aneurysm was ruptured at presentation. Eight (8.7%) aneurysms were recurrences of previous treatment modalities. The morphology was saccular in 77 (83.7%) aneurysms, fusiform in 14 (15.2%), and blister-like in 1 (1.1%). Among saccular aneurysms, 60 (77.9%) were wide-necked. Seventy-five (81.5%) aneurysms were in the internal carotid artery, 12 (13.0%) were vertebrobasilar, 3 (3.3%) were in the middle cerebral artery, and 2 (2.2%) were in the posterior cerebral artery. Angiographic follow-up at 1, 3, 5, and 10 years was available for 75, 59, 50, and 15 patients, respectively. The complete occlusion rates at 1, 3, 5, and 10 years were 94.7%, 96.6%, 96.0%, and 100%, respectively. The retreatment rates at 1, 3, 5, and 10 years were 8.0%, 6.8%, 8.0%, and 6.7%, respectively., Conclusions: The authors provide their single-institution series of IA patients treated with a PED ≥ 10 years ago, with the first report of 10-year follow-up for the available patients.

Background: Intraoperative aneurysm rupture during microsurgical clipping can be managed with different salvage techniques. In an aneurysm with a very wide neck that is located at a bifurcation, repairing an iatrogenic tear can be challenging and carry the risk of branch occlusion and infarction., Objective: To describe a variation of the cotton-clipping technique modified to better fit the bifurcation anatomy, which we call "felt-fenestrated clipping.", Methods: An illustrative case of intraoperative rupture of a wide-necked middle cerebral artery bifurcation aneurysm is presented. Radiological imaging, operative video, and technique illustration were obtained and prepared for this report., Results: A middle-aged woman underwent microsurgical clipping of a wide-necked middle cerebral artery bifurcation aneurysm. A right-angle clip became dislodged from the clip applier and snapped across the aneurysm causing a small rupture at the base. This was later determined to be the result of improper placement of a standard clip onto a mini-clip applier. After a few salvage attempts, a small piece of Teflon felt was placed over the rupture site and held in place using a straight, fenestrated clip. Then, the right-angle clip was applied over the true neck of the aneurysm and the edge of the rupture site, covering the Teflon felt to obtain true hemostasis., Conclusion: We demonstrate a technically successful felt-fenestrated clipping technique for treatment of an intraoperative rupture not amenable to other salvage options. This technique is useful to achieve hemostasis while preserving branches in wide-necked bifurcation aneurysms., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)