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Background and purpose In patients with acute ischemic stroke treated with reperfusion therapy we aimed to evaluate whether pretreatment blood-brain barrier (BBB) leakage is associated with subsequent hemorrhagic transformation (HT). Methods We prospectively screened patients with acute ischemic stroke treated with intravenous thrombolysis and/or endovascular treatment. Before treatment, each patient received computed tomography (CT), CT angiography, and CT perfusion. We assessed pretreatment BBB leakage within the ischemic area using the volume transfer constant (Ktrans ) value. Our primary outcome was relevant HT, defined as hemorrhagic infarction type 2 or parenchymal hemorrhage type 1 or 2. We evaluated independent associations between BBB leakage and HT using logistic regression, adjusting for age, sex, baseline stroke severity, Alberta Stroke Program Early CT Score (ASPECTS) ≥ 6, treatment type, and onset-to-treatment time. Results We enrolled 171 patients with available assessment of BBB leakage. The patients' mean (±SD) age was 75.5 (±11.8) years, 86 (50%) were men, and the median (interquartile range) National Institutes of Health Stroke Scale score was 18 (12-23). A total of 32 patients (18%) received intravenous thrombolysis, 102 (60%) underwent direct endovascular treatment, and 37 (22%) underwent both. Patients with relevant HT (N = 31;18%) had greater mean BBB leakage (Ktrans 0.77 vs. 0.60; p = 0.027). After adjustment in the logistic regression model, we found that BBB leakage was associated both with a more than twofold risk of relevant HT (odds ratio [OR] 2.50; 95% confidence interval [CI] 1.03-6.03 per Ktrans point increase; OR 2.34; 95% CI 1.06-5.17 for Ktrans values > 0.63 [mean BBB leakage value]) and with symptomatic intracerebral hemorrhage (OR 4.30; 95% CI 1.13-13.77 per Ktrans point increase). Conclusion Pretreatment BBB leakage before reperfusion therapy was associated with HT, and may help to identify patients at risk of HT.

Carotid cavernous fistulas (CCFs) are abnormal connections between the cavernous sinus (CS) and carotid arteries. In direct CCFs, a transarterial route is often the preferred vascular access; in case of indirect CCFs, the complex anatomy of the feeder vessels and their extra-intracranial anastomosis makes the transarterial embolization challenging and often ineffective. The aim of this study was to review our experience with the transorbital approach to treat patients affected by CCF who have already experienced an endovascular failure procedure, in order to assess this salvage technique feasibility, by analyzing possible risks and complications. We performed a retrospective study of all patients affected by CCFs who underwent transorbital embolization between February 2017 and February 2019 at our institution. All patients (3 cases) tolerated both the retrograde embolization and the direct surgical approach with clinical improvement; the closure of the fistula was complete and verified intraoperatively by angiography. Esthetic result was acceptable in all cases with reduction of the proptosis and the intraocular pressure, and increased visual acuity. There were no complications or clinical recurrence. Transorbital approach for the endovascular treatment of CCFs is a feasible and safe salvage procedure, which can find indication after other endovascular access failures.

BackgroundClinical trials and observational studies have demonstrated the benefit of thrombectomy up to 16 or 24 hours after the patient was last known to be well. This study aimed to evaluate the outcome of stroke patients treated beyond 24 hours from onset.MethodsWe analyzed the outcome of 34 stroke patients (mean age 70.7±12.3 years; median National Institutes of Health Stroke Scale (NIHSS) score 13) treated with endovascular thrombectomy beyond 24 hours from onset who were recruited in the Italian Registry of Endovascular Thrombectomy in Acute Stroke. Selection criteria for patients were: pre-stroke modified Rankin scale (mRS) score of ≤2, non-contrast CT Alberta Stroke Program Early CT score of ≥6, good collaterals on single phase CT angiography (CTA) or multiphase CTA, and CT perfusion mismatch with an infarct core size ≤50% of the total hypoperfusion extent or involving less than one-third of the extent of the middle cerebral artery territory evaluated by visual inspection. The primary outcome measure was functional independence assessed by the mRS at 90 days after onset. Safety outcomes were 90 day mortality and the occurrence of symptomatic intracranial hemorrhage (sICH).ResultsSuccessful recanalization (Thrombolysis in Cerebral Infarction score of 2b or 3) was present in 76.5% of patients. Three month functional independence (mRS score 0–2) was observed in 41.1% of patients. The case fatality rate was 26.5%. and the incidence of sICH was 8.8%.ConclusionsThese findings suggest that, in a real world setting, very late endovascular therapy is feasible in appropriately selected patients.

Background and purpose Wide-necked brain aneurysms therapy remains a challenge for neurointerventionalists, mainly for the high recurrence rate. Low-profile stents make feasible the treatment of these aneurysms. In our multicenter series we analyzed clinical and angiographic results of Neuroform Atlas stent-assisted coiling. Materials and methods From January 2016 to March 2017, 113 wide-necked aneurysms were discovered with CTA, MRA and DSA. The Atlas stent-assisted coiling procedures were performed under general anesthesia with sequential or jailing techniques. Six months follow-up DSA was performed to assess the recurrence rate through the modified Raymond-Roy occlusion scale (RROC). Moreover, patients were evaluated clinically to analyse the degree of disability according to the mRS. MRI was performed at 12 months evaluating both the cerebral tissue and the vessels. Results In all the procedures it was feasible to navigate the Neuroform Atlas to the goal vessel and deploy the stent across the aneurysmal neck. Intra-procedural complications account for the 6.2% (7/113). The immediate occlusion rate was RROC 1 in 88%, 2 in 9% and 3 in 3% of cases. The 6 months clinical data showed mRS Score 0–1 in 96.5% of patients; 3 patients died of complications related to SAH. The 12 months follow-up showed RROC of 1 in 82%, 2 in 13% and 3 in 5% of cases. No aneurysm has been retreated. Conclusions In our multicenter experience the Neuroform Atlas stent assisted-coiling has shown to be a safe and effective technique for the treatment of wide-necked intracranial aneurysms with encouraging clinical and angiographic results.

Partially thrombosed intracranial aneurysms (PTIA) represent a unique subset of intracranial aneurysms with an ill-defined natural history, posing challenges to standard management strategies. This study aims to assess the efficacy of flow diversion in the treatment of this pathology.A retrospective review of patients with flow-diverted PTIA at 6 cerebrovascular centers was performed. Clinical and radiographic data were collected from the medical records, with the primary outcome of aneurysmal occlusion and secondary outcomes of clinical status and complications.Fifty patients with 51 PTIA treated with flow diversion were included. Median age was 56.5 years. Thirty-three (64.7%) aneurysms were saccular and 16 (31.4%) were fusiform/dolichoectatic. The most common location was the internal carotid artery (54.9%) followed by the vertebral and basilar arteries (17.7% and 17.7%, respectively). Last imaging follow-up was performed at a median of 25.1 (interquartile range, 12.8-43) months. Complete occlusion at last radiographic follow-up was achieved in 37 (77.1%) aneurysms. Pretreatment aneurysm thrombosis of50% was associated with a significantly lower rate of complete aneurysm occlusion (58.8 vs. 87.1%, P = 0.026) with a trend toward better functional outcome (modified Rankin scale2) at last follow-up in patients with50% pretreatment aneurysm thrombosis (96.8 vs. 82.4; P = 0.08). Ischemic complications occurred in 5 (9.8%) patients, producing symptoms in 4 (7.8%) and resultant mortality in 2 (4.2%) patients.Flow diversion treatment of PTIA has adequate efficacy along with a reasonable safety profile. Aneurysms harboring large amounts of pretreatment thrombus were associated with lower rates of complete occlusion.

The Careggi Collateral Score (CCS) (qualitative–quantitative evaluation) was developed from a single-centre cohort as an angiographic score to describe both the extension and effectiveness of the pial collateral circulation in stroke patients with occlusion of the anterior circulation. We aimed to examine the association between CCS (quantitative evaluation) and 3-month modified Rankin Scale (mRS) score in a large multi-center cohort of patients receiving thrombectomy for stroke with occlusion of middle cerebral artery (MCA). We conducted a study on prospectively collected data from 1284 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. According to the extension of the retrograde reperfusion in the cortical anterior cerebral artery (ACA)-MCA territories, CCS ranges from 0 (absence of retrograde filling) to 4 (visualization of collaterals until the alar segment of the MCA). Using CCS of 4 as reference, CCS grades were associated in the direction of unfavourable outcome on 3-month mRS shift (0 to 6); significant difference was found between CCS of 0 and CCS of 1 and between CCS of 3 and CCS of 4. CCS ≥ 3 was the optimal cut-off for predicting 3-month excellent outcome, while CCS ≥ 1 was the optimal cut-off for predicting 3-month survival. CCS of 0 and CCS

Flow diverter devices have gained wide acceptance for the treatment of unruptured intracranial aneurysms. Most studies are based on the treatment of large aneurysms harboring on the carotid syphon. However, during the last years the “off-label” use of these stents has widely grown up even if not supported by randomized studies. This review examines the relevant literature concerning “off-label” indications for flow diverter devices, such as for distal aneurysms, bifurcation aneurysms, small aneurysms, recurrent aneurysms, and direct carotid cavernous fistulas.

Pre-existing small vessel disease (SVD) has been associated with poor functional outcomes in patients with acute ischemic stroke treated with intravenous thrombolysis; however, there are scarce data in patients treated with endovascular therapy. We aimed to investigate the associations between SVD and clinical outcomes in patients treated with endovascular therapy. We retrospectivel y evaluated patients with acute ischemic stroke in the anterior circulation receiving endovascular treatment. We assessed SVD markers with visual scales using non-contrast computed tomography. Early outcomes included intracerebral hemorrhage and 7-day/discharge stroke severity, and late outcomes included modified Rankin scale (mRS) 90 days after stroke. We used logistic and ordinal regression models adjusted for age, sex, stroke severity, and time-to-groin puncture time. A total of 175 patients were included in the study, mean (±SD) age 72.3 (± 12.4) years, 90 (51%) males. Among SVD features, only brain atrophy was associated with 7-day stroke severity (OR = 2.28; 95% CI = 1.11–4.68) and with worse mRS at 90 days (OR = 2.72; 95% CI = 1.25–5.91). Global SVD burden was associated with worse mRS at 90 days (OR = 1.63; 95% CI = 1.01–2.62) but not with 7-day stroke severity (OR = 1.71; 95% CI = 0.97–3.01). Pre-existing SVD burden, mainly driven by brain atrophy, negatively affects early and late clinical outcomes in anterior circulation ischemic stroke treated with endovascular therapy. Our results may help prognostic stratification of stroke patients treated with endovascular therapy.

Background Recent trials established the efficacy of mechanical stent-retriever thrombectomy for treatment of stroke patients with large vessel occlusion (LVO) in the anterior circulation. However, stent-retriever thrombectomy may not accomplish successful recanalization in all patients. The aim of this study is to report the role of bail-out permanent stenting after failure of mechanical thrombectomy. Methods Among 430 patients included in a prospectively maintained database, we analysed 325 cases of anterior circulation LVO. Mechanical thrombectomy (mTICI 2b-3) was effective in 213/325 (65%) and failed in 112/325 (35%). Bail-out intracranial stenting was performed in 17/325 (5.2%) patients. In all cases a fully retrievable detachable stent was used (Solitaire AB, Medtronic). Results No intraprocedural technical complications occurred. Successful reperfusion (mTICI 2b/3) was achieved in 12/17 patients (70.6%). Three (17.6%) patients died: one extensive infarction in the internal carotid artery territory, one large intracerebral haemorrhage, and one massive pulmonary embolism. Haemorrhagic conversion, both symptomatic and asymptomatic, occurred in 2/17 (11.7%). Good clinical outcome (mRS 0–2) at 3-months was achieved in 41.2% of patients. Conclusion Bail-out intracranial stenting after unsuccessful thrombectomy is technically feasible and the associated haemorrhagic risk seems acceptable in selected patients. We suggest that bail-out intracranial stenting, is safe and effective in selected patients with LVO stroke who failed to respond to thrombectomy.

Background and Purpose: Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19. Methods: Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality. Secondary outcomes: early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0–1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage. Results: We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years [interquartile range, 59–79]; 63 men [67.7%]). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11–21) and 8 (interquartile range, 7–9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients [95% CI, 71.3–87.8]). Thirty-day mortality was 29% (27 patients [95% CI, 20–39.4]). Early neurological improvement was 19.5% (17 patients [95% CI, 11.8–29.5]), and symptomatic intracranial hemorrhage was 5.4% (5 patients [95% CI, 1.7–12.1]). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 [95% CI, 1.21–5.98] per SD-log decrease in lymphocyte count, 2.66 [95% CI, 1.22–5.77] per SD-log increase in aspartate, and 4.30 [95% CI, 1.43–12.91] per SD-log increase in LDH). Conclusions: The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient’s profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT04406090.

BACKGROUND AND PURPOSE The aim was to assess functional and radiological outcomes after bridging therapy (intravenous thrombolysis plus mechanical thrombectomy) versus direct mechanical thrombectomy (MT) in unknown onset stroke patients. METHODS A cohort study was conducted on prospectively collected data from unknown onset stroke patients who received endovascular procedures at ≤6 h from symptom recognition or awakening time. RESULTS Of the 349 patients with a 10-point Alberta Stroke Program Early Computed Tomography Score (ASPECTS), 248 received bridging and 101 received direct MT. Of the 134 patients with 6-9-point ASPECTS, 123 received bridging and 111 received direct MT. Each patient treated with bridging was propensity score matched with a patient treated with direct MT for age, sex, study period, pre-stroke disability, stroke severity, type of stroke onset, symptom recognition to groin time (or awakening to groin time), ASPECTS and procedure time. In the two matched groups with 10-point ASPECTS (n = 73 vs. n = 73), bridging was associated with higher rates of excellent outcome (46.6% vs. 28.8%; odds ratio 2.302, 95% confidence interval 1.010-5.244) and successful recanalization (83.6% vs. 63%; odds ratio 3.028, 95% confidence interval 1.369-6.693) compared with direct MT; no significant association was found between bridging and direct MT with regard to rate of symptomatic intracerebral hemorrhage (0% vs. 1.4%). In the two matched groups with 6-9-point ASPECTS (n = 45 vs. n = 45), no significant associations were found between bridging and direct MT with regard to rates of excellent functional outcome (44.4% vs. 31.1%), successful recanalization (73.3% vs. 76.5%) and symptomatic intracerebral hemorrhage (0% vs. 0%). CONCLUSIONS Bridging at ≤ 6 h of symptom recognition or awakening time was associated with better functional and radiological outcomes in unknown onset stroke patients with 10-point ASPECTS.

During the coronavirus disease 2019 (COVID-19) pandemic, the World Health Organization recommended measures to mitigate the outbreak such as social distancing and confinement. Since these measures have been put in place, anecdotal reports describe a decrease in the number of endovascular therapy (EVT) treatments for acute ischemic stroke due to large vessel occlusion. The purpose of our study was to determine the effect on EVT for patients with acute ischemic stroke during the COVID-19 confinement. In this retrospective, observational study, data were collected from November 1, 2019, to April 15, 2020, at 17 stroke centers in countries where confinement measures have been in place since March 2020 for the COVID-19 pandemic (Switzerland, Italy, France, Spain, Portugal, Germany, Canada, and United States). This study included 1600 patients treated by EVT for acute ischemic stroke. Date of EVT and symptom onset-to-groin puncture time were collected. Mean number of EVTs performed per hospital per 2-week interval and mean stroke onset-to-groin puncture time were calculated before confinement measures and after confinement measures. Distributions (non-normal) between the 2 groups (before COVID-19 confinement versus after COVID-19 confinement) were compared using 2-sample Wilcoxon rank-sum test. The results show a significant decrease in mean number of EVTs performed per hospital per 2-week interval between before COVID-19 confinement (9.0 [95% CI, 7.8–10.1]) and after COVID-19 confinement (6.1 [95% CI, 4.5–7.7]), ( P P

Background Shunt-dependent hydrocephalus significantly complicates subarachnoid hemorrhage (SAH), and reliable prognosis methods have been sought in recent years to reduce morbidity and costs associated with delayed treatment or neglected onset. Machine learning (ML) defines modern data analysis techniques allowing accurate subject-based risk stratifications. We aimed at developing and testing different ML models to predict shunt-dependent hydrocephalus after aneurysmal SAH. Methods We consulted electronic records of patients with aneurysmal SAH treated at our institution between January 2013 and March 2019. We selected variables for the models according to the results of the previous works on this topic. We trained and tested four ML algorithms on three datasets: one containing binary variables, one considering variables associated with shunt-dependency after an explorative analysis, and one including all variables. For each model, we calculated AUROC, specificity, sensitivity, accuracy, PPV, and also, on the validation set, the NPV and the Matthews correlation coefficient (ϕ). Results Three hundred eighty-six patients were included. Fifty patients (12.9%) developed shunt-dependency after a mean follow-up of 19.7 (± 12.6) months. Complete information was retrieved for 32 variables, used to train the models. The best models were selected based on the performances on the validation set and were achieved with a distributed random forest model considering 21 variables, with a ϕ = 0.59, AUC = 0.88; sensitivity and specificity of 0.73 (C.I.: 0.39–0.94) and 0.92 (C.I.: 0.84–0.97), respectively; PPV = 0.59 (0.38–0.77); and NPV = 0.96 (0.90–0.98). Accuracy was 0.90 (0.82–0.95). Conclusions Machine learning prognostic models allow accurate predictions with a large number of variables and a more subject-oriented prognosis. We identified a single best distributed random forest model, with an excellent prognostic capacity (ϕ = 0.58), which could be especially helpful in identifying low-risk patients for shunt-dependency.

Background and Purpose: As numerous questions remain about the best anesthetic strategy during thrombectomy, we assessed functional and radiological outcomes in stroke patients treated with thrombectomy in presence of general anesthesia (GA) versus conscious sedation (CS) and local anesthesia (LA). Methods: We conducted a cohort study on prospectively collected data from 4429 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. Results: GA was used in 2013 patients, CS in 1285 patients, and LA in 1131 patients. The rates of 3-month modified Rankin Scale score of 0–1 were 32.7%, 33.7%, and 38.1% in the GA, CS, and LA groups: GA versus CS: odds ratios after adjustment for unbalanced variables (adjusted odds ratio [aOR]), 0.811 (95% CI, 0.602–1.091); and GA versus LA: aOR, 0.714 (95% CI, 0.515–0.990). The rates of modified Rankin Scale score of 0–2 were 42.5%, 46.6%, and 52.4% in the GA, CS, and LA groups: GA versus CS: aOR, 0.902 (95% CI, 0.689–1.180); and GA versus LA: aOR, 0.769 (95% CI, 0.566–0.998). The rates of 3-month death were 21.5%, 19.7%, and 14.8% in the GA, CS, and LA groups: GA versus CS: aOR, 0.872 (95% CI, 0.644–1.181); and GA versus LA: aOR, 1.235 (95% CI, 0.844–1.807). The rates of parenchymal hematoma were 9%, 12.6%, and 11.3% in the GA, CS, and LA groups: GA versus CS: aOR, 0.380 (95% CI, 0.262–0.551); and GA versus LA: aOR, 0.532 (95% CI, 0.337–0.838). After model of adjustment for predefined variables (age, sex, thrombolysis, National Institutes of Health Stroke Scale, onset-to-groin time, anterior large vessel occlusion, procedure time, prestroke modified Rankin Scale score of Conclusions: GA during thrombectomy was associated with worse 3-month functional outcomes, especially when compared with LA. The inclusion of an LA arm in future randomized clinical trials of anesthesia strategy is recommended.

Background The applicability of the current models for predicting functional outcome after thrombectomy in strokes with large vessel occlusion (LVO) is affected by a moderate predictive performance. Aims We aimed to develop and validate a nomogram with pre- and post-treatment factors for prediction of the probability of unfavorable outcome in patients with anterior and posterior LVO who received bridging therapy or direct thrombectomy Methods We conducted a cohort study on patients data collected prospectively in the Italian Endovascular Registry (IER). Unfavorable outcome was defined as three-month modified Rankin Scale (mRS) score 3–6. Six predictors, including NIH Stroke Scale (NIHSS) score, age, pre-stroke mRS score, bridging therapy or direct thrombectomy, grade of recanalization according to the thrombolysis in cerebral ischemia (TICI) grading system, and onset-to-end procedure time were identified a priori by three stroke experts. To generate the IER-START, the pre-established predictors were entered into a logistic regression model. The discriminative performance of the model was assessed by using the area under the receiver operating characteristic curve (AUC-ROC). Results A total of 1802 patients with complete data for generating the IER-START was randomly dichotomized into training ( n = 1219) and test ( n = 583) sets. The AUC-ROC of IER-START was 0.838 (95% confidence interval [CI]): 0.816–0.869) in the training set, and 0.820 (95% CI: 0.786–0.854) in the test set. Conclusions The IER-START nomogram is the first prognostic model developed and validated in the largest population of stroke patients currently candidates to thrombectomy which reliably calculates the probability of three-month unfavorable outcome.

Background and Purpose— Despite the recent technical evolution of the endovascular treatment of acute ischemic stroke, late and incomplete recanalization can be achieved after several maneuvers but with a potentially higher risk of futile reperfusion and complications, such as clot fragmentation. The aim of this article is to investigate the impact of the angiographic phenotype of M1-middle cerebral artery occlusions, classified as regular and irregular in aspect, on the results of treatment by stent retrievers (SRs) or contact aspiration (CA). Methods— From January to April 2016, 84 consecutive patients, admitted for acute ischemic stroke with a middle cerebral artery occlusion, were treated by endovascular therapy. Among them, 60 patients (26M, 34F, median age, 70.5; interquartile range, 58.5–80.0) were treated by SR (25/60, 41.7%) or CA (35/60, 58.3%) as a first-line approach in 2 experienced centers. Patients’ characteristics, timing, and procedural data were prospectively recorded and compared between the 2 study subgroups (regular and irregular phenotype). Results— A regular phenotype at the occlusion site was observed in 24 patients (40%). Among these, successful recanalization after the first-line strategy (Thrombolysis in Cerebral Infarction 2b-3) was achieved in 100% of patients treated by CA and in only 33.3% of patients treated by SR ( P =0.001). For irregular phenotypes, SR achieved Thrombolysis in Cerebral Infarction 2b-3 in 73.9% and CA, in 38.5% ( P =0.036) of cases. Among regular phenotype patients, the average number of maneuvers was 1.3 (median, 1; range 1–3) with first-line CA and 2.7 (median, 3; range 1–5) with first-line SR ( P =0.008). Conclusions— The angiographic phenotype of the occlusion site may be associated with a different response to SR and CA in this preliminary experience.

Background PulseRider (Pulsar Vascular, Los Gatos, California, USA) is a new endovascular device designed to treat wide-neck bifurcation intracranial aneurysms. Deployment of a stent through a PulseRider to treat an aneurysm's recurrence has never been described before. Case Description We report the case of a 55-year-old man who underwent coiling of an 8-mm anterior communicating artery aneurysm with assistance of a PulseRider neck reconstruction device. The 6-month digital subtraction angiography control showed aneurysm recurrence, so we deployed an Enterprise 2 closed-cell stent (Codman, Miami Lakes, Florida, USA) in the A1-A2 segment passing across the previously implanted PulseRider. Enterprise correctly expanded and allowed for adequate coiling of the aneurysm. Conclusion An Enterprise stent can be safely opened through a PulseRider in order to treat aneurysm recurrence.

BACKGROUND Y-stenting is an effective but challenging approach for wide-neck aneurysms. PulseRider (PR) (Pulsar/Cerenovus) is a new device designed to provide scaffolding during coiling but has never been compared with other techniques. OBJECTIVE To compare the immediate and 6-mo results of Y-stenting vs PR assisted coiling. METHODS A total of 105 consecutive patients were retrospectively divided into 2 groups (73 Y-stenting and 32 PR). All underwent angiographic 6-mo follow-up. We evaluated if some anatomical features could influence treatment results. RESULTS The groups were homogeneous. Immediate adequate occlusions as well as complication rates were similar in Y-stenting and PR group (94.5% vs 96.9% and 8.2% vs 6.2%, respectively). At 6 mo, adequate occlusion was 93.1% after Y-stenting and 84.3% after PR (P = .28), complete occlusion was significantly higher after Y-stenting: 90.3% vs 62.5% (P = .0017). Occlusion grade worsening occurred in 6.9% of Y-stenting and 18.7% of PR patients (P = .09).Neck size was associated with occlusion grade in both groups. Maximal aneurysm size was associated with occlusion grade in the PR group (P = .023) but not in the Y-stenting group (P = .06). After PR, 6-mo occlusion rate was higher in small (< 10 mm) than in large aneurysms (P = .0094); this was not observed after Y-stenting (P = .54).Location did not significantly affect the mid-term occlusion rate in both the groups. After PR, occlusion was more stable in basilar than anterior or middle cerebral artery aneurysms. CONCLUSION Y-stenting and PR are both effective with similar immediate and mid-term results. However, treatment stability seems higher after Y-stenting. Aneurysm size seems to negatively affect PR results.

Background: Whether direct aspiration first pass technique (ADAPT) is associated with better clinical and procedural outcomes compared with stent retriever thrombectomy in basilar artery occlusion (BAO) is uncertain. We compared reperfusion and clinical outcomes between ADAPT and stent retriever thrombectomy (SR) in BAO. Methods: Clinical and procedural data of consecutive endovascular-treated stroke patients with BAO diagnosed on CT angiography from the multisite international Basilar Artery Treatment and MANagement (BATMAN) collaboration were retrospectively analysed. Good outcome was defined as modified Rankin Scale≤3 at 3 months; successful reperfusion as mTICI 2b-3 and complete reperfusion as TICI 3. Results: We included 107 BAO patients treated with mechanical thrombectomy [31 treated with first-line ADAPT and 76 with stent retriever or combined approach (“Solumbra technique”)]. An additional SR was used in 3/28 (11%) patients in the ADAPT group. Mean age was 67 (SD 14), median NIHSS 18 (IQR 7-29.5), 36% of patients received intravenous thrombolysis prior to mechanical thrombectomy. Median procedural time was 91min (IQR 49-132). Successful reperfusion was achieved in 87/107 (81%) of patients and good outcome was observed in 42/100 (42%) patients. Although a greater proportion of patients achieved successful reperfusion in the ADAPT group, this was not significant (ADAPT 87% vs SR 79%, p=0.4). Similarly, complete reperfusion occurred in 67% ADAPT vs 51% SR (p=0.2).14% of patients were treated beyond 6 hours in the ADAPT group vs 38% in the SR group (p=0.02). Procedural times were significantly shorter in the ADAPT group [52min (IQR 29-103.5) vs SR 99.5min (IQR 72-143); p6 hours, ADAPT remained associated with good outcome (cOR 3.4, 95%CI 1.3-8.6, p=0.01). Conclusions: ADAPT is associated with shorter procedural times and improved outcomes in comparison with stent retriever thrombectomy in BAO. Rates of successful reperfusion were similar in the two groups. Randomized controlled trials to determine the optimal endovascular technique are warranted.

Multiple carotid cavernous fistula (CCF) classifications have been proposed. However, they lacked predictive factors for the clinical presentation, natural history, and hemorrhagic risk. Our aim was to externally validate a new classification according to venous drainage (i.e., the Thomas classification [TC]) to assess its relationship with symptoms, endovascular treatment, and outcomes.We performed a multicenter retrospective review of CCFs at 2 major academic institutions. The CCFs were classified using the Barrow classification (BC) and TC systems.The data from 94 patients with a diagnosis of CCF were collected during a study period 23 years, 4 months. Of these 94 patients, 89 had undergone CCF treatment and 5 had experienced spontaneous occlusion. Complete occlusion was achieved in 89.9% of the treated patients. Complications occurred in 5.3% of the patients, including permanent deficits in 2.1%. TC type 4 was associated with cortical symptoms compared with type 2 (P = 0.003) and type 3 (P0.001). The BC was not able to detect significant differences among the symptom types. Significant differences were found using the TC for the transarterial-only, transvenous anterior-only, and transvenous posterior-only approaches (P0.001, P = 0.03, and P = 0.001, respectively). The transvenous posterior and transvenous anterior approach were significantly associated with type 2 and 3 TC, respectively. Excluding direct CCFs, the BC was not related to the treatment approach. No significant differences in the outcomes were found. However, a trend toward a lower occlusion rate for TC type 4 compared with type 3 was observed.The TC provided useful information regarding the fistula anatomy and venous hemodynamics, which correlated with the clinical symptoms and treatment strategy.

BACKGROUND: Flow diversion for anterior communicating artery aneurysms required further investigation. PURPOSE: Our aim was to analyze outcomes after treatment of anterior communicating artery aneurysms with flow-diverter stents. DATA SOURCES: A systematic search of 3 data bases was performed for studies published from 2008 to 2018. STUDY SELECTION: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting anterior communicating artery aneurysms treated with flow diversion. DATA ANALYSIS: Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and factors influencing the studied outcomes. DATA SYNTHESIS: We included 14 studies and 148 unruptured saccular anterior communicating artery aneurysms treated with flow diversion. The long-term complete/near-complete (O'Kelly-Marotta C–D) occlusion rate was 87.4% (91/105; 95% CI, 81.3%–93.6%; I(2) = 0%) (mean radiologic follow-up of 11 months). The treatment-related complication rate was 8.6% (14/126; 95% CI, 4%–13.1%; I(2) = 0%), with morbidity and mortality rates of 3.5% (5/126; 95% CI, 2%–7%; I(2) = 0%) and 2.5% (2/148; 95% CI, 0.3%–5%; I(2) = 0%), respectively. Most complications were periprocedural (12/126 = 7%; 95% CI, 3%–11%; I(2) = 0%). Thromboembolic events were slightly higher compared with hemorrhagic complications (10/126 = 6%; 95% CI, 2%–10%; I(2) = 0% and 4/126 = 3%; 95% CI, 1%–6%; I(2) = 0%). Branching arteries (A2 or the recurrent artery of Heubner) covered by the stent were occluded in 16% (7/34; 95% CI, 3.5%–28%; I(2) = 25%) of cases. Pre- and posttreatment low-dose and high-dose of antiplatelet therapy was not associated with significantly different complication and occlusion rates. LIMITATIONS: We reviewed small and retrospective series. CONCLUSIONS: Flow diversion for unruptured saccular anterior communicating artery aneurysms appears to be an effective alternative treatment for lesions difficult to treat with coiling or microsurgical clipping. The treatment-related complication rate was relatively low. However, larger studies are needed to confirm these results.

Introduction We report our experience with the novel stent-type clot-retrieval device EmboTrap II for the revascularization of large artery occlusions in acute ischaemic stroke. Materials and methods Twenty-nine patients with acute ischaemic stroke due to large artery occlusion underwent mechanical thrombectomy with the new EmboTrap II in two Italian centres. Clinical, procedural and radiological data were collected. Angiographic results and neurological outcomes were analysed. Results Only large vessel occlusions were included. Intravenous thrombolysis was administered in 72% of patients. Successful reperfusion (TICI 2b-3) was obtained in 76% of patients treated exclusively with EmboTrap II. No device-related permanent complications occurred. Conclusion In our experience, mechanical thrombectomy with EmboTrap II is safe and effective. Reperfusion rate was comparable to that obtained with other stent retrievers.

This case describes the strong utility of optical coherence tomography in multidisciplinary management of a complex case of type 2 neurofibromatosis.

Background and Importance: Symptomatic vasospasm is a well-known pathology associated with ruptured aneurysms. Nevertheless, this condition is rarely found as a result of skull base tumor removal. Case Presentation: We reported a new case of 40-year-old woman previously treated for a tuberculum and diaphragma sellae meningioma showing symptomatic vasospasm after twelve post-operative days without previously documented sub-arachnoid hemorrhage (SAH). A digital subtraction angiography (DSA) was performed, and a bilateral vasospasm was detected. After subsequent endovascular treatments by intra-arterial infusion of nimodipine, the patient experienced a full recovery. Conclusion: Symptomatic vasospasm after meningioma removal is a challenging and life-threatening condition. Early diagnosis is the key for successful treatment.

Background Mechanical thrombectomy is now standard of care for treatment of acute ischemic stroke secondary to large vessel occlusion in the setting of high NIHSS. We analysed a large nationwide registry focusing on patients with large vessel occlusion and low NIHSS on admission to evaluate the efficacy and safety of thrombectomy in this patient population Methods 2826 patients treated with mechanical thrombectomy were included in a multicentre registry from January 1, 2011 to December 31, 2015. We included patients with large vessel occlusion and NIHSS ≤ 6 on admission. Baseline characteristics, imaging, clinical outcome, procedure adverse events and positive and negative outcome predictors were analysed. Results 134 patients were included. 90/134 had an anterior circulation and 44 a posterior circulation stroke. One patient died before treatment. Successful revascularization (mTICI 2b-3) was achieved in 73.7% (98/133) of the patients. Intraprocedural adverse event was observed in 3% (4/133) of cases. Symptomatic intracranial haemorrhage rate was 5.3% (7/133). At three months, 70.9% (95/134) of the patients had mRS score 0-2, 15.7% (21/134) mRS 3-5 and 13.4% (18/134) mRS 6. Age and successful recanalization were significant predictors of a good clinical outcome on both univariate (p= 0.005 and p=0.007) and multivariable (p=0.0018 and p=0.009 [nat log]) analysis. Absence of vessel recanalization and symptomatic intracranial hemorrhage were independent predictors of poor outcome (p=0.021) . Conclusions Our study suggests that patients with large vessel occlusion and low NIHSS score on admission can benefit from mechanical thrombectomy. Randomized trials are warranted.

BACKGROUND: Y-stent-assisted coiling for wide-neck intracranial aneurysms required further investigation. PURPOSE: Our aim was to analyze outcomes after Y-stent placement in wide-neck aneurysms. DATA SOURCES: We performed a systematic search of 3 data bases for studies published from 2000 to 2018. STUDY SELECTION: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting Y-stent-assisted coiling of wide-neck aneurysms. DATA ANALYSIS: Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and factors influencing the studied outcomes. DATA SYNTHESIS: We included 27 studies and 750 aneurysms treated with Y-stent placement. The immediate complete/near-complete occlusion rate was 82.2% (352/468; 95% CI, 71.4%–93%; I(2) = 92%), whereas the long-term complete/near-complete occlusion rate was 95.4% (564/598; 95% CI, 93.7%–97%; I(2) = 0%) (mean radiologic follow-up of 14 months). The aneurysm recanalization rate was 3% (20/496; 95% CI, 1.5%–4.5%; I(2) = 0%), and half of the recanalized aneurysms required retreatment. The treatment-related complication rate was 8.9% (63/614; 95% CI, 5.8%–12.1%; I(2) = 44%). Morbidity and mortality after treatment were 2.4% (18/540; 95% CI, 1.2%–3.7%; I(2) = 0%) and 1.1% (5/668; 95% CI, 0.3%–1.9%; I(2) = 0%), respectively. Crossing Y-stent placement was associated with a slightly lower complication rate compared with the kissing configuration (56/572 = 8.4%; 95% CI, 5%–11%; I(2) = 46% versus 4/30 = 12.7%; 95% CI, 3%–24%; I(2) = 0%). Occlusion rates were quite comparable among Enterprise, Neuroform, and LVIS stents, whereas the Enterprise stent was associated with lower rates of complications (8/89 = 6.5%; 95% CI, 1.6%–11%; I(2) = 0%) compared with the others (20/131 = 14%; 95% CI, 5%–26%; I(2) = 69% and 9/64 = 11%; 95% CI, 3%–20%; I(2) = 18%). LIMITATIONS: This was a small, retrospective series. CONCLUSIONS: Y-stent-assisted coiling yields high rates of long-term angiographic occlusion, with a relatively low rate of treatment-related complications. Y-stent placement with a crossing configuration appears to be associated with better outcomes. Although Y-configuration can be obtained using many types of stents with comparable occlusion rates, the Enterprise stent is associated with lower complication rates.

Background Ethmoidal dural arteriovenous fistulas (DAVFs) are rare and aggressive lesions, usually treated by microsurgical disconnection of the fistula. Transarterial embolization rarely is performed because of the risk of retinal ischemia. Transvenous embolization has been reported as an alternative approach. We describe our experience in transvenous embolization of ethmoidal DAVFs and review the literature focusing on technical and safety aspects of the procedure. Methods We retrospectively identified 4 patients with ethmoidal DAVFs treated by transvenous embolization in a single center. Clinical data and angiographic images were reviewed. We reviewed the literature after PubMed searching for articles describing patients treated by a transvenous approach. Results One patient was treated by transvenous coiling and 3 patients by retrograde Onyx injection through a detachable-tip microcatheter. Three fistulas drained in an ascending cortical frontal vein and one drained posteriorly in the olfactory vein. In all patients the fistula was occluded, in one case an asymptomatic hemorrhage occurred. In the literature 12 further cases of transvenous embolization of ethmoidal DAVFs have been reported. Conclusions Transvenous embolization is an effective approach for the treatment of ethmoidal DAVFs in properly selected patients. Onyx injection through detachable-tip microcatheters increases the feasibility of the intervention.

Anton-Babinski syndrome is a rare neuropsychiatric syndrome characterized by bilateral cortical blindness and anosognosia with visual confabulation. We present the case of a patient presenting with occlusion of both posterior cerebral arteries (PCA), with Anton-Babinski syndrome, completely solved after combined systemic thrombolysis and mechanical thrombectomy with a stent-retriever.

The experience with Woven EndoBridge (WEB) device is still limited. The aim of this study is to discuss the efficacy of this new device, focusing on any anatomical and procedural factors influencing aneurysm occlusion.Between October 2011 and November 2016, 24 patients (10 female, 14 male) harboring 24 cerebral aneurysms treated with WEB in a single center were retrospectively reviewed. Patients underwent 6-month and 12- to 24-month (median 18 months) clinical and neuroradiologic follow-up. We evaluated whether any procedural or anatomical aspect influenced the occlusion rate.Adequate occlusion (AO) was achieved in 68% of cases at 6 months' and in 87% at 18 months' follow-up respectively. Technical difficulties occurred in 3 procedures (12.5%). No postprocedural morbidity was reported. One patient (4%) died after 1 month for reasons unrelated to the procedure. Neck size and dome-to-neck ratio were significantly associated with aneurysm occlusion (P0.05). AO was not associated with postoperative dual antiplatelet therapy (P0.99) or device compression at both first and second follow-up (P0.99). Immediate contrast agent stagnation was more common in aneurysms that were occluded at first (P = 0.37) and second follow-up (P = 0.24), but statistical significance was not reached.Endovascular treatment with WEB is a safe treatment for unruptured cerebral aneurysms, also resulting in a good AO rate in aneurysms that would otherwise require complex assisted coiling techniques. However, results are less favorable in cases of very large aneurysmal neck. Nevertheless, further series with larger patient populations and longer follow-up will define the role of WEB in the treatment of aneurysms.

BackgroundY-stent assisted coiling has been proposed for the treatment of wide-neck bifurcation aneurysms, but there are many technical variations. We report our single-center experience of Y-stent assisted coiling of bifurcation aneurysms with the closed cell Enterprise stent in order to evaluate the safety and long-term results of this technique. The literature on Y-stenting and its hemodynamic effects are reviewed.MethodsFifty-two consecutive patients with wide-neck bifurcation aneurysms underwent Y-stent assisted coiling with two Enterprise stents. The procedure was completed in 48 cases (92.3%) and technical failure occurred in 4 cases (7.3%). Cases performed with other stents were excluded. All procedures were performed under double antiplatelet therapy. Periodic clinical and neuroradiological follow-up was performed.ResultsMean neuroradiological follow-up time was 26 months. Complete immediate occlusion was obtained in 87.5% of patients. Two remnants had regrown at follow-up and were recoiled, achieving complete occlusion. The late neuroradiological occlusion rate was: complete occlusion 93.6%, neck remnant 4.3%, sac remnant 2.1%. No in-stent stenosis was detected at follow-up. Among the 48 procedures, two complications occurred (4.2%). Mortality was 2.1%. No delayed ischemic stroke occurred.ConclusionsY-stent assisted coiling has a high immediate occlusion rate and very good long-term stability. The procedure is relatively safe, although the complication and mortality rates are not negligible. Two Enterprise stents can be safely used for Y-stenting and, indeed, offer the advantage of easier catheterization, delivery and deployment into distal and tortuous vessels than open cell stents.

Endovascular treatment of wide-neck bifurcation aneurysms is challenging and often requires adjunctive techniques and devices. We report our experience with the hybrid Y stenting with the waffle-cone technique, combining Y stent-assisted coiling and waffle-cone stenting techniques. This approach has been described only in a single case report using a combination of open and closed cell stents. We describe four cases treated by hybrid Y stenting with the waffle-cone procedure with a variation from the originally reported technique, consisting in deploying two closed cell stents. All patients were successfully treated without complications. We propose hybrid Y stenting with the waffle-cone for the treatment of wide-neck bifurcation aneurysms as a bailout technique after failure of Y stent-assisted coiling.

Brain arteriovenous malformations (AVMs) are a rare pathology, and their treatment is discussed. The development of techniques and materials in endovascular, radiosurgical, and neurosurgical fields led to higher rates of complete occlusions and good clinical outcomes.84 patients (52 men, 32 women; mean age 38.2 years; range, 9-70 years) were treated at our institution with Onyx18 from 2001 to 2011. Patients treated with other embolic agents, with micro-AVMs, were not included in the analysis.Complete occlusion was achieved in 27/84 patients (32.2%), in 40/84 (47.6%) brain AVMs occlusion of 80-90% of the nidus was obtained, and in 17/84 (20.3%) cases80% of the nidus was occluded. Intraprocedural adverse events occurred in 11/84 patients (13.1%), and overall mortality and disabling permanent morbidity were 2.3% (2/84) and 4.7% (4/84), respectively.Endovascular treatment may be considered a safe and effective approach in superficial small brain AVMs in addition to surgery, mostly in ruptured AVMs. The therapeutic strategy should be to cure small and medium AVMs with endovascular treatment alone or combined treatment. Large unruptured AVMs (Spetzler-Martin grades IV-V) should be treated with target embolization of high flow fistulas or intranidal aneurysms.

This study evaluated clinical and neuroradiological results in 13 consecutive patients with spontaneous and traumatic direct carotid cavernous fistulas treated at our center between January 2006 and September 2012. All patients were treated by coiling of the cavernous sinus. Coiling was always performed while a semi-compliant non-detachable balloon was temporarily inflated in the internal carotid artery. This technique (balloon-assisted coiling) permitted a clear visualization of the fistula, facilitated coil positioning and protected the patency of the artery. All patients' clinical data and radiological examinations were reviewed; nine patients underwent radiological and clinical follow-up, with a mean duration of 3.8 years (range: six months-six years). Overall results at discharge showed a complete occlusion of the fistula in seven patients (7/13, 54%) and a resolution of symptoms in eight patients (8/12, 67%). Radiological follow-up showed complete occlusion of the fistula in all patients (9/9, 100%) and clinical follow-up showed a resolution of symptoms in eight patients (8/9, 89%) and persistent symptoms in one (1/9, 11%). No procedure-related complications occurred. Balloon-assisted coiling of the cavernous sinus for the treatment of direct carotid cavernous fistulas proved an effective and safe technique, both in angiographic and clinical terms, and may be considered a technical improvement.

Despite the encouraging results obtained with the endovascular treatment of ruptured intracranial aneurysms, few data are available on the effects of the timing of this approach on clinical outcome. The aim of our study was to evaluate the effects of the hyper-early timing of treatment and of pre-treatment and treatment-related variables on the clinical outcome of patients with ruptured intracranial aneurysms. Five hundred and ten patients (167 M, 343 F; mean age 56.45 years) with 557 ruptured intracranial aneurysms were treated at our institution from 2000 to 2011 immediately after their admission. The total population was divided into three groups: patients treated within 12 hours (hyper-early, group A), between 12–48 hours (early, group B) and after 48 hours (delayed, group C). A statistical analysis was carried out for global population and subgroups. Two hundred and thirty-four patients (46%) were included in group A, 172 (34%) in group B and 104 (20%) in group C. Pre-treatment variables (Hunt&Hess, Fisher grades, older age) and procedure-related variable (ischaemic/haemorrhagic complications) showed a significant correlation with worse clinical outcomes. The hyper-early treatment showed no correlation with good clinical outcomes. The incidence of intraprocedural complications was not significantly different between the three groups; 1.2% of pre-treatment rebleedings were observed. The hyper-early endovascular treatment of ruptured intracranial aneurysm does not seem to be statistically correlated with good clinical outcomes although it may reduce the incidence of pre-treatment spontaneous rebleedings without being associated with a higher risk of intraprocedural complications. However, since no significant differences in terms of clinical outcome and pre-treatment rebleeding rate were observed, a hyper-early treatment is not be supported by our data.

Background Arteriovenous malformation (AVM) treatment is multidisciplinary, and the patient may undergo embolization, neurosurgery, or radiosurgery combined. Great improvement in endovascular techniques was provided by the introduction of Onyx with different kinds of approach. Objective To evaluate the efficacy and the safety of Onyx embolization of brain AVMs with the double arterial catheterization technique (DACT). Methods This was a retrospective study. From January 2006 until June 2011, 61 AVMs eligible for the DACT were treated. Forty-one of the 61 AVMs were treated with single arterial catheterization technique and 20 of 61 with DACT; patient age and Spetzler-Martin AVM grade were similar in the 2 groups. Results In the DACT group, we obtained complete occlusion of the nidus in all small AVMs, whereas in the single arterial catheterization technique group, we obtained complete occlusion in only 1 of the 36% of the cases. Among the medium-size AVMs, there were no significant differences in the 2 groups, but we performed fewer procedures per patient when we used the DACT (1.4 vs 2.2). In the DACT group, we observed fewer hemorrhagic complications (3.4% vs 12.5% per procedure) and lower morbidity (5% vs 7% per patient) and mortality (0% vs 2.4%) rates. Conclusion The DACT in multifeeder AVMs may lead to a higher occlusion rate of the nidus for small AVMs and reduce the number of procedures, ensuring a higher standard of safety because of the possibility of managing the progression of Onyx into venous drainage.

Carotid artery dissection is a common cause of juvenile stroke. Endovascular treatment of acute stroke due to carotid dissection can be challenging, and endoluminal crossing of the dissection is sometimes impossible. We describe a case of intentional subintimal recanalisation of a cervical carotid dissection followed by intracranial thrombectomy and stenting. We report the case of a young woman with severe acute ischaemic stroke due to carotid artery dissection and intracranial embolism. After failure of endoluminal crossing of the dissected segment, intentional subintimal crossing with re-entry distally to the dissection was achieved and a stent was deployed. Then, middle cerebral artery thrombectomy was performed achieving good recanalisation. Acute thrombus formed in the bulged segment of the carotid stent and was managed with additional stent placement. The patient had a good clinical recovery. In selected cases, after failure of conventional techniques, subintimal recanalisation of carotid dissections may be performed.

Endovascular management of maxillary arteriovenous malformation (AVMs) can be complex. Transarterial, transvenous, and direct puncture embolization has been described. The authors report the case of a 9-year-old girl with a hemorrhagic maxillary AVM, which has been treated by transvenous embolization after failure of transarterial embolization. The venous pouch was catheterized with a detachable tip microcatheter and occluded by slow Onyx injection. Onyx filled the pouch and retrogradely reached some arterial feeders, achieving complete occlusion. Bleeding episode ceased and at 6 months follow-up no recurrence was found. Maxillary AVMs can be successfully treated by transvenous Onyx embolization.

Dural arteriovenous fistula (DAVF) may present with a variety of neurological symptoms, ranging from tinnitus to fatal hemorrhage. We report a case of rapidly progressive cognitive impairment due to cerebral venous engorgement that reversed after endovascular treatment in a patient with DAVF, cerebral sinus thrombosis and protein S deficiency. DAVF may be a cause of vascular cognitive impairment and should be considered particularly in cases with a rapidly progressive course because they are potentially treatable.

The treatment of brain arteriovenous malformations (AVMs) in children has always been a challenge for interventionalists, neurosurgeons, and radiosurgeons. Endovascular embolization is usually performed through transarterial access, but in selected cases the transvenous approach can be considered. The authors of this report aimed to evaluate the efficacy of transvenous embolization in very selected pediatric cases. They describe 4 children treated using transvenous embolization for AVMs that were small, had a single drainage vein, and were deeply located or had a difficult arterial access. The 6-month angiographic and clinical follow-ups are reported as well. In all cases, complete occlusion of the AVM was achieved with no side effects for the patient. Transvenous embolization may represent a promising alternative therapeutic option in very selected cases.

Background The main target of stroke intervention is the revascularization of occluded vessels, usually achieved with thrombectomy or thrombus aspiration. Despite good results in limited series, intracranial primary stenting is controversial for increased hemorrhagic risk owing to the need for dual antiplatelet therapy. Case Description We present a case of trans-anterior communicating artery primary stenting in an acute tandem middle cerebral artery–internal carotid artery occlusion in a patient harboring a thoracic aortic stent graft partially covering the origin of the left common carotid artery. Conclusion Our experience with this patient demonstrates that primary intracranial stenting shoud be considered in selected cases when other revascularization techniques are difficult or impossible to perform owing to anatomic reasons. Extreme care should be taken in patient selection because of the risks associated with antiplatelet therapy. In particular, it may be recommended in patients with a small core on computed tomography perfusion or diffusion-weighted magnetic resonance imaging and in whom thrombectomy and thromboaspiration are impossible for anatomic reasons.

Background and purposeAssisted coiling with stents or balloons enables a higher percentage of complete occlusions of saccular unruptured intracranial aneurysms to be achieved with a reasonable complication rate. The aim of this study was to compare stent-assisted coiling and the balloon remodeling technique in terms of efficacy, stability, and safety for the treatment of comparable unruptured saccular intracranial aneurysms.Materials and methods268 patients with 286 saccular unruptured wide-necked intracranial aneurysms were treated at our institution with stent- or balloon-assisted coiling and retrospectively reviewed. Statistical analysis was performed to assess significant differences between the two groups.ResultsThe rate of complete occlusion at the end of the procedure was higher with stent-assisted coiling than with balloon-assisted coiling (86.8% vs 78%) and the same results were also observed after 6 months (92.1% vs 77.6%; p=0.05). About 50% of major recurrences occurred in large to giant aneurysms (pConclusionsStent-assisted coiling achieved better results in terms of complete occlusion and stability than balloon-assisted coiling with a lower rate of recurrence without being associated with a higher risk of intraprocedural complications. Bifurcational and large to giant aneurysms were associated with higher complication rates and higher recurrence rates, respectively, and still represent a challenge for both techniques.

Identification of patients with acute ischaemic stroke who could most benefit from arterial recanalization after endovascular treatment remains an unsettled issue. Although several classifications of collateral circulation have been proposed, the clinical role of collaterals is still debated. We evaluated the effect of the collateral circulation in relation to recanalization as a predictor of clinical outcome. Data were prospectively collected from 103 patients consecutively treated for proximal middle cerebral or internal carotid artery occlusion. The collateral circulation was evaluated with a novel semiquantitative-qualitative score, the Careggi collateral score (CCS), in six grades. Both CCS and recanalization grades (TICI) were analysed in relation to clinical outcome. A statistical analysis was performed to evaluate the effect of interaction between recanalization and collateral circulation on clinical outcome. Out of the 103 patients, 37 (36.3%) had poor collaterals, and 65 (63.7%) had good collaterals. Patients with good collaterals had lower basal National Institute of Health Stroke Scale (NIHSS), more distal occlusion, smaller lesions at 24h CT scan and better functional outcome. After multivariate analysis, the interaction between recanalization and collateral grades was significantly stronger as a predictor of good outcome (OR 6.87, 95% CI 2.11–22.31) or death (OR 4.66, 95% CI 1.48–14.73) compared to the effect of the single variables. Collaterals showed an effect of interaction with the recanalization grade in determining a favourable clinical outcome. Assessment of the collateral circulation might help predict clinical results after recanalization in patients undergoing endovascular treatment for acute ischaemic stroke.

SUMMARY: Brain AVMs are a rare cause of cerebral hemorrhage and SAH, and their treatment is still debated. The aim of this study was to describe a novel endovascular approach with transvenous embolization of deep hemorrhagic brain AVMs. Five patients (3 females, 2 males; mean age, 33.2 years) underwent a transvenous embolization of a deep hemorrhagic brain AVM at our institution between February and April 2012. Clinical and angiographic data at the end of the procedure and after 6 months are reported. All the AVMs were completely obliterated, and no intra- or postprocedural complications occurred. The clinical outcome was unchanged or improved in all patients. Transvenous endovascular treatment may be considered in small, hemorrhagic, and deep AVMs with single deep drainage in those cases in which neurosurgical and radiosurgical treatment might not be indicated. ABBREVIATIONS: ACA anterior cerebral artery; AchoA anterior choroidal artery; bAVMs brain AVM; mRS modified Rankin Scale; PCA posterior cerebral artery

Background An anesthetic technique, which allows for neurological monitoring as well as continuous and safe monitoring of the airways with orotracheal intubation (cooperative patient general anesthesia [Co.Pa.Ge.A.]) has been described in patients undergoing elective thromboendoarterectomy surgery. The aim of this paper is to evaluate the effectiveness and the safety of Co.Pa.Ge.A. during scheduled endovascular treatments of brain arteriovenous malformations with a polymeric embolization agent, Onyx18. Methods Ten patients (3 F, 7 M; median age: 33.5±6.0 y, range: 20 to 39 y, American Society of Anesthesiologists class I to II) underwent endovascular embolization of brain arteriovenous malformations located in an eloquent area. Remifentanil was administered i.v. until an anesthetic target level was reached which allowed the anesthesiologists and the neuroradiologists to perform neurological monitoring during the entire procedure. The degree of patient satisfaction was evaluated based on a questionnaire administered the day after the procedure. Results Co.Pa.Ge.A. was successfully performed on all of the patients. No intraprocedural or postprocedural adverse events occurred. Hemodynamic stability was maintained in 5 cases with Remifentanil alone, in 2 cases with Remifentanil and Clonidine and in 1 case with Remifentanil and Nimodipine. Conclusions At the moment and to the best of our knowledge, this is the first report in the medical literature on this new anesthetic technique in interventional neuroradiology. Co.Pa.Ge.A. can be considered a safe, effective, and satisfactory technique characterized by hemodynamic stability and good control of the respiratory pattern, offering the possibility to perform real-time neurological monitoring and easy conversion to general anesthesia in case of intraprocedural complications or anesthetic necessity.

A 60-year-old man with progressive gait ataxia and mild pyramidal signs showed at MRI a pontine lesion with post-contrast enhancement in the left middle cerebellar peduncle. Diagnosis of Erdheim-Chester disease (ECD), a rare non-Langerhans cell histiocytosis, was suggested, further supported by a previously diagnosed retroperitoneal fibrosis. X-ray films demonstrated characteristic bilateral and symmetric osteosclerosis of the long bones of the lower limbs, which at radionuclide studies exhibited a marked increase in technetium-99 uptake. A cerebral 18FDG-PET showed a relevant pontine uptake of the tracer. Re-evaluation of a past retroperitoneal biopsy showed an intense CD68+, CD1a-, and S100- infiltrate of histiocytes with foamy cytoplasm, thus confirming the diagnosis. ECD should be regarded as a rare cause of adult-onset sporadic ataxia, especially when pontine lesions and extraneurological manifestations are present.

Intracranial pseudoaneurysms represent a potentially fatal complication of intracranial surgery. Our purpose is to describe their neuroradiological characteristics, prognostic features and possible treatment. Eight cases of postsurgical intracranial pseudoaneurysms have been observed at our institution since 1988. Four were observed following transsphenoidal (TS) surgery and four after pterional craniotomies. Two types of iatrogenic pseudoaneurysms were observed: “fusiform”, probably due to weakening of the adventitia during surgical peeling of the tumour from the artery (three cases) and “saccular”, occurring after a more focal or complete laceration of the vessel (five cases), more often after TS surgery. A thorough preoperative neuroradiological examination may identify anatomical conditions at risk for development of this severe complication. Postoperative neuroradiological follow-up is mandatory in cases in which unusual bleeding has occurred during the perioperative period, but absence of bleeding does not exclude the possible devel opment of a pseudoaneurysm. Endovascular treatment of pseudoaneurysms represents a safe and durable procedure, specifically in those cases in which damage to the carotid siphon occurred during TS surgery.

The cardinal and classic features of postural headache and low cerebrospinal fluid (CSF) pressure in intracranial hypotension may not dominate the clinical picture of the syndrome and may be associated with additional various neurological symptoms and signs. Reports of unusual clinical presentations continue to appear in the literature. Despite the considerable variability of the clinical spectrum, neuroradiological studies reveal more constant and characteristic features. Brain MRI findings include intracranial pachymeningeal thickening and post-contrast enhancement, subdural fluid collections and downward displacement or “sagging” of the brain. Spinal MRI findings include collapse of the dural sac with a festooned appearance, intense epidural enhancement owing to dilatation of the epidural venous plexus, and possible epidural fluid collections. In fact, spinal studies may demonstrate CSF leakage from spinal dural defects, which are considered the most common cause of the syndrome. Myelo-MR may suggest the possible point of CSF leakage, by demonstrating an irregular root sleeve; myelo-CT and radioisotope myelocisternography (RMC) are often needed to confirm the point of CSF leakage. Neuroimaging studies are, therefore, essential for suggesting and confirming the diagnosis.

Background and purpose Fenestration of the vertebrobasilar junction (VBJ) is a rare condition which may be associated with the presence of aneurysms. The endovascular approach is usually the first-line treatment in these cases since the location of the aneurysm may be unsuitable for a surgical approach. This anatomical variation may even influence the endovascular strategy, particularly in those cases in which the sacrifice of a vessel could be avoided. This paper describes an innovative approach of flow diversion in such challenging situations. Methods Two women were admitted after an occasional diagnosis of an aneurysm arising from a fenestrated VBJ. In both cases the endovascular approach was performed with two flow diverter stents and dual antiplatelet therapy was administered for 6 months. Results Complete exclusion of the two aneurysms was obtained after 6 and 7 months, respectively, and the clinical outcome was excellent. Conclusions Endovascular treatment of unruptured aneurysms located on a fenestrated VBJ with flow diverter stents represents a valid therapeutic approach with excellent clinical and radiological outcomes.

Purpose Neurosurgical and endovascular treatment of fragile and recurrent aneurysms of the non-branching portion of the internal carotid artery, known as blister-like aneurysms, is challenging. The aim of this paper is to describe two cases of ruptured blister-like aneurysms of the internal carotid artery and of the vertebral artery at the origin of the postero-inferior cerebellar artery, which were both treated with flow diverter (FD) stents. Methods Two patients with a sub-arachnoid hemorrhage secondary to the rupture of a blister-like aneurysm were treated with a Pipeline (ev3, Irvine, California, USA) stent. Digital subtraction angiography and clinical follow-up were carried out. Results Both patients treated with FD stents had an excellent clinical (modified Rankin Scale, mRS 0) and angiographic outcome. In both cases the aneurysms were completely excluded after 6 months. Conclusions Although the use of this endovascular approach is still debated because of poor experience and pharmacological limitations, FD stents may represent a valid alternative approach for treatment of this aneurysm subtype.