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Background: The Neuroform Atlas Stent System is an established treatment modality for unruptured anterior and posterior circulation intracranial aneurysms. Location-specific results are needed to guide treatment decision-making. However, it is unclear whether there are differences in safety and efficacy outcomes between carotid and more distal anterior circulation aneurysms., Methods: The ATLAS IDE trial was a prospective, multicenter, single-arm, open-label interventional study that evaluated the safety and efficacy of the Neuroform Atlas Stent System. We compared differences in efficacy and safety outcomes of proximal internal carotid artery (ICA) versus distal and bifurcation anterior circulation aneurysms., Results: Of 182 cases, there were 70 aneurysms in the ICA and 112 in the distal anterior circulation (including ICA terminus/bifurcation). There were no significant differences in the primary efficacy endpoint (85.5% vs 83.9%, p=0.78) and complete aneurysm occlusion rates (88.7% vs 87.9%, p=0.78) between proximal ICA aneurysms and distal aneurysms, respectively. Complications were more often encountered in distal and bifurcation aneurysms, but the overall rate of major safety events was low and comparable between the two groups (1.4% vs 6.3%, p=0.14). Recanalization and retreatment rates were also similar between the groups., Conclusion: The results of this study suggest that the Neuroform Atlas Stent System is a safe and efficacious treatment modality for unruptured anterior circulation intracranial aneurysms, regardless of aneurysm location., Trial Registration Number: NCT02340585., Competing Interests: Competing interests: RAH is a consultant for Medtronic, Stryker, Cerenovous, Microvention, Balt, Phenox, Rapid Medical and Q’Apel, Imperative Care, Phenox, and Rapid Medical. He is on the advisory board for MiVI, eLum, Three Rivers, Shape Medical, and Corindus. He is in receipt of unrestricted research grants from the National Institutes of Health (NIH), Interline Endowment, Microvention, Stryker, CNX, and Balt. He is an investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RisT, BlinkTBI, and Corindus. BTJ is a consultant for Stryker and a consultant/proctor for Medtronic. ES reports a speaker’s agreement with Stryker. BG is a consultant for Medtronic, Microvention, and Stryker. RGG is a consultant and receives personal fees from Cerenovus. DF reports consultant/speakers bureau for Stryker, Siemens, Penumbra, and Scientia; and serves on the SNIS board of directors. LLP is a Principal Biostatistician employed at Stryker Neurovascular and holds stock in Stryker. SWH reports core lab services for Stryker, Route 92; is an Imperative Care consultant; is a stockholder for Filtro and ThrombX; and serves on the SNIS board of directors. OOZ reports research grants from Stryker, Medtronic, Cerenovus, Penumbra, and Genentech; he is a consultant and speaker for Cerenovus, Stryker, Penumbra, and Medtronic; data safety monitoring board for Premier; has an ownership interest in Galaxy Therapeutics Inc.; and serves on SVIN committees. The other authors report no conflicts of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: We compared the outcomes of wide necked aneurysms (WNA) treated with the Neuroform Atlas with those treated with the low profile visualized intraluminal stent (LVIS) or the Woven EndoBridge (WEB)., Methods: Objective, prospectively collected, core laboratory adjudicated data from published trials for the Neuroform Atlas, LVIS, and WEB devices were reviewed. ATLAS (Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System) study patients were included if they met other studies' inclusion criteria. Outcomes included (1) primary effectiveness (complete aneurysmal occlusion without retreatment/>50% parent vessel stenosis), (2) primary safety, (3) complete aneurysmal occlusion, and (4) retreatment rates (outcomes evaluated at the 12 month follow-up). Matching adjusted indirect comparison analysis was used to compare outcomes., Results: Analytical samples included 141 ATLAS subjects meeting WEB-IT (Woven EndoBridge Intrasaccular Therapy Study) criteria (ATLAS/WEB-IT) and 241 meeting LVIS (Pivotal Study of the Low Profile Visualized Intraluminal Support) criteria (ATLAS/LVIS). ATLAS/WEB-IT exhibited significantly higher rates of primary effectiveness and complete occlusion versus WEB (86.6% vs 53.9 %, P<0.0001, and 90.3% vs 53.9%, P<0.0001, respectively). For LVIS, there was no significant differences in primary effectiveness rates between ATLAS and LVIS (84.2% vs 77.7%, respectively, P=0.12). However, ATLAS/LVIS had a significantly higher proportion of patients achieving complete occlusion than LVIS (88.1 vs 79.1, P=0.03). Retreatment rates and primary safety outcomes were not significantly different (P>0.05) for the Atlas versus other devices except for a lower retreatment rate for ATLAS/WEB-IT versus WEB-IT (2.4% vs 9.8%, P=0.01)., Conclusion: The Neuroform Atlas provided higher occlusion rates and similar retreatment rates in comparable datasets compared with LVIS and WEB devices when treating WNA., Competing Interests: Competing interests: BJ and OOZ are national co-PIs of the ATLAS trial. LLP is a senior clinical statistician at Stryker Neurovascular., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Heterogeneous effect of endovascular aneurysm therapy has been observed across different anatomic locations. There is a paucity of data for stent-assisted coiling of middle cerebral artery (MCA) aneurysms., Objective: To present the results of the MCA aneurysm group from the Neuroform Atlas (Stryker Neurovascular) investigational device exemption (IDE) trial., Methods: The Atlas IDE trial is a prospective, multicenter, single-arm, open-label study of wide-neck aneurysms (neck ≥ 4 mm or dome-to-neck ratio < 2) in the anterior circulation treated with the Neuroform Atlas Stent and approved coils. Follow-up was obtained immediately postprocedure and 2, 6, and 12 mo postoperatively. We herein describe safety and efficacy outcomes, and functional independence of the subjects with aneurysms from all segments of MCA., Results: A total of 35 patients were included (27 MCA bifurcation, 5 M1, 3 M2). The mean aneurysm size was 6.0 ± 1.8 mm, and the mean neck was 4.4 ± 1.2 mm. Technical procedural success was achieved in all patients. A total of 26 patients had follow-up digital subtraction angiography available at 12 mo, with 80.8% (21/26) having complete aneurysm occlusion. Twelve-month safety data were collected for 91.4% (32/35), 8.5% (3/35) had primary safety endpoint, all 3 major ischemic strokes. Mortality occurred in 2 patients beyond 30 d unrelated to procedure (1 gallbladder cancer and 1 fentanyl intoxication). At 1 yr, modified Rankin Score was 0 to 2 in 84.4% (27/32), 3 in 9.4%, and 3 patients were missing. Approximately 5.7% (2/35) of patients were retreated at 12 mo., Conclusion: Stent-assisted coiling with the Neuroform Atlas Stent is a viable alternative to clipping for selected MCA aneurysms. Complete aneurysm occlusion rates have improved compared to historical data. Proper case selection can lead to acceptable endovascular results., (© Congress of Neurological Surgeons 2021.)

Background and Purpose: Stent-assisted coil embolization using the new generation Neuroform Atlas Stent System has shown promising safety and efficacy. The primary study results of the anterior circulation aneurysm cohort of the treatment of wide-neck, saccular, intracranial, aneurysms with the Neuroform Atlas Stent System (ATLAS trial [Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System]) are presented., Methods: ATLAS IDE trial (Investigational Device Exemption) is a prospective, multicenter, single-arm, open-label study of wide-neck (neck ≥4 mm or dome-to-neck ratio <2) intracranial aneurysms in the anterior circulation treated with the Neuroform Atlas Stent and approved coils. The primary efficacy end point was complete aneurysm occlusion (Raymond-Roy class 1) on 12-month angiography, in the absence of retreatment or parent artery stenosis (>50%) at the target location. The primary safety end point was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary end points was performed by an independent Imaging Core Laboratory and the Clinical Events Committee., Results: A total of 182 patients with wide-neck anterior circulation aneurysms at 25 US centers were enrolled. The mean age was 60.3±11.4 years, 73.1% (133/182) women, and 80.8% (147/182) white. Mean aneurysm size was 6.1±2.2 mm, mean neck width was 4.1±1.2 mm, and mean dome-to-neck ratio was 1.2±0.3. The most frequent aneurysm locations were the anterior communicating artery (64/182, 35.2%), internal carotid artery ophthalmic artery segment (29/182, 15.9%), and middle cerebral artery bifurcation (27/182, 14.8%). Stents were placed in the anticipated anatomic location in all patients. The study met both primary safety and efficacy end points. The composite primary efficacy end point of complete aneurysm occlusion (Raymond-Roy 1) without parent artery stenosis or aneurysm retreatment was achieved in 84.7% (95% CI, 78.6%-90.9%) of patients. Overall, 4.4% (8/182, 95% CI, 1.9%-8.5%) of patients experienced a primary safety end point of major ipsilateral stroke or neurological death., Conclusions: In the ATLAS IDE anterior circulation aneurysm cohort premarket approval study, the Neuroform Atlas stent with adjunctive coiling met the primary end points and demonstrated high rates of long-term complete aneurysm occlusion at 12 months, with 100% technical success and <5% morbidity. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02340585.

Background and Purpose: The Neuroform Atlas is a new microstent to assist coil embolization of intracranial aneurysms that recently gained FDA approval. We present a postmarket multicenter analysis of the Neuroform Atlas stent., Materials and Methods: On the basis of retrospective chart review from 11 academic centers, we analyzed patients treated with the Neuroform Atlas after FDA exemption from January 2018 to June 2019. Clinical and radiologic parameters included patient demographics, aneurysm characteristics, stent parameters, complications, and outcomes at discharge and last follow-up., Results: Overall, 128 aneurysms in 128 patients (median age, 62 years) were treated with 138 stents. Risk factors included smoking (59.4%), multiple aneurysms (27.3%), and family history of aneurysms (16.4%). Most patients were treated electively (93.7%), and 8 (6.3%) underwent treatment within 2 weeks of subarachnoid hemorrhage. Previous aneurysm treatment failure was present in 21% of cases. Wide-neck aneurysms (80.5%), small aneurysm size (<7 mm, 76.6%), and bifurcation aneurysm location (basilar apex, 28.9%; anterior communicating artery, 27.3%; and middle cerebral artery bifurcation, 12.5%) were common. A single stent was used in 92.2% of cases, and a single catheter for both stent placement and coiling was used in 59.4% of cases. Technical complications during stent deployment occurred in 4.7% of cases; symptomatic thromboembolic stroke, in 2.3%; and symptomatic hemorrhage, in 0.8%. Favorable Raymond grades (Raymond-Roy occlusion classification) I and II were achieved in 82.9% at discharge and 89.5% at last follow-up. mRS ≤2 was determined in 96.9% of patients at last follow-up. The immediate Raymond-Roy occlusion classification grade correlated with aneurysm location ( P  < .0001) and rupture status during treatment ( P  = .03)., Conclusions: This multicenter analysis provides a real-world safety and efficacy profile for the treatment of intracranial aneurysms with the Neuroform Atlas stent., (© 2020 by American Journal of Neuroradiology.)

Introduction: Treatment of acute large vessel occlusion (LVO) stroke secondary to intracranial atherosclerotic disease (ICAD) is more nuanced with disparate and infrequently reported outcomes. The deployment of balloon-mounted stents presents an expedient approach with renewed feasibility in the modern era of supple intermediate catheters., Methods: A prospectively maintained endovascular stroke database was searched for patients undergoing intracranial stenting with balloon-mounted stents for acute LVO. Demographic, angiographic, and clinical data were extracted to determine procedural technique and success, measured both angiographically and clinically., Results: Sixty patients underwent stenting for acute LVO secondary to ICAD. Mean presenting National Institutes of Health Stroke Scale (NIHSS) score was 18 and 62% of treated sites were in the posterior circulation. Cases were performed under IV conscious sedation unless the patient was already intubated. Successful recanalization was achieved in 93% of cases (Thrombolysis in Cerebral Infarction (TICI) grade 2b in 48% and TICI grade 3 in 45%). Mean improvement in NIHSS score on post-procedure day 1 was 3.4. Good outcome (modified Rankin Scale score 0-2) at 3 months was 34% and the mortality rate was 34%. The rate of peri-procedural symptomatic hemorrhage was 8% and the rate of acute/subacute stent thrombosis was 7%. In this small cohort, patient age, sex, presenting NIHSS, comorbidities, smoking, tissue plasminogen activator administration, and stent location were not significant predictors of recanalization or good outcome., Conclusion: Treatment of acute LVO stroke with balloon-mounted stents for ICAD has reperfusion rates and clinical outcomes comparable to thrombectomy, with higher rates of hemorrhage and mortality. Because stent placement was performed after attempted thrombectomy, a trial of primary stenting versus thrombectomy should be considered in patients suspected of underlying ICAD., Competing Interests: Competing interests: BTJ: Consultant, Medtronic. BAG: Consultant, Microvention. TGJ: Consultant, Stryker Neurovascular (PI DAWN-unpaid); Ownership interest: Anaconda; Advisory Board/Investor: FreeOx Biotech, Advisory Board/Investor; Route92, Advisory Board/Investor; Blockade Medical, Consultant; Honoraria: Cerenovus., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Manual aspiration thrombectomy (MAT) and stent retriever mediated aspiration thrombectomy (SMAT) are well described reperfusion strategies for large vessel occlusions. This study aims to identify predictors of successful crossover to SMAT after failed first pass MAT., Methods: Prospectively collected data for patients with acute large vessel occlusions undergoing thrombectomy over a 23 month period at a comprehensive stroke center were reviewed. The primary outcome was successful removal of the index clot with resultant Thrombolysis in Cerebral Infarction 2b or greater reperfusion at any point after a failed initial MAT attempt, and multivariate logistic regression analyses were performed to determine predictors of successful crossover to SMAT., Results: Of 433 large vessel thrombectomies, 319 underwent first pass MAT, and 113 patients required a repeated pass for the index thrombus. Second pass MAT was performed in 77% of cases and was successful in 54%; second pass SMAT was performed in 23% of cases and was successful in 73% (P=0.11). Third pass MAT was employed in 45% of cases and was successful in 43% while SMAT was performed in 55% of cases and was successful in 77% (P=0.03). Overall, 12% of patients undergoing MAT on the first pass crossed over to successful SMAT. Predictors of successful crossover were internal carotid artery (ICA) location and higher presenting National Institutes of Health Stroke Scale (NIHSS) score., Conclusion: After failed first pass MAT, subsequent passes with SMAT had higher rates of successful index clot removal; patients with a higher initial NIHSS score and ICA clot location should be considered for early crossover or even initial SMAT for their clots., Competing Interests: Competing interests: BTJ: consultant, Medtronic, investor, Penumbra Inc. BAG: consultant, Microvention. TGJ: consultant, Stryker Neurovascular (PI DAWN-unpaid), ownership interest: Anaconda, advisory board/investor; FreeOx Biotech, advisory board/investor; Route92, advisory board/investor; Blockade Medical, consultant; honoraria: Cerenovus., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Case series have described the safety and efficacy of LVIS Jr and Atlas stent-assisted aneurysm coiling, but their comparative clinical performance has not yet been formally studied., Objective: To clinically compare LVIS Jr and Atlas stents, emphasizing comparative rates of technical success and complications., Methods: Our institutional endovascular database was queried for aneurysms treated by stent-assisted coiling with either the LVIS Jr or Atlas stents. Demographic data, aneurysm information, treatment technique, periprocedural and device-related complications, and initial and follow-up angiographic results were evaluated., Results: Thirty-seven patients underwent Atlas stent placement and 27 patients underwent LVIS Jr stent placement for aneurysm coiling. There was no significant difference in aneurysm location, size, coiling technique, and coil packing density between the two cohorts. The rate of initial Raymond 1 occlusion was significantly greater in the Atlas cohort (57% vs 41%, P=0.03). The rate of postoperative ischemic complications, both clinically apparent and as defined on postoperative MRI diffusion-weighted imaging, did not significantly differ between the two groups. Follow-up DSA demonstrated a significantly greater rate of Raymond 1 or 2 occlusion for the Atlas cohort (100% vs 81%, P=0.04), and a significantly lower rate of in-stent stenosis (0% vs 19%, P=0.04)., Conclusion: This institutional analysis demonstrates greater obliteration rates and lower in-stent stenosis rates for aneurysms treated via Atlas stent-assisted coiling as compared with those treated via LVIS Jr stent-assisted coiling., Competing Interests: Competing interests: TGJ received a grant, non-financial, from Fundació Ictus Malaltia Vascular and modest honoraria from Silk Road (consultant), Medtronic and Stryker Neurovascular (consultant/advisory board), and Neuravi (consultant). BTJ is a consultant for Medtronic and Stryker Neurovascular (Co-PI, ATLAS study). AFD is a consultant for Medtronic and Penumbra., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Symptomatic internal carotid artery occlusion (ICAO) can lead to neurologic decline, recurrent stroke, and mortality., Objective: We sought to evaluate the safety and feasibility of endovascular revascularization for ICAO without tandem intracranial large vessel occlusion (LVO)., Design, Setting, and Participants: This is a retrospective cohort analysis of all patients presenting to a single academic center with ischemic stroke and ipsilateral cervical ICAO from November 2003 through April 2016. Patients were excluded if pre-procedural angiography demonstrated tandem LVO or if patients were known to have chronic ICAO., Main Outcomes and Measures: Study endpoints included discharge neurologic examination, post-procedural infarct burden, 3-month functional outcomes, and treatment durability., Results: A total of 107 patients with symptomatic angiographically-confirmed cervical ICAO without tandem LVO were identified. Median admission NIH Stroke Scale (NIHSS) score was 8 (IQR 11). Baseline radiographic stroke severity was assessed by ASPECT score (median 9; IQR 2), perfusion mismatch (present in 93%), and clinical imaging mismatch (42%). Median time from symptom onset to treatment was 25 hours (IQR 61). Successful revascularization was achieved in 92% of patients. At discharge, 83% had stable/improved NIHSS score, while at 3 months 65% achieved independence (modified Rankin Scale score ≤2). The most common complication was distal embolization (22%) of which 16% required intra-arterial treatment. Rate of significant restenosis (≥70%) was 15% at 1 year., Conclusions: Stenting in selected patients at risk of neurologic deterioration due to symptomatic ICAO can be performed with high rates of technical success and good clinical outcomes. Because of significant peri-procedural risks and high rates of restenosis, randomized studies are necessary to understand the benefit of this approach., Competing Interests: Competing interests: TGJ has the following disclosures: Consultant, Neuravi (steering committee -modest), Codman Neurovascular (DSMB - modest), Stryker Neurovascular (PI DAWN - unpaid), Fundacio Ictus (PI REVASCAT unpaid); stock, Anaconda, Silk Road, Blockade Medical (modest). AFD has the following disclosure: Consultant, Medtronic (device proctor - modest)., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Metal allergies affect a significant portion of the population; intracranial flow diverters contain many of the most commonly allergenic metals. Prior literature has suggested patch testing for all patients with documented or suspected metal allergies before intracranial flow diverter placement; however, there remains a paucity of reports of patients with documented metal allergies undergoing intracranial flow diversion., Case Description: We report 2 patients with documented nickel allergies, confirmed via patch testing by a board-certified allergist, and unruptured intracranial aneurysms that underwent treatment with the PED. Both patients developed contact dermatitis when a PED was affixed to their skin during their preoperative workup. Follow-up arteriography at 12 and 36 months post PED placement showed no evidence of in-stent stenosis or intimal hyperplasia, and both patients never developed systemic allergic reactions., Conclusions: In 2 patients with known nickel allergies and intracranial aneurysms treated with the PED, there were no clinically or radiographically apparent allergic reactions at greater than 2 years of follow-up., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Medical treatment, cerebrospinal fluid (CSF) shunting, and optic nerve sheath fenestration are standard treatments for increased intracranial pressure (ICP) in patients with idiopathic intracranial hypertension (IIH). Venous sinus stenting provides a novel alternative surgical treatment in cases of venous sinus stenosis with elevated ICP., Methods: 12 consecutive subjects with papilledema, increased ICP, and radiological signs of dural sinus stenosis underwent cerebral venography and manometry. All subjects had papilledema and demonstrated radiological evidence of dural venous sinus stenosis., Results: Six subjects chose venous stenting (Group A) and six declined and were managed conservatively with oral acetazolamide (Group B). The relative pressure gradient across the venous narrowing was 29±16.3 mm Hg in Group A and 17.6±9.3 mm Hg in Group B (p=0.09). The mean lumbar puncture opening pressure was 40.4±7.6 cm H 2 O in Group A and 35.6±10.6 cm H 2 O in Group B (p=0.4). Spectral domain optical coherence tomography (SD-OCT) showed mean average retinal nerve fiber layer (RNFL) thickness of 210±44.8 µm in Group A and 235±124.7 µm in Group B. However, the mean average RNFL thickness at 6 months was 85±9 µm in Group A and 95±24 µm in Group B (p=0.6). The total duration of acetazolamide treatment was 188±209 days in Group A compared with 571±544 days in Group B (p=0.07)., Conclusions: In subjects with venous sinuses stenosis, endovascular stenting offers an effective treatment option for intracranial hypertension which may shorten the duration of medical therapy., Competing Interests: Competing interests: TGJ received a grant (non-financial) from Fundació Ictus Malaltia Vascular and honoraria from Silk Road (consultant), Medtronic and Stryker Neurovascular (consultant/advisory board), and J&J and Neuravi (consultant)., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Two positive randomized trials established carotid endarterectomy (CEA) as a superior treatment to medical management alone for the treatment of asymptomatic carotid artery stenosis. However, advances in medical therapy have led to an active and spirited debate about the best treatment for asymptomatic carotid stenosis. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis (CREST 2) trial aims to better define the best treatment for the average patient with severe asymptomatic carotid stenosis. Enrollment in the trial may be hampered by strong opinions on either side of the debate. It is important to realize that equipoise exists and that neither the old data on CEA nor the new data on optimal medical therapy provide a rigorous answer. The assumption that medical therapy has already been proven superior to revascularization procedures may hinder both enrollment in the trial and technical advancements in revascularization procedures., (© 2017 American Academy of Neurology.)

The endovascular management of giant aneurysms often proves difficult with standard techniques. Obtaining distal access to allow catheter reduction is often key to approaching these aneurysms, but several anatomic challenges make this task unsafe and not feasible. Obtaining distal anchor points and performing catheter reduction maneuvers using adjunctive devices is not a novel concept, however using the Solitaire in order to do so may have some distinct advantages compared with previously described methods. Here we describe our novel Solitaire salvage technique, which allowed successful reduction of a looped catheter within an aneurysm in three cases. While this technique is expensive and therefore best performed after standard maneuvers have failed, in our experience it was effective, safe, and more efficient than other methods., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

The complication rates of carotid artery stenting (CAS) vary from 3.0% to 4.4%, and most commonly include ischemic stroke, intracranial hemorrhage, or groin complications. We present the rare complication of a patient who underwent CAS for a symptomatic 90% left internal carotid artery stenosis and developed an expanding cervical hematoma after the procedure with imminent respiratory compromise. After intubation, an arteriogram revealed perforation of the external carotid artery trunk, proximal to the origin of the internal maxillary artery. The artery was subsequently embolized and the hematoma resolved without further intervention. We present a potential catastrophic complication and suggest potential causes and treatment options available., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Cervical dissections are a rare but potentionally devastating complication of positioning in anesthetized patients. A 40-year-old woman was noted to have right arm weakness after a prolonged dental procedure. Imaging revealed bilateral carotid dissections with severe stenosis. The patient had further clinical deterioration despite therapeutic anticoagulation. Carotid stenting of the symptomatic left carotid artery led to improved flow and the patient had no further events. Caution should be exercised during prolonged neck hyperextension to avoid the potentially devastating complication of cervical dissection. Carotid stenting may be necessary to maintain adequate flow in patients with clinical instability despite medical therapy., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The complication rates of carotid artery stenting (CAS) vary from 3.0% to 4.4%, and most commonly include ischemic stroke, intracranial hemorrhage, or groin complications. We present the rare complication of a patient who underwent CAS for a symptomatic 90% left internal carotid artery stenosis and developed an expanding cervical hematoma after the procedure with imminent respiratory compromise. After intubation, an arteriogram revealed perforation of the external carotid artery trunk, proximal to the origin of the internal maxillary artery. The artery was subsequently embolized and the hematoma resolved without further intervention. We present a potential catastrophic complication and suggest potential causes and treatment options available.

Background and Purpose: Coiling of wide neck, bifurcation aneurysms often requires creative techniques to ensure optimal and safe embolization. The Y stenting technique utilizing kissing stents provides an alternative endovascular treatment of this complex pathology., Materials and Methods: A triple wire technique was used to place side by side stents within the parent artery and extending into the bilateral bifurcation vessels. The third wire enabled placement of a microcatheter within the aneurysm, which remained trapped by the opposing stents., Results: 9 patients obtained acceptable angiographic partial or total occlusion of their aneurysm. Follow-up was variable, ranging from none to 26 months. There were two early deaths at postprocedures day 1 and 10, with one mortality being a direct result of the intervention. One patient experienced delayed in-stent thrombosis resulting in a periprocedural morbidity and mortality of 11% and 22%, respectively. One patient required retreatment., Conclusion: Y stenting utilizing the triple catheter technique is an alternative endovascular treatment for wide neck, bifurcation aneurysms. Caution should be used, especially in the setting of subarachnoid hemorrhage, as the complication rate and overall risk increase significantly with this technique's complexity.

Object: The development of self-expanding stents dedicated to intracranial use has significantly widened the applicability of endovascular therapy to many intracranial aneurysms that would otherwise have been untreatable by endovascular techniques. Recent Food and Drug Administration approval of the Enterprise Vascular Reconstruction Device and Delivery System (Cordis) has added a new option for self-expanding stent-assisted intracranial aneurysm coiling., Methods: The authors established a collaborative registry across multiple institutions to rapidly provide largevolume results regarding initial experience in using the Enterprise in real-world practice. Ten institutions (University at Buffalo, Thomas Jefferson University, University of Florida, Cleveland Clinic, Northwestern University, West Virginia University, University of Puerto Rico, Albany Medical Center Hospital, the Neurological Institute of Savannah, and the Barrow Neurological Institute) have provided consecutive data regarding their initial experience with the Enterprise., Results: In total, 141 patients (119 women) with 142 aneurysms underwent 143 attempted stent deployments. The use of Enterprise assistance with aneurysm coiling was associated with a 76% rate of > or = 90% occlusion. An inability to navigate or deploy the stent was experienced in 3% of cases, as well as a 2% occurrence of inaccurate deployment. Procedural data demonstrated a 6% temporary morbidity, 2.8% permanent morbidity, and 2% mortality (0.8% unruptured, 12% ruptured)., Conclusions: The authors report initial results of the largest series to date in using the Enterprise for intracranial aneurysm treatment. The Enterprise is associated with a high rate of successful navigation and low occurrence of inaccurate stent deployment. The overall morbidity and mortality rates were low; however, caution should be exercised when considering Enterprise deployment in patients with subarachnoid hemorrhage as the authors' experience demonstrated a high rate of associated hemorrhagic complications leading to death.