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Background Balloon‐assisted coiling (BAC) and stent‐assisted coiling (SAC) have been established as feasible approaches to manage ruptured wide‐necked intracranial aneurysms. Antiplatelet medications used with SAC theoretically increase risk of thrombotic and hemorrhagic complications. This study aims to evaluate safety and efficacy of SAC versus BAC for acutely ruptured wide‐necked intracranial aneurysms. Methods We performed a 2‐center retrospective observational study of consecutive patients treated with SAC or BAC for ruptured wide‐necked intracranial aneurysms from 2015 to 2020. Baseline demographics, comorbidities, and aneurysm characteristics were collected. Primary and secondary efficacy outcomes were radiographic aneurysm occlusion at follow‐up and functional status at 3 months. Safety outcomes included periprocedural hemorrhagic/ischemic complications and symptomatic ventriculostomy tract and cerebrospinal shunt hemorrhage rates. Univariable and multivariable analyses with multiple imputations to account for follow‐up loss were performed. Results A total of 112 and 109 patients underwent SAC and BAC, respectively. Median cohort age was 56 years, and 72% were female. Baseline characteristics were similar. Hydrocephalus rate was higher in the SAC group (78% versus 64%; P=0.02). Median aneurysm size was 5.1 mm. Anterior circulation aneurysms were most common (81%). Aneurysm and neck size were different, more aneurysms measuring

Background and Purpose Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT). Methods This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS). Results Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P

Introduction Intracranial dural arteriovenous fistulae (dAVFs) are typified by pathological anastomoses between meningeal arteries and dural venous sinuses or cortical veins. DAVFs can mimic other neurologic disorders and produce a broad spectrum of signs and symptoms, including headache, tinnitus, vertigo, Parkinsonism, and visual field and gait disturbances. We present a case report of extensive dural AV Fistula which lead to brainstem ischemic stroke from compression of brainstem flow void. Methods Case Report Results 64 year old man with past medical History of Rheumatoid arthritis, presented with sudden onset of right facial weakness. On arrival patient was noted to be hypertensive to 200/105 and on exam noted to have right complete facial nerve palsy. Patient also revealed a significant history of severe, throbbing, posterior headaches in the last 1–2 months. Patient had CT head which was negative for bleed. CT angiography showed Abnormal hyperattenuating tubular vessel extending along the right cerebellar hemisphere and posterolateral pons extending towards the venous confluence at Galen. Over the course of 5 hours, the patient reported difficulty swallowing and intense headaches. MRI brain showed acute to early subacute infarct involving the right dorsolateral medulla and abnormal T2 prolongation involving essentially the entire cross‐section of the upper medulla and inferior pons representing edema. The patient was taken for Diagnostic catheter angiogram which showed dural AV fistula extending along the right cerebellar hemisphere. Onyx embolization was performed on the Right Middle meningeal artery and right Superior cerebellar artery with complete obliteration of dAVF. Conclusions The spectrum of signs and symptoms associated with DAVFs has been attributed to any one or combination of 6 pathophysiologic factors: the arteriovenous shunt, cerebral hypoxia and ischemia, increased venous pressure, retrograde drainage and secondary engorgement of basal sinuses, sinus obstruction, and subarachnoid hemorrhage secondary to involvement of the pial venous system. Prompt evaluation and management is necessary for patients presenting with neurological symptoms with headache.

Introduction Intracranial pseudoaneurysms are rare lesions that represent less than 1% of all intracranial aneurysms.1They typically occur due to disruption of the arterial wall layers and subsequent extramural/extraluminal hematoma formation following traumatic brain injury, resulting in a higher risk of rebleeding than that of saccular cerebral aneurysms.2Pseudoaneurysms have higher incidence in children and young adults, and given their association with high morbidity and mortality, early detection and management is essential.2‐4The purpose of this study is to highlight the importance of early recognition and management of traumatic pseudoaneurysms prior to decompressive hemicraniectomy. Methods This is a case report of a six‐year‐old previously healthy male who presented as a level 1 trauma alert after sustaining a gunshot wound to the face while manipulating an unsecured weapon at his residence. Upon arrival, lack of airway protection requiring intubation, entry wound to the anterior forehead, and diffuse forehead and periorbital edema were observed. CT head demonstrated multicompartmental hemorrhage with 6mm right to left midline shift and diffuse cerebral edema. CTA head and neck noted possible thrombosed right anterior cerebral artery (ACA) pseudoaneurysm in the right frontoparietal region (Figure 1‐A). Prior to decompressive hemicraniectomy, neuro‐endovascular consultation was obtained, and emergent cerebral angiogram was recommended. This case highlights the findings demonstrated on cerebral angiography, the technique by which the pseudoaneurysm was detected and secured, and the importance of doing so prior to further neurosurgical interventions. Results The patient was taken for diagnostic cerebral angiogram via femoral artery access. Initial angiographic run of the right internal carotid artery demonstrated distal right pericallosal artery slowing without clear evidence of underlying vascular injuries. Given concern for underlying thrombosed pseudoaneurysm and its parent branch, selective catheterization of the proximal pericallosal artery off the distal ACA was performed. Gentle angiographic run was obtained via microcatheter that demonstrated superior parietal artery pseudoaneurysm without active extravasation (Figure 1‐B). The microcatheter was advanced and placed in the proximal portion of the pseudoaneurysm sac and five platinum coils were deployed to fully obliterate the pseudoaneurysm and its parent feeder while protecting the adjacent paracentral artery (Figure 1‐C, 1‐D). Following completion of the endovascular procedure, the patient was transferred to the operative room for right decompressive hemicraniectomy and clot evacuation, which were completed successfully. Conclusions Prompt detection and securement of traumatic intracranial pseudoaneurysms are essential prior to invasive neurosurgical interventions to reduce risk of recurrent bleeding. Selective angiographic evaluation of the parent injured vessel(s) is crucial for optimal assessment of the underlying lesion. Neuro‐endovascular interventions including coil embolization, stenting, flow‐diverter implantation, and parental artery occlusion have emerged as alternatives to conventional neurosurgical management.2 This case highlights the successful early detection and treatment of a traumatic intracranial pseudoaneurysm with coil embolization followed by uncomplicated decompressive hemicraniectomy.

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