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Active extravasation into the upper aerodigestive tract is a dramatic and potentially life-threatening complication in patients with head and neck cancers. It prompts presentation to the emergency room and subsequent urgent imaging to identify the source of hemorrhage. Imaging of these patients may be complicated by treatment-altered anatomy, posing a challenge to the emergency radiologist who needs to rapidly identify the presence of active hemorrhage and the potential source vessel. This retrospective review summarizes the clinical and imaging findings of 6 oropharyngeal and oral cavity squamous cell cancer (SCC) patients with active upper aerodigestive tract hemorrhage. Most patients had advanced stage disease and prior radiation therapy. All CECT or CTA exams on presentation demonstrated the “dot-in-sludge” sign of active extravasation, as demonstrated by a “dot” of avidly enhancing extravasated contrast material layered against a background “sludge” of non-enhancing debris in the lumen of the upper aerodigestive tract. Common sources of hemorrhage included the lingual, facial, and superior thyroidal arteries. Familiarity with these findings will help radiologists increase their accuracy and confidence in interpreting these urgent, complex examinations.

OBJECTIVE Overlapping surgery, in which one attending surgeon manages two overlapping operating rooms (ORs) and is present for all the critical portions of each procedure, is an important policy that improves healthcare access for patients and case volumes for surgeons and surgical trainees. Despite several studies demonstrating the safety and efficacy of overlapping neurosurgical operations, the practice of overlapping surgery remains controversial. To date, there are no studies that have investigated long-term complication rates of overlapping functional and stereotactic neurosurgical procedures. The primary objective of this study was to investigate the 1-year complication rates and OR times for nonoverlapping versus overlapping functional procedures. The secondary objective was to gain insight into what types of complications are the most prevalent and test for differences between groups. METHODS Seven hundred eighty-three functional neurosurgical cases were divided into two cohorts, nonoverlapping (n = 342) and overlapping (n = 441). The American Society of Anesthesiologists (ASA) scale score was used to compare the preoperative risk for both cohorts. A complication was defined as any surgically related reason that required readmission, reoperation, or an unplanned emergency department or clinic visit that required intervention. Complications were subdivided into infectious and noninfectious. Chi-square tests, independent-samples t-tests, and uni- and multivariable logistic regressions were used to determine significance. RESULTS There were no significant differences in mean ASA scale score (2.7 ± 0.6 for both groups, p = 0.997) or overall complication rates (8.8% nonoverlapping vs 9.8% overlapping, p = 0.641) between the two cohorts. Infections accounted for the highest percentage of complications in both cohorts (46.6% vs 41.8%, p = 0.686). There were no statistically significant differences between mean in-room OR time (187.5 ± 141.7 minutes vs 197.1 ± 153.0 minutes, p = 0.373) or mean open-to-close time (112.2 ± 107.9 minutes vs 121.0 ± 123.1 minutes, p = 0.300) between nonoverlapping and overlapping cases. CONCLUSIONS There was no increased risk of 1-year complications or increased OR time for overlapping functional and stereotactic neurosurgical procedures compared with nonoverlapping procedures.

Background Mechanical thrombectomy (MT) is the standard of care for the treatment of proximal anterior circulation large vessel occlusions. However, little is known about its efficacy and safety in the treatment of distal intracranial occlusions. Methods This is a multicenter retrospective study of patients treated with MT at 15 comprehensive centers between January 2015 and December 2018. The study cohort was divided into 2 groups based on the location of occlusion (proximal vs. distal). Distal occlusion was defined as occlusion of M3 segment of the middle cerebral artery, any segment of the anterior cerebral artery, or any segment of the posterior cerebral artery. Only isolated distal occlusion was included. Good outcome was defined as 90-day modified Rankin scale score 0–2. Results A total of 4710 patients were included in this study, of whom 189 (4%) had MT for distal occlusions. Compared with the proximal occlusion group, distal occlusion group had a higher rate of good outcome (45% vs. 36%; P = 0.03) and a lower rate of successful reperfusion (78% vs. 84%; P = 0.04). However, the differences did not retain significance in adjusted models. Otherwise there was no difference in the rate of hemorrhagic complications, mortality, or procedure-related complications between the 2 groups. Successful reperfusion, age, and admission stroke severity emerged as predictors of good functional outcome in the distal occlusion group. Conclusions Thrombectomies of distal vessels achieve high rate of successful reperfusion with similar safety profile to those in more proximal locations.

BackgroundEndovascular thrombectomy (EVT) has become the mainstay treatment for large vessel occlusion, with favorable safety and efficacy profile. However, the safety and efficacy of EVT in concurrent multi-territory occlusions (MTVOs) remains unclear.ObjectiveTo investigate the prevalence, clinical and technical outcomes of concurrent EVT for MTVOs.MethodsData were included from the Stroke Thrombectomy and Aneurysm Registry (STAR) with 32 stroke centers for EVT performed to treat bilateral anterior or concurrent anterior and posterior circulation occlusions between 2017 and 2021. Patients with MTVO were identified, and propensity score matching was used to compare this group with patients with occlusion in a single arterial territory.ResultsOf a total of 7723 patients who underwent EVT for acute ischemic stroke, 54 (0.7%) underwent EVT for MTVOs (mean age 69±12.5; female 50%). 28% had bilateral and 72% had anterior and posterior circulations occlusions. The rate of successful recanalization (Thrombolysis in Cerebral Infarction 2b/3), complications, modified Rankin score at 90 days, and mortality was not significantly different between the matched cohorts. Multivariate analysis confirmed that MTVOs were not associated with poor functional outcome, symptomatic intracranial hemorrhage, or longer procedure time.ConclusionCompared with EVT for single vessel occlusions, EVT in appropriately selected patients with MTVOs has a similar efficacy and safety profile.

Aneurysmal recurrence after successful flow-diversion embolization is exceptionally rare. The rarity of recurrence has called into question the yield of interval surveillance imaging. Here we report the case of a recurrent intracranial aneurysm despite complete angiographic resolution after flow-diversion therapy with a Pipeline embolization device (PED). Given the absence of poor wall apposition, endoleak, and device migration, how this aneurysm recurred remains unclear, particularly given the recurrence was at a timepoint at which complete reendothelialization of the device would be expected. The patient ultimately underwent interval treatment with a second device placed across the neck of the aneurysm. Although rare, reports of aneurysmal recurrences support the use of interval non-invasive imaging surveillance to ensure successful embolization in this patient population.

BackgroundEndovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited.MethodsThis was a retrospective study of patients undergoing EVT for stroke at 32 international centers. Patients were divided into LVOs (internal carotid artery/M1/vertebrobasilar), medium vessel occlusions (M2/A1/P1) and isolated DVOs (M3/M4/A2/A3/P2/P3) and categorized by thrombectomy technique. Primary outcome was a good functional outcome (modified Rankin Scale ≤2) at 90 days. Secondary outcomes included recanalization, procedure-time, thrombectomy attempts, hemorrhage, and mortality. Multivariate logistic regressions were used to evaluate the impact of technical variables. Propensity score matching was used to compare outcome in patients with DVO treated with aspiration versus stent retrieverResultsWe included 7477 patients including 213 DVOs. Distal location did not independently predict good functional outcome at 90 days compared with proximal (p=0.467). In distal occlusions, successful recanalization was an independent predictor of good outcome (adjusted odds ratio (aOR) 5.11, pConclusionsOutcomes following EVT for DVO are comparable to LVO with similar results between techniques. Techniques may exhibit different futility metrics; stent retriever thrombectomy was influenced by attempts whereas aspiration was more dependent on procedure time.

BackgroundThe safety and efficacy of bridging therapy with intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in patients with large core infarct has not been sufficiently studied. In this study, we compared the efficacy and safety outcomes between patients who received IVT+MT and those treated with MT alone.MethodsThis is a retrospective analysis of the Stroke Thrombectomy Aneurysm Registry (STAR). Patients with Alberta Stroke Program Early CT Score (ASPECTS) ≤5 treated with MT were included in this study. Patients were divided into two groups based on pre-treatment IVT (IVT, no IVT). Propensity score matched analysis were used to compare outcomes between groups.ResultsA total of 398 patients were included; 113 pairs were generated using propensity score matching analyses. Baseline characteristics were well balanced in the matched cohort. The rate of any intracerebral hemorrhage (ICH) was similar between groups in both the full cohort (41.4% vs 42.3%, P=0.85) and matched cohort (38.55% vs 42.1%, P=0.593). Similarly, the rate of significant ICH was similar between the groups (full cohort: 13.1% vs 16.9%, P=0.306; matched cohort: 15.6% vs 18.95, P=0.52). There was no difference in favorable outcome (90-day modified Rankin Scale 0–2) or successful reperfusion between groups. In an adjusted analysis, IVT was not associated with any of the outcomes.ConclusionPretreatment IVT was not associated with an increased risk of hemorrhage in patients with large core infarct treated with MT. Future studies are needed to assess the safety and efficacy of bridging therapy in patients with large core infarct.

Background By 2030, nonacute subdural hematomas (NASHs) will likely be the most common cranial neurosurgery pathology. Treatment with surgical evacuation may be necessary, but the recurrence rate after surgery is as high as 30%. Minimally invasive middle meningeal artery embolization (MMAE) during the perioperative period has been posited as an adjunctive treatment to decrease the potential for recurrence after surgical evacuation. We evaluated the safety and efficacy of concurrent MMAE in a multi-institutional cohort. Methods Data from 145 patients (median age 73 years) with NASH who underwent surgical evacuation and MMAE in the perioperative period were retrospectively collected from 15 institutions. The primary outcome was the rate of recurrence requiring repeat surgical intervention. We collected clinical, treatment, and radiographic data at initial presentation, after evacuation, and at 90-day follow-up. Outcomes data were also collected. Results Preoperatively, the median hematoma width was 18 mm, and subdural membranes were present on imaging in 87.3% of patients. At 90-day follow-up, median NASH width was 6 mm, and 51.4% of patients had at least a 50% decrease of NASH size on imaging. Eight percent of treated NASHs had recurrence that required additional surgical intervention. Of patients with a modified Rankin Scale score at last follow-up, 87.2% had the same or improved mRS score. The total all-cause mortality was 6.0%. Conclusion This study provides evidence from a multi-institutional cohort that performing MMAE in the perioperative period as an adjunct to surgical evacuation is a safe and effective means to reduce recurrence in patients with NASHs.

While most intracranial aneurysms (IAs) remain asymptomatic over a patient's lifetime, those that rupture can cause devastating outcomes. The increased usage and quality of neuroimaging has increased detection of unruptured IAs and driven an increase in surveillance and treatment of these lesions. Standard practice is to treat incidentally discovered unruptured IAs that confer high rupture risk as well as ruptured IAs to prevent rehemorrhage. IAs are increasingly treated with coil embolization instead of microsurgical clipping; more recently, flow diversion and intrasaccular flow disruption have further expanded the versatility and utility of endovascular IA treatment. Imaging is increasingly used for posttreatment IA follow-up in the endovascular era. While cerebral angiography remains the standard for IA characterization and treatment planning, advances in CT and CT angiography and MR angiography have improved the diagnostic accuracy of noninvasive imaging for initial diagnosis and surveillance. IA features including size, dome-to-neck ratio, location, and orientation allow rupture risk stratification and determination of optimal treatment strategy and timing. The radiologist should be familiar with the imaging appearance of common IA treatment devices and the expected imaging findings following treatment. In distinction to clipping and coil embolization, flow diversion and intrasaccular flow disruption induce progressive aneurysm obliteration over months to years. Careful assessment of the device; the treated IA; adjacent brain, bone, meninges; and involved extracranial and intracranial vasculature is crucial at posttreatment follow-up imaging to confirm aneurysm obliteration and identify short-term and long-term posttreatment complications.

Background Endovascular thrombectomy(EVT) is the standard of care for large vessel occlusion(LVO) stroke. Data on technical and clinical outcome in proximal medium vessel occlusions(pMeVOs) comparing frontline techniques remain limited. Methods We report an international multicenter retrospective study of patients undergoing EVT for stroke at 32 centers between 2015–2021. Patients were divided into LVOs(ICA/M1/Vertebrobasilar) or pMeVOs(M2/A1/P1) and categorized by thrombectomy technique. Primary outcome was 90-day good functional outcome(mRS ≤ 2). Multivariate logistic regressions were used to evaluate the impact of technical variables on clinical outcomes. Propensity score matching was used to compare outcome in patients with pMeVO treated with aspiration versus stent-retriever. Results In the cohort of 5977 LVO and 1287 pMeVO patients, pMeVO did not independently predict good-outcome(p = 0.55). In pMeVO patients, successful recanalization irrespective of frontline technique(aOR = 3.2,p Conclusions Clinical outcomes following EVT for pMeVO are comparable to those in LVOs. The golden hour or 3-pass rules in LVO thrombectomy still apply to pMeVO thrombectomy. Different techniques may exhibit different futility metrics; SR thrombectomy was more influenced by attempts whereas aspiration was more dependent on procedure time.

Introduction The COVID-19 pandemic has led to excess mortality out of proportion to documented COVID-19 cases while also affecting the care of non-COVID-19 related diseases. No data exist on the effects of the COVID-19 pandemic on the care and outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). Here we determine the impact of the COVID-19 pandemic on latency to presentation and clinical outcomes for aneurysmal subarachnoid hemorrhage. Methods We performed a retrospective cohort study of all patients presenting to a single center in Atlanta, Georgia, USA with aSAH between 2012 and 2020. COVID-19 was first reported in Georgia on March 2, 2020. All patients presenting from March 2nd through June 30th of a given calendar year were compared from the pre-COVID-19 era (2012- 2019) to the COVID-19 era (2020). Patient characteristics, latency from ictus to presentation, and clinical outcomes were compared. Every index digital subtraction angiogram was scored for the presence of vasospasm, and all cranial imaging studies were reviewed for infarcts consistent with delayed cerebral ischemia. Results 470 patients presented with aneurysmal subarachnoid hemorrhage during the study period. 433 and 37 presented before and during the COVID-19 era, respectively. Compared to the pre-COVID-19 era patients, patients presenting during the early phase of the pandemic were more likely to delay presentation (2.3 ± 1.3 days vs. 0.9 ± 2.2 days, respectively, p

BackgroundAtrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely, AF is not associated with hemorrhagic complications or functional outcomes in patients undergoing mechanical thrombectomy (MT). This differential effect of MT and IVT in AF associated stroke raises the question of whether bridging thrombolysis increases hemorrhagic complications in AF patients undergoing MT.MethodsThis international cohort study of 22 comprehensive stroke centers analyzed patients with large vessel occlusion (LVO) undergoing MT between June 1, 2015 and December 31, 2020. Patients were divided into four groups based on comorbid AF and IVT exposure. Baseline patient characteristics, complications, and outcomes were reported and compared.Results6461 patients underwent MT for LVO. 2311 (35.8%) patients had comorbid AF. In non-AF patients, bridging therapy improved the odds of good 90 day functional outcomes (adjusted OR (aOR) 1.29, 95% CI 1.03 to 1.60, p=0.025) and did not increase hemorrhagic complications. In AF patients, bridging therapy led to significant increases in symptomatic intracranial hemorrhage and parenchymal hematoma type 2 (aOR 1.66, 1.07 to 2.57, p=0.024) without any benefit in 90 day functional outcomes. Similar findings were noted in a separate propensity score analysis.ConclusionIn this large thrombectomy registry, AF patients exposed to IVT before MT had increased hemorrhagic complications without improved functional outcomes, in contrast with non-AF patients. Prospective trials are warranted to assess whether AF patients represent a subgroup of LVO patients who may benefit from a direct to thrombectomy approach at thrombectomy capable centers.

The early phase of the COVID-19 pandemic led to significant healthcare avoidance, perhaps explaining some of the excess reported deaths that exceeded known infections. The impact of the early COVID-19 era on aneurysmal subarachnoid hemorrhage (aSAH) care remains unclear.To determine the impact of the early phase of the COVID-19 pandemic on latency to presentation, neurological complications, and clinical outcomes after aSAH.We performed a retrospective cohort study from March 2, 2012, to June 30, 2021, of all patients with aSAH admitted to our center. The early COVID-19 era was defined as March 2, 2020, through June 30, 2020. The pre-COVID-19 era was defined as the same interval in 2012 to 2019.Among 499 patients with aSAH, 37 presented in the early COVID-19 era. Compared with the pre-COVID-19 era patients, patients presenting during this early phase of the pandemic were more likely to delay presentation after ictus (median, interquartile range; 1 [0-4] vs 0 [0-1] days, respectively, P.001). Radiographic-delayed cerebral ischemia (29.7% vs 10.2%, P.001) was more common in the early COVID-19 era. In adjusted analyses, presentation in the early COVID-19 era was independently associated with increased inhospital death or hospice disposition (adjusted odds ratio 3.29 [1.02-10.65], P = .046). Both latency and adverse outcomes returned to baseline in 2021.aSAH in the early COVID-19 era was associated with delayed presentation, neurological complications, and worse outcomes at our center. These data highlight how healthcare avoidance may have increased morbidity and mortality in non-COVID-19-related neurosurgical disease.

Background The Pipeline Embolization Device (PED) has been increasingly used for the treatment of posterior circulation aneurysms. The purpose of the present study was to examine the clinical and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. Methods We performed a retrospective review of vertebrobasilar aneurysms treated with the PED at 4 high-volume neurovascular centers. Patient, aneurysm, and procedural data were collected, including perioperative and delayed complications. Aneurysm occlusion on follow-up imaging studies was defined as complete (100%), near-complete (>90%), or incomplete ( Results The cohort included 35 patients with 37 vertebrobasilar aneurysms who underwent 36 treatment sessions. Of the 35 patients, 10 were men (29%), and the mean patient age was 54.1 years (range, 32–75). Eight patients (23%) underwent urgent treatment because of a ruptured aneurysm (n = 6), brainstem perforator stroke (n = 1), or post-traumatic pseudoaneurysm (n = 1). Of the 37 aneurysms, 22 arose from the vertebral artery (59%) and 15 from the basilar artery (41%). Also, 19 were saccular aneurysms (51%), with a mean size of 7.7 mm (range, 1.7–38.0); 17 were fusiform aneurysms (46%), with a mean size of 11.0 mm (range, 4.3–34); and 1 was a 2.9-mm blister aneurysm. The overall procedural complication rate was 14% (5 of 36), including 3 neurologically symptomatic complications. At a mean follow-up period of 14 months (range, 3–59), 24 of 34 aneurysms (71%) were completely occluded and 29 of 34 (85%) were completely or near-completely occluded. Conclusion Our results show that Pipeline embolization of vertebrobasilar aneurysms is associated with acceptable occlusion and complication rates.

BackgroundThe pipeline embolization device (PED) is approved for the treatment of large aneurysms of the proximal internal carotid artery (ICA). Its off-label application in treating aneurysms located specifically at the ICA terminus (ICA-T) has not been studied.MethodsWe conducted a retrospective chart review of patients from 2011 to 7 treated with PEDs. Out of 365 patients, 10 patients with ICA-T aneurysms were included. Patient demographics, procedural information, follow-up imaging, and clinical assessments were recorded.ResultsMean age was 46.9 years (± 8.8), and 6 (60%) patients were women. The mean maximum diameter of the aneurysms treated was 14.7 mm (± 10.7) and the mean neck diameter was 9.3 mm (± 6.6). Reasons for presentation included six incidental findings, one acute subarachnoid hemorrhage (SAH), and three patients with prior SAH. Kamran–Byrne Occlusion Scale scores for the treated aneurysms were as follows: three class IV (complete obliteration), four class III (ConclusionThe PED has potential for treating ICA-T aneurysms not amenable to conventional treatment strategies. Further studies are warranted to confirm the long term outcomes.

* on behalf of the Stroke Thrombectomy and Aneurysm Registry (STAR) Collaborators Introduction: Intravenous thrombolysis complications are enriched in AF associated stroke, as these patients have worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications. These data suggest that AF patients may be at particularly high risk for complications of bridging therapy for large vessel occlusions treated with mechanical thrombectomy (MT). Here we determine whether clinical outcomes differ in AF associated stroke treated with MT and bridging therapy. Methods: We performed a retrospective cohort study of the Stroke and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4,169 patients who underwent MT for an anterior circulation stroke, 1,517 (36.4 %) of which had comorbid AF. Prospectively defined baseline characteristics and clinical outcomes were compared. Results: Hemorrhagic complications after MT were similar in patients with or without AF. In patients without AF, bridging therapy improved 90-day outcomes (aOR 1.32, 1.02-1.74, p Conclusions: Bridging therapy in AF patients undergoing thrombectomy independently increased the odds of intracranial hemorrhage and did not improve functional outcomes. AF patients may represent a high-risk subgroup for thrombolytic complications. Randomized trials are warranted to determine whether patients with AF associated stroke may benefit by deferring bridging therapy at thrombectomy-capable centers.

Introduction: The benefit of thrombectomy for large vessel occlusion (LVO) is well proven. There is minimal data on concurrent thrombectomy for multi-territory occlusions. Methods: We reviewed the STAR registry from 2015-8 for patients treated with either right and left sided thrombectomy or anterior and posterior circulation thrombectomy at 15 comprehensive stroke centers. Results: There were 4966 patients in the study period who had completed outcome data and LVO thrombectomy. 38 (0.8%) underwent endovascular thrombectomy for multi-territory occlusions. 26% had bilateral occlusions and 74% had anterior and posterior circulation occlusions. Among the 38, 50% were female, 49% were white, and 91% had a prestroke mRS6 and 55% received iv t-pa. 83% of patients had successful recanalization (TICI 2B/3) for both territories. The overall complication rate was 15%. 5% of patients had sICH or PH2. 26% of patients had a 90day mRS Conclusion: With similar selection to single territory LVOs, good outcome can be achieved in multi-territory infarction with reasonable procedure time and no additional risk of hemorrhage or poor outcome.

Developmental venous anomalies (DVA) are the most common blood vessel abnormality of the central nervous system. The etiology of DVAs remains unclear. DVAs drain normal brain and are associated with other cerebrovascular lesions, such as cavernous malformations (CM). Consensus dictates that isolated DVAs do not require treatment and, in fact, removal of a DVA may lead to extreme venous stasis, infarction and hemorrhage. When associated with abnormalities that require resection, such as CMs, care should be taken not to violate the venous collector of the DVA given the aforementioned potential complications.

Background The Woven EndoBridge (WEB) device was granted premarket approval in the United States following results of the Woven EndoBridge Intrasaccular Therapy (WEB-IT) study. WEB-IT reported excellent adequate angiographic occlusion of treated aneurysms with a high safety profile. These results were achieved, however, in the context of a prospective study with strict inclusion criteria and rigorous training support. Objective To review early as-practiced clinical experience with the WEB device in the United States. Methods Retrospective review across 6 institutions identified 91 patients undergoing 92 treatment sessions for WEB device placement in treatment of 91 intracranial aneurysms. Details regarding demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed in a multicenter database. Angiograms from the index procedure and follow-up studies were reviewed by a blinded and independent adjudicator. Results The middle cerebral, anterior communicating, and basilar artery complexes were the commonly treated locations. Eight patients presented with ruptured aneurysms. A mean of 1.2 devices were introduced per case. Technical failure without deployment of a WEB device occurred in 2% (2/92) of sessions. Adequate aneurysm occlusion for patients with imaging follow-up was 49% (mean follow-up of 8 mo). Four aneurysms were retreated. 90% of patients had modified Rankin Scale ≤ 2 at last clinical follow-up with no mortalities. Conclusion Immediate postmarket experience with the WEB device, newly introduced at American centers, confirms safe procedural use, but long-term efficacy remains unclear. Early challenges include accurate sizing and device selection.

BackgroundThe coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT).MethodsWe used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020).ResultsWe identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, PConclusionThe COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.

Introduction The NAPA study was a prospective, multicenter, single-arm IDE trial of the PulseRider device as an adjunctive treatment in conjunction with coil embolization of unruptured wide-neck bifurcation aneurysms which was electively discontinued for reasons not related to the safety or performance of the device. We report on the available enrollments in NAPA and their available follow up. Methods The PulseRider device was implanted in 18/21 enrollments. Available core-lab adjudicated data from the first 18 implants is presented. Of those, 5 have one year follow up data available. Of the 3 device implantation failures, the locations included basilar (1), carotid terminus (1), and ACOMM (1). Results For the 18 patients with PulseRider implanted as a coil-adjunct device, the mean age was 60.7± 8.9 yrs and 16 were female. The mean aneurysm diameter was 6.6± 2.2 mm, height 5.3±1.7 mm and neck 4.8 ±1.5 mm. Locations included the basilar apex (11), MCA bifurcation (4) and ACOMM (3). Thirteen of 18 were de novo aneurysms while the remainder (5) were treated in the setting of aneurysmal recurrence. The most common PulseRider placement was extra-aneurysmal (12/18), followed by intra-aneurysmal (4/18) and hybrid (2/18). Immediate angiographic occlusions were 66.6% RR-I, 16.7% RR-II, 16.7% RR-III. There were no device related adverse events. There were 3 (16.7%) procedure-related adverse events which did not result in neurological changes. Seven enrollments have 6 month follow up and all are RRI-II. Only 1 has one year angiographic follow up (RRI) adjudicated by the core lab, and 4 have clinical follow up (4/4 mRS 0–2). None of the target aneurysms have required retreatment. Conclusions The results of the discontinued NAPA provide high quality data on the occlusion rates and safety profile for the PulseRider device. Further one year angiographic and clinical follow up will be reported when available. Disclosures A. Spiotta: 1; C; Microvention. 2; C; Minnetronix, Penumbra, Cerenovus. 6; C; Cerenovus, Penumbra, Pulsar Vascular, Stryker, Microvention. K. Ebersole: None. J. Lena: None. R. Starke: 2; C; Medtronic Neurovascular, Penumbra, Cerenovus, Abbott. R. De Leacy: 6; C; Penumbra, Cerenovus, Siemens. A. Puri: 1; C; Stryker Neurovascular, Medtronic Neurovascular. 2; C; Stryker Neurovascular, Medtronic Neurovascular. D. Yavagal: 2; C; Medtronic Neurovascular, Rapid Medical, Steering Committee, Neuralanalytics. 6; C; Medtronic, Cerenovus/Johnson & Johnson, Rapid Medical, Neuralanalytics. B. Bohnstedt: 2; C; Penumbra, Stryker, Medtronic. L. Rangel-Castilla: None. A. Cheema: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University of Buffalo. 2; C; Medtronic, Neurotrauma Science, LLC. 4; C; RIST Neurovascular. K. de Macedo Rodrigues: None. J. Grossberg: None. B. Howard: None. C. Kellner: 1; C; Penumbra, Siemens Corp. G. Lanzino: None. S. Tateshima: 2; C; Cerenovus, Medtronic, Neurovasc, Stryker. 4; C; Neurovasc.

We report a multicenter experience using endovascular embolization as the first line approach for treatment of anterior cranial fossa (ACF) dural arteriovenous fistula (DAVF). All patients with DAVFs located in the anterior cranial fossa who were treated with endovascular technique as a first line approach were included. Demographics, clinical presentation, angioarchitecture, strategy, complications, immediate angiographic, and follow-up results were included in the analysis. Twenty-three patients met the inclusion criteria (18 male and 5 female). Age ranged from 14 to 79 years (mean 53 years). Twelve patients presented with hemorrhage. Twenty-eight endovascular procedures were performed. The overall immediate angiographic cure rate after endovascular treatment was 82.6% (19/23 patients). The angiographic cure rate of the transvenous strategy was significantly superior to the transarterial strategy (p ≤ 0.001). There was 1 complication in 28 total procedures (3.6%). Angiographic follow-up was available in 21 out of the 23 patients with a mean of 25 months (range 2 to 108 months). In these 21 patients, the DAVF was completely cured in 20 (95%). At last follow-up, all patients had a modified Rankin scale (mRS) 0 to 2. Our experience suggests that endovascular treatment for ACF DAVFs has an acceptable safety profile with high rates of complete occlusion, particularly with transvenous approach. Whenever possible, transvenous approach should be preferred over transarterial approach as first line strategy.

BackgroundRuptured aneurysms of the intracranial vertebral artery (VA) or posterior inferior cerebellar artery (PICA) are challenging to treat as they are often dissecting aneurysms necessitating direct sacrifice of the diseased segment, which is thought to carry high morbidity due to brainstem and cerebellar stroke. However, relatively few studies evaluating outcomes following VA or proximal PICA sacrifice exist. We sought to determine the efficacy and outcomes of endovascular VA/PICA sacrifice.MethodsA retrospective series of ruptured VA/PICA aneurysms treated by endovascular sacrifice of the VA (including the PICA origin) or proximal PICA is reviewed. Collected data included demographic, radiologic, clinical, and disability information.ResultsTwenty-one patients were identified. Median age was 57 years (IQR 11); 15 were female. The Hunt and Hess grade was mostly 3 and 4 (18/21). Seven cases (33%) involved VA-V4 at the PICA take-off, and 14 cases (67%) involved the PICA exclusively. For VA pathology, V4 was sacrificed in all cases, while for PICA pathology, sacrificed segments included anterior medullary (4/14), lateral medullary (7/14), and tonsillomedullary (3/14) segments. Four patients went to hospice (19%). Twelve patients (57%) had evidence of stroke on follow-up imaging: cerebellar (8), medullary (1), and both (3). One patient required suboccipital decompression for brainstem compression. No aneurysm re-rupture occurred. Median discharge modified Rankin Scale score was 2.0 (IQR 2), which decreased to 1.0 (IQR 1) at median follow-up of 6.5 months (IQR 23).ConclusionsEndovascular sacrifice of V4 or PICA aneurysms may carry less morbidity than previously thought, and is a viable alternative for poor surgical candidates or those with good collateral perfusion.

BackgroundAtrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT).ObjectiveTo determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT.MethodsWe performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared.ResultsAF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (pConclusionsIn patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.

BackgroundIn response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied.MethodsA prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders.Results458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (PConclusionWe observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.

Flow diversion is a viable alternative for treatment of wide-neck and fusiform aneurysms originating from the posterior inferior cerebellar artery (PICA), but coverage of the PICA and vertebral perforating arteries may be a concern. The aim of this study was to examine procedural, clinical, and angiographic outcomes of patients with PICA aneurysms treated with the Pipeline Embolization Device.Retrospective review was performed of PICA aneurysms treated with the Pipeline device at 3 neurovascular centers, including periprocedural complications and clinical and angiographic outcomes.In 16 procedures, 14 PICA aneurysms were treated with the Pipeline device. These included 11 saccular aneurysms with a mean size of 7.4 mm (range, 2.0-11.1 mm) and 3 fusiform aneurysms with a mean diameter of 6.1 mm (range, 5.0-8.0 mm) and mean length of 10.3 mm (range, 6.0-15.0 mm). One patient developed a PICA territory infarct with mild leg weakness that resolved in7 days. Overall complication rate was 7% (1/14) per patient and 6% (1/16) per procedure. Mean duration of clinical follow-up was 13.5 months (range, 3 weeks to 61.7 months), with all patients returning to baseline functional status. Complete or near-complete aneurysm occlusion was achieved in 58% (7/12) of cases with angiographic follow-up (mean, 15 months; range, 4-61 months). All covered PICAs remained patent.Flow diversion of PICA aneurysms is a safe and viable treatment option when traditional endovascular options are unlikely to preserve parent vessel patency.

Background Flow diversion of posterior cerebral artery (PCA) aneurysms has not been widely reported, possibly owing to concerns regarding parent vessel size and branch vessel coverage. Objective To examine the safety and effectiveness of PCA aneurysm flow diverter treatment. Methods Retrospective review of PCA aneurysms treated with the Pipeline Embolization Device (PED; Medtronic Inc, Dublin, Ireland) at 3 neurovascular centers, including periprocedural complications and clinical and angiographic outcomes. Systematic review of the literature identified published reports of PCA aneurysms treated with flow diversion. Rates of aneurysm occlusion and complications were calculated, and outcomes of saccular and fusiform aneurysm treatments were compared. Results Ten PCA aneurysms in 9 patients were treated with the PED. There were 2 intraprocedural thromboembolic events (20%), including 1 symptomatic infarction and 1 delayed PED thrombosis. Eight of 10 patients returned to or improved from their baseline functional status. Complete aneurysm occlusion with parent vessel preservation was achieved in 75% (6/8) of cases at mean follow-up of 16.7 mo. Eleven of 12 (92%) major branch vessels covered by a PED remained patent. Including the present study, systematic review of 15 studies found a complete aneurysm occlusion rate of 88% (30/34) and complication rate of 26% (10/38), including 5 symptomatic ischemic strokes (13%; 5/38). Fusiform aneurysms more frequently completely occluded compared with saccular aneurysms (100% vs 70%; P = .03) but were associated with a higher complication rate (43% vs 9%; P = .06). Conclusion The safety and effectiveness profile of flow diverter treatment of PCA aneurysms may be acceptable in select cases.

Key Points Question What is the 90-day outcome for patients with stroke presenting with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5 who underwent mechanical thrombectomy? Findings In this multicenter cohort study of 2345 patients presenting with an intracranial internal carotid artery or M1 occlusion who underwent mechanical thrombectomy, 213 [9.1%] had an ASPECTS of 2 to 5, and 22% of these patients achieved favorable 90-day outcomes (modified Rankin scale score of 0-2). Patients who achieved successful recanalization were nearly 5 times more likely to achieve favorable outcomes compared with patients who had unsuccessful recanalization. Meaning This study suggests that patients with a low ASPECTS on presentation may achieve 90-day functional independence after mechanical thrombectomy if they achieve successful recanalization., Importance Limited data are available about the outcomes of mechanical thrombectomy (MT) for real-world patients with stroke presenting with a large core infarct. Objective To investigate the safety and effectiveness of MT for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5. Design, Setting, and Participants This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combines the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. The study included 2345 patients presenting with an occlusion in the internal carotid artery or M1 segment of the middle cerebral artery from January 1, 2016, to December 31, 2020. Patients were followed up for 90 days after intervention. The ASPECTS is a 10-point scoring system based on the extent of early ischemic changes on the baseline noncontrasted computed tomography scan, with a score of 10 indicating normal and a score of 0 indicating ischemic changes in all of the regions included in the score. Exposure All patients underwent MT in one of the included centers. Main Outcomes and Measures A multivariable regression model was used to assess factors associated with a favorable 90-day outcome (modified Rankin Scale score of 0-2), including interaction terms between an ASPECTS of 2 to 5 and receiving MT in the extended window (6-24 hours from symptom onset). Results A total of 2345 patients who underwent MT were included (1175 women [50.1%]; median age, 72 years [IQR, 60-80 years]; 2132 patients [90.9%] had an ASPECTS of ≥6, and 213 patients [9.1%] had an ASPECTS of 2-5). At 90 days, 47 of the 213 patients (22.1%) with an ASPECTS of 2 to 5 had a modified Rankin Scale score of 0 to 2 (25.6% [45 of 176] of patients who underwent successful recanalization [modified Thrombolysis in Cerebral Ischemia score ≥2B] vs 5.4% [2 of 37] of patients who underwent unsuccessful recanalization; P = .007). Having a low ASPECTS (odds ratio, 0.60; 95% CI, 0.38-0.85; P = .002) and presenting in the extended window (odds ratio, 0.69; 95% CI, 0.55-0.88; P = .001) were associated with worse 90-day outcome after controlling for potential confounders, without significant interaction between these 2 factors (P = .64). Conclusions and Relevance In this cohort study, more than 1 in 5 patients presenting with an ASPECTS of 2 to 5 achieved 90-day functional independence after MT. A favorable outcome was nearly 5 times more likely for patients with low ASPECTS who had successful recanalization. The association of a low ASPECTS with 90-day outcomes did not differ for patients presenting in the early vs extended MT window., This cohort study uses data from the Stroke Thrombectomy and Aneurysm Registry to investigate the safety and effectiveness of mechanical thrombectomy for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score of 2 to 5.

Background Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). Objective To determine the safety and efficacy of MMA embolization. Methods Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. Results A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. Conclusion MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.

The proportion of intracranial aneurysms treated by microsurgical clip ligation has drastically decreased in the endovascular era. However, some aneurysms cannot be treated by current endovascular techniques. Therefore, trainees and young vascular neurosurgeons must develop and maintain microsurgical skills to safely treat aneurysms that require surgery. Ruptured, basilar artery apex, blister-type aneurysms are particularly treacherous and require a high degree of skill to safely manage them surgically. In this video, 2 companion cases are exhibited to demonstrate the nuances of the subtemporal, skull base, approach to the basilar apex region. In each case, the patient consented to surgery and anonymized recording. The subtemporal approach is favored over the trans-sylvian for posteriorly directed basilar apex region aneurysms as the former affords a complete view of the relevant anatomy. Points for consideration include variations on the standard subtemporal approach, use of retractors vs lumbar drainage to mobilize the temporal lobe, and splitting the tentorium vs a suture-retraction technique for visualization of the basilar artery apex region. Techniques for successful navigation of intraoperative rupture are demonstrated. As the number of intracranial aneurysms treated by microsurgery continues to ebb, high-quality educational videos that supplement surgeon experience will become increasingly critical to ensure that a cohort of capable microvascular neurosurgeons is prepared to tackle challenging, but manageable aneurysms, such as the blister-type basilar apex variety. Video (c) Emory University School of Medicine, 2021. Used with permission.

Background Aneurysms at the origin of the posterior communicating artery (PcommA) have been demonstrated to be effectively treated with the pipeline embolization device (PED). Much less is known about the efficacy of the PED for aneurysms associated with a fetal posterior cerebral artery (fPCA) variant. Objective To study PED treatment efficacy of PcommA aneurysms, including fPCA aneurysms. Methods A prospectively maintained university database of aneurysm patients treated with the PED was retrospectively reviewed. Demographics, treatment details, and imaging were reviewed for all PcommA and fPCA aneurysms. Results Out of a total of 285 patients treated with PED, 50 patients (mean age 57.5 ± 12.2 yr, 42 females) with unruptured PcommA (9 fPCA) aneurysms were identified. Mean follow-up duration was 14.0 ± 11.6 mo (48 patients). Roy-Raymond class I occlusion on follow-up magnetic resonance or catheter angiography (mean time 11.7 ± 6.8 mo) was achieved in 30 patients (62.5%), class II occlusion in 11 patients (22.9%) and class III occlusion in 7 patients (14.5%). The PcommA was occluded in 56% of patients without any clinical symptoms. No deaths or permanent neurological complications occurred. In fPCA aneurysms, class I occlusion was seen in 1 patient, class 2 occlusion in 2 patients, and class III occlusion in 6 patients. Multivariate analysis revealed an independent association between incomplete occlusion and fPCA configuration (OR 73.65; 95% CI: 5.84-929.13; P = .001). Conclusion The PED is a safe and effective treatment for PcommA aneurysms, although fetal anatomy should increase consideration of traditional endovascular techniques or surgical clipping.

Background Interhospital transfer of neurosurgical patients is common; however, little is known about the impact of transfer parameters on clinical outcomes. Lower survival rates have been reported for patients admitted at night and on weekends in other specialties. Whether time or day of admission affects neurosurgical patient outcomes, specifically those transferred from other facilities, is unknown. Objective To examine the impact of the timing of interhospital transfer on the hospital course and clinical outcomes of neurosurgical patients. Methods All consecutive admissions of patients transferred to our adult neurosurgical service were retrospectively analyzed for a 1-year study period using data from a central transfer database and the electronic health record. Results Patients arrived more often at night (70.8%) despite an even distribution of transfer requests. The lack of transfer imaging did not affect length of stay, intervention times, or patient outcomes. Daytime arrivals had shorter total transfer time, but longer intenstive care unit and overall length of stay (8.7 and 11.6 days, respectively), worse modified Rankin Scale scores, lower rates of functional independence, and almost twice the mortality rate. Weekend admissions had significantly worse modified Rankin Scale scores and lower rates of functional independence. Conclusions The timing of transfer arrivals, both by hour or day of the week, is correlated with the time to intervention, hospital course, and overall patient outcomes. Patients admitted during the weekend suffered worse functional outcomes and a trend towards increased mortality. While transfer logistics clearly impact patient outcomes, further work is needed to understand these complex relationships.

Data suggest that patients who present to trauma centers with mild traumatic brain injury (TBI) are admitted to an excessively high level of care and undergo myriad, unnecessary repeat radiographic and laboratory tests that do not affect outcome. Surprisingly, a paucity of data exists regarding the management of isolated, traumatic, parafalcine, or tentorial acute subdural hematoma (aSDH). Therefore, a retrospective, cohort study was completed to analyze factors associated with outcomes in patients who present to a high-volume, urban, level 1 trauma center with isolated parafalcine or tentorial aSDH after closed head injury. Out of 3097 patients admitted with TBI over the study period, 65 met inclusion criteria. More than 90% of patients were admitted to the intensive care unit (ICU), irrespective of Glasgow Coma Scale (GCS) score at presentation or the presence of systemic injury. Factors determined to be statistically associated with increased ICU and total length of stay were GCS ≤ 12 on presentation and presence of systemic injury. Depressed GCS, systemic injury, and being elderly were associated with poor discharge disposition; whereas being systemically injured, female, or elderly were associated with poor functional status at discharge. Although 94% of admitted patients underwent at least one repeat head computed tomography (CT) scan while hospitalized, not a single aSDH enlarged, including four patients on antiplatelet agents, anticoagulants, or both. Based on these data, young patients who present with GCS 13-15 without systemic injury following blunt trauma with an associated isolated parafalcine and tentorial aSDH may be safely admitted to a standard medical/surgical floor for observation.