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Background The optimal endovascular approach for acutely ruptured wide‐neck intracranial aneurysms remains uncertain, and the use of stent‐assisted coiling or flow diversion is controversial due to antiplatelet therapy requirements and potential risks. Various techniques have been developed to address these challenges, including balloon‐assisted coiling (BAC) and intrasaccular flow‐disruption. The Woven EndoBridge (WEB) is an intrasaccular device that has shown a favorable efficacy and safety profile for ruptured aneurysms with minimal rebleeding rates. We aimed to compare the clinical and radiological outcomes between WEB and BAC in a cohort of patients with ruptured wide‐necked intracranial aneurysms. Methods In this international multicenter cohort study, we included consecutive patients treated for ruptured wide‐neck intracranial aneurysms with either WEB or BAC at 4 neurovascular centers. The primary effectiveness outcome was complete aneurysm occlusion at the final imaging follow‐up using the Raymond–Roy scale. Secondary outcomes included a composite of periprocedural hemorrhagic/ischemia‐related complications and favorable functional outcome. Results The study included 104 patients treated with WEB and 107 patients treated with BAC. Of the patients, 60.5% in the WEB group and 53% in the BAC group achieved complete occlusion, with no significant difference between the 2 groups after adjusting for covariates (adjusted odds ratio [OR] = 1.02; 95% CI 0.46–2.25; P = 0.964). The odds of favorable functional outcome did not significantly differ between the WEB (74.8%) and BAC groups (77.4%, adjusted OR = 1.45; 95% CI 0.65–3.24; P = 0.368). Procedure‐related complications were similar in both groups (WEB: 9.6%, BAC: 10.3%, P = 0.872), with no significant difference observed in the rates of ischemic events (WEB: 6.7% versus BAC: 2.8%; P = 0.180) and hemorrhagic events (WEB: 3.8% versus BAC: 7.5%; P = 0.255) between the 2 groups. Conclusion In conclusion, both WEB and BAC techniques showed similar effectiveness and safety outcomes in treating ruptured wide‐neck intracranial aneurysms. Further prospective comparative studies are needed to better guide treatment decisions for this patient population.

Introduction Dural arteriovenous fistulas (dAVFs) have been associated with rapidly progressive dementia in relatively young patients. However, the specific angioarchitecture and characteristics of these dAVFs remain to be fully described. To better understand the specific characteristics of dAVFs associated with cognitive impairment (dAVF‐CI), we utilized the CONDOR multicenter database, which provides a large cohort of dAVF available. By analyzing data from patients with dAVFs‐ CI, we aimed to identify the key features distinguishing these cases and elaborate on the pathophysiology of dAVF‐CI. Methods CONDOR is an international multicenter database comprising 1077 (dAVFs) from 14 international centers. We conducted a retrospective analysis of the CONDOR database, focusing on patients diagnosed with dAVFs‐CI. Propensity score matching analysis was performed to compare Borden type II and type III dAVFs with and without cognitive impairment as control groups. Only dAVFs with cortical venous drainage were included as this aggressive subtype can present with non‐hemorrhagic neurologic deficits. Additionally, logistic regression was then employed to identify significant characteristics associated with dAVF‐CI. Results A total of 60 patients with dAVF‐CI and 60 control dAVFs were included in the analysis. The patients with dAVF‐CI had a mean age of 58 ± 18 years. It was found that all cases of dAVF‐CI exhibited venous hypertension. Additionally, there was a significant association between sinus stenosis and dAVF‐CI (OR: 2.85, 95% CI: 1.16‐7.55, p = 0.027). Moreover, dAVF‐CI cases were characterized by the presence of multiple arteriovenous shunts, with more arterial feeders (OR 1.56, 95% CI 1.22‐2.05, p

Introduction The 2015 American Heart Association Guidelines recommended mechanical thrombectomy with stent‐retriever devices. A prior published analysis of national trends after one year in mechanical thrombectomy use and outcomes for stroke before and after publication of the 2015 US guideline update showed improved functional outcomes and lower peri‐procedural mortality. We analyze the national trends in mechanical thrombectomy use and outcomes for stroke five years after publication of the US guideline update. Methods We analyzed the National Inpatient Sample from 2012‐2019. ICD‐9 and ICD‐10 codes identified Ischemic stroke and mechanical thrombectomy patients. Similar to the previous study, discharge to home was the primary efficacy outcome measure in this study since it strongly correlates with mild degree of disability at discharge and 3 months post‐stroke. Safety outcomes include in‐hospital medical complications and mortality. We utilized multivariate logistic regression to assess outcomes. Results From 2012‐2019, 4,003,405 individuals with a diagnosis of ischemic stroke were recorded, 103,605 (2.6%) of which were treated with mechanical thrombectomy, proportionally increased from 4,910/452,905 (1.1%) in 2012 to 26,365/552,780 (4.8%) in 2019. The proportion of endovascular thrombectomy performing hospitals nearly doubled during the study period from 2012 (295/4,378; 6.7%) to 2019 (582/4,568; 12.7%). Odds of a mild disability outcome increased from 16% to 20%, OR 0.65 (0.57, 0.74), while mortality decreased from 15% to 12%, OR 0.69 (0.61, 0.78). Compared with 2012‐2014, the 2015‐2019 cohort showed increased odds of ICH and shock while the odds of DVT, pulmonary embolism, pneumonia, and UTI were significantly lower. The presence of septicemia, shock, and cardiac arrest were unchanged. Conclusion The number of large vessel occlusion stroke patients receiving mechanical thrombectomy treatment in the United States is increasing rapidly each year after the 2015 US guideline update. As the use of mechanical thrombectomy expands, included patients have more medical complications at baseline, but experience fewer complications, peri‐procedural mortality and overall improved outcomes.

Introduction The optimal endovascular approach for wide‐neck intracranial aneurysms (IAs) during the acute phase of bleeding remains uncertain, and the use of stent‐assisted coiling or flow diversion is controversial due to antiplatelet therapy requirements and potential risks (1, 2). Various techniques have been developed to address these challenges, including balloon‐assisted coiling (BAC) and intrasaccular flow‐disruption. The Woven EndoBridge (WEB) is a flow disrupter that has gained popularity in treating ruptured IAs due to its effectiveness in occluding aneurysms with minimal rebleeding (3, 4). The aim of this study is to provide outcome comparisons between WEB and BAC in a specific cohort of patients with ruptured wide‐necked IAs. Methods In this international cohort study, we included consecutive patients treated for ruptured wide‐neck IAs with either WEB or BAC at three neurovascular centers. The primary effectiveness outcome was complete aneurysm occlusion at the final imaging follow‐up using the Raymond‐Roy (RR) occlusion classification. Secondary outcomes included favorable functional outcome and periprocedural hemorrhagic/ischemia‐related complications. Comparisons were performed using multivariable logistic and ordinal regressions. Results One hundred four patients treated with WEB and 107 patients treated with BAC were included. The mean length of imaging follow‐up was 17.5 (± 17.6) months in the WEB group and 11.8 (± 10.3) months in the BAC group (p = 0.142). Of the patients, 60.5% in the WEB group and 53% in the BAC group achieved complete occlusion, with no significant difference between the two groups after adjusting for covariates (adjusted OR [aOR] = 1.02; 95% CI 0.46 – 2.25; p = 0.964). The odds of favorable functional outcome did not significantly differ between the WEB (74.8%) and BAC groups (77.4%, aOR = 1.45; 95% CI 0.65 – 3.24; p = 0.368). Procedure‐related complications were similar in both groups (WEB: 9.6%, BAC: 10.3%, p = 0.872). There was no statistically significant difference observed in the rates of ischemic events (WEB: 6.7% vs. BAC: 2.8%, p = 0.180) and hemorrhagic events (WEB: 3.8% vs. BAC: 7.5%, p = 0.255) between the two groups. Conclusion In conclusion, both WEB and BAC techniques showed similar effectiveness and safety outcomes in treating ruptured wide‐neck IAs. Further research and direct comparative studies are needed to better guide treatment decisions for this patient population.

Introduction There is growing evidence supporting endovascular treatment with middle meningeal artery embolization (MMAE) for the treatment of chronic subdural hematoma (cSDH). We aimed to compare Onyx vs. N‐Butyl cyanoacrylate (n‐BCA) as liquid embolic materials for MMAE. Methods We included all eligible patients undergoing MMAE for cSDH at University of Pittsburgh Medical Center from April 2019 to December 2022. The main outcomes included radiographic resolution of cSDH with at least 50% reduction of hematoma thickness as a surrogate for treatment success in addition to the need for rescue surgical intervention. Additional outcomes including complication rates and hematoma thickness at the last available follow up. Results A total of 195 patients underwent embolization of 234 hemispheres including 39 bilateral procedures and had available data for final analysis (168 (71.8%) in Onyx group vs. 66 (28.2%) in n‐BCA group). There were no significant differences in age, sex, co‐morbidities, prior SDH/evacuation, pre‐operative cSDH thickness, or use of antithrombotic therapy(P>0.05) while concurrent surgical intervention and midline shift showed a statistically significant difference (P

Introduction Endovascular thrombectomy (EVT) is the standard of care in acute ischemic stroke secondary to large vessel occlusion in selective patients within the first 24 hours. With the evolving technology and newer generation of catheters and devices, the interest in improving the technical and procedural factors that can help better the recanalization success, clinical outcomes, and efficiency is ever‐growing. Proximal flow arrest with balloon guide catheters (BGC) has been shown to optimize revascularization success and functional outcome in stroke EVT. We aim to evaluate the performance of the Emboguard BGC (Cerenovus, Irvine, CA, USA) in anterior circulation large vessel occlusion (LVO) acute ischemic strokes. Methods A prospectively maintained EVT database was reviewed for 12 months between May 2022 to May 2023 to identify all patients at our institution with intracranial vessel occlusion who underwent EVT using Emboguard BGC. Included patients were ≥18 years with large‐vessel occlusion who presented within 24 hours of time from last‐known‐well and had baseline National Institutes of Health Stroke Scale (NIHSS) score ≥ 6. Non‐dominant M2, M3, and A2 occlusions were excluded. We collected baseline demographic, clinical, and radiographic characteristics including age, sex, co‐morbidities, baseline NIHSS score, baseline modified Rankin Score (mRS), ASPECTS score, site of occlusion, imaging at our site, and use of intravenous and/or intra‐arterial thrombolytics. Outcomes included complications, NIHSS at discharge, final modified TICI (thrombolysis in cerebral ischemia) scores including the first‐pass effect (FPE, defined as mTICI 2c/3 after first pass), modified‐FPE (defined as, mTICI 2b‐3 after first pass), symptomatic intracranial hemorrhage (SITS‐MOST definition), and death at discharge. Data were analyzed using descriptive statistics, with frequency/percent for qualitative data and median/ interquartile range (IQR) for quantitative data. Results A total of 57 patients underwent EVT using Emboguard BGC. Among them, 54.4% were female and the median age was 72 years [IQR 66‐80]. Most of the patients had MCA occlusion (68.4% with 50.9% M1 and dominant/co‐dominant M2s 17.5%) with median ASPECTS 9 [IQR 8‐10]). About one‐third of our patients received intravenous thrombolytics. Following EVT, successful recanalization defined as modified TICI (thrombolysis in cerebral ischemia) scores of 2b/3 was achieved in 56 cases (98.2%) with 1 being the median number of passes (IQR 1‐2). The first pass effect (defined as one pass with mTICI of 2c/3) was achieved in 45.6% of cases. The median National Institutes of Health Stroke Scale (NIHSS) reduced significantly from 16 (IQR 12‐22) at baseline to 4 (IQR 1.5–12) at discharge (Table). Symptomatic intracranial hemorrhage was reported in 6 cases (10.5%), death at discharge was reported in 9 cases (15.8%), and access site complications were reported in 3 cases (5.3%). Conclusion Emboguard BGC showed promising results evident by a high rate of FPE, smaller number of EVT passes and improved recanalization rates with reasonable safety profile. Comparative prospective studies are needed to confirm these results.

Introduction Flow diverters (FDs) have demonstrated a safe and effective profile for the treatment of intracranial aneurysms with complex morphologies and variable anatomic locations. However, aneurysmal persistence after flow diversion still presents in up to 25% of treated aneurysms. Herein, we aimed to perform a pooled analysis of two large studies (SCENT [Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Neck Wide Neck Aneurysms] and SESSIA [Safety and Efficacy of the Surpass Streamline for Intracranial Aneurysms]) to evaluate the predictors of occlusion at final follow‐up after treatment with a 72–96 wire device. Methods We pooled all data from the SCENT (prospective) and SESSIA (retrospective) studies that included patients treated with the Surpass Streamline. From the studies, a subset of patients with unruptured saccular aneurysms located in the internal carotid artery (ICA) up to its terminus were included. The authors collected baseline demographics, comorbidities, aneurysm dimensions, and procedural and follow‐up characteristics for each patient. For our analysis, the outcome was complete aneurysm occlusion, as reported by the studies. We performed a multivariable logistic regression to identify the predictors of complete occlusion. Next, we performed a mediation analysis framework to identify the causal relationship of the predictors with the outcome. Finally, we calculated the predicted probability of occlusion for the continuous predictors. Results A total of 348 patients with 348 aneurysms were included, 394 devices were implanted (1.13 per patient). Median age was 61 [22‐85] years, and 83.6% were females. Hypertension was the most common comorbidity (57%) followed by hyperlipidemia (36%). The ICA paraophthalmic segment was the most common location (45%), followed by the petrocavernous (29%) and supraclinoid (25%). Median aneurysm size was 7.5 [1‐29] mm, and neck size was 4.3 [1‐23] mm. At the final follow‐up, the complete occlusion rate was 73% (255/348). After adjusting for confounders and accounting for collinearity, the multivariable analysis identified aneurysm size (OR 0.89; 95% CI 0.85‐0.93;p< .001), procedural technical events (OR 0.31; 95% CI 0.15‐0.65;p = .002), and first device length (OR 0.98; 95% CI 0.96‐1.00;p = .036) as predictors of complete occlusion. Age had a non‐significant direct effect on complete occlusion (p = .091) but a significant indirect effect mediated through aneurysm size (p< .001) and technical events (p< .02). Using our model, the predicted probability of occlusion is≥ 75% in aneurysms measuring < 10 mm when no technical events are encountered. However, when technical events are encountered, the probability decreases to 50–75%. Conclusions Successful aneurysm occlusion after flow diversion is associated with aneurysm size, procedural technical events, and FD length. Age does not directly affect occlusion, but its influence is mediated through the aneurysm size and technical events. Therefore, a priori knowledge of the patient and aneurysm characteristics might guide FD selection to favor the best treatment outcomes.

Introduction: Flow diversion has established itself as standard treatment of wide complex intracranial aneurysms (IA). Its recognition has been validated with positive occlusion rates and favorable clinical outcomes. The Surpass Streamline (SS) flow diverter (FD) is a braided cobalt/chromium alloy implant with 72 or 96 wires approved by the FDA in 2018. The aim of this study is to determine the safety and efficacy of the SS in a post‐marketing large US cohort. Methods: We performed a multicenter, retrospective study for consecutive patients treated with the SS FD for IA between January 2018 and June 2021 in the United States. Inclusion criteria for participants were: 1. Adults (≥ 18 years) and 2. Treatment with SS FD for IA. Primary safety end point was a major ipsilateral stroke (increase in National Institutes of Health Stroke Scale Score of ≥ 4) or neurological death within 12 months. Primary efficacy was assessed using the 3‐point Raymond‐Roy (RR) occlusion scale on digital subtraction angiography (DSA) at 6‐12‐month follow‐up. Results: A total of 276 patients with 313 aneurysms were enrolled. The median age was 59 years and 199 (72%) were females. The most common comorbidities included hypertension in 156 (57%) subjects followed by hyperlipidemia in 76 (28%) patients. One hundred and twenty‐two (44%) patients were asymptomatic while subarachnoid hemorrhage was present in only 10 (4%) patients. A total of 143 (46%) aneurysms were left‐sided. Aneurysms were located as follows: 274 (88%) were in the anterior circulation with paraophthalmic being the most common in 120 (38%) followed by petrocavernous ICA in 81 (26%); 33 (11%) aneurysms were located in the posterior circulation with basilar trunk being the most common in 14 (5%). The mean maximum aneurysm dome width was 5.77 ± 4.7 mm, neck width 4.22 ± 3.8 mm and dome to neck ratio was 1.63 ± 1.3 mm. The mean number of SS FD implanted per aneurysm was 1.06 (range 1–3) with more than one SS FD implanted in 21 (7%) aneurysms. Modified Rankin Scale (mRS) of 0–2 was present in 206/213 (97%) patients at 6–12 month follow‐up. The complete aneurysm occlusion (RR 1) rate was 145/175 (83%) among subjects who had angiographic follow‐up at 6–12 months. Major stroke and death was encountered in 7 (2%) and 5 (1.8%) of the patients respectively. Conclusions: Our data represent the largest real‐world study using SS FD. These results corroborate its post‐marketing safety and efficacy for the treatment of intracranial aneurysms showing more favorable rates to the initial experience during SCENT trial.