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Background Intrathecal nusinersen is the first Food and Drug Administration-approved treatment for spinal muscular atrophy. Reliable intrathecal access is critical for initial and maintenance therapy; however, this can be challenging in older patients with spinal muscular atrophy many of whom have had prior lumbar instrumentation and osseous fusion. Transforaminal lumbar punctures have emerged as a technique for intrathecal access that avoids the hazards of cervical punctures. We describe our technique for transforaminal lumbar punctures under computed tomography guidance using local anesthesia and a straight 22-gauge needle. Methods Following local institutional review board approval, medical records of all patients undergoing computed tomography-guided transforaminal lumbar puncture for intrathecal nusinersen injection were obtained and analyzed. The rate of technical success and immediate complications were recorded. Any delayed complications noted in a 3-day follow-up phone call and future office visit were also recorded. Data collation and analysis were performed using Excel. Results A total of 77 transforaminal lumbar punctures were performed with intrathecal administration of nusinersen, for a 100% technical success rate. Local anesthesia was used in 76 cases, with conscious sedation used in one case. General anesthesia was not used in any case. There were no major complications. One patient had a postdural puncture headache that resolved completely after a transforaminal epidural blood patch performed 4 days later. Conclusions Intrathecal administration of nusinersen is critical for treatment of patients with spinal muscular atrophy. Our described technique allows for reliable access to the intrathecal space using local anesthesia and a straight 22-gauge spinal needle under computed tomography guidance, and is easily reproducible.

BackgroundThere is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA).MethodsWe searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality.ResultsAmong 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41], P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups.ConclusionsNon-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence.

Background Osteoradionecrosis (ORN) refers to the degenerative changes seen in bone after local radiation, particularly in head and neck cancer. ORN can present as neck or facial pain and may be confused with tumor recurrence. Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans are often inconclusive, requiring percutaneous biopsy to differentiate ORN from infection and recurrent disease. We reviewed the utility of preprocedural imaging in guiding the decision to biopsy in cases of ORN. Case Description Eight patients with a history of prior head and neck cancer, radiation therapy, and suspected ORN at the skull base, occipitocervical junction, and atlantoaxial spine were identified retrospectively from a single academic medical center. In 4 cases, MRI findings and PET imaging were negative for recurrence. One patient in this group underwent an aborted biopsy. Four patients had MRI concerning for infection or recurrent tumor with PET-positive lesions. Three patients in this group underwent biopsy that was negative for recurrent tumor. One patient developed an arteriovenous fistula after biopsy. The fourth patient was observed and did not demonstrate progression at 5 months. At last follow-up for all patients, there was no evidence of tumor recurrence or metastasis at the index site to indicate a misdiagnosis for recurrent tumor. Conclusions This case series highlights that PET scanning may not be useful in predicting which patients will benefit from biopsy for ORN because no patients with PET-positive lesions had histopathologic evidence of tumor recurrence or metastasis on biopsy.

Background Endovascular procedures such as intraarterial (IA) vasodilator injection and balloon angioplasty are used to treat medically refractory cerebral vasospasm. The effects of IA therapy may be short lived and thus require multiple treatments. Balloon angioplasty also has limitations including transient occlusion of the spastic blood vessel, possible endothelial injury, and limited access to proximal vessels. We aim to demonstrate a novel technique using a stent retriever for the management of medically refractory vasospasm, especially in distal vessels. Compared with balloon angioplasty, stent retrievers provide a passive, self-limiting expansion of blood vessels. Other benefits over balloon angioplasty include 1) ability to simultaneously inject IA vasodilators, 2) limited contact and damage to vessel wall, 3) nonocclusive expansion, and 4) technical ease. Methods Fourteen blood vessels from 6 patients with symptomatic vasospasm after subarachnoid hemorrhage were identified. We injected 5 mg of IA vasodilator medication into the vasospastic segments without radiographic improvement in vessel diameter and blood flow. The stent retriever was deployed for 2–5 minutes in each vasospastic segment. Results Distal anterior and posterior circulation segments were easily accessible with the stent retriever system. It resulted in improved vessel diameter and blood flow with subsequent improvement in neurologic examination. All patients demonstrated radiographic resolution of vasospasm. No procedural-related complications were noted. Conclusions We demonstrate the safety and efficacy of a novel technique for the treatment of medically refractory cerebral vasospasm using stent retriever angioplasty in distal vessels. Stent angioplasty can be used as an additional tool in the management of subarachnoid hemorrhage−induced cerebral vasospasm.

OBJECTIVE The ULTRA Registry is a national multicenter prospective study designed to assess aneurysm occlusion rates and safety profiles of the Target Ultra and Nano coils in the treatment of small intracranial aneurysms (IAs). METHODS Patients with small (≤ 5 mm) ruptured and unruptured IAs were treated exclusively with Target Ultra and Nano coils. The primary endpoints were the initial rate of complete or near-complete aneurysm occlusion, aneurysm recurrence, and need for retreatment. Secondary endpoints were device- and procedure-related adverse events, hemorrhage from the coiled aneurysm at any time during follow-up, and clinical outcomes. RESULTS The ULTRA Registry included 100 patients with a mean ± SD age of 56 ± 11.6 years, of whom 75 were women and 48 presented after aneurysm rupture. The mean aneurysm size was (3.5 ± 0.9) × (2.8 ± 0.9) × (3.0 ± 1.0) mm, and the mean packing density was 34.4% ± 16.7%. Posttreatment complete or near-complete occlusion reported by an independent imaging core laboratory was seen in 92% of patients at baseline and in 87%, 87%, and 83% of patients at first, second, and final follow-up, respectively. At first, second, and final follow-up, 10%, 11%, and 15%, respectively, of patients were deemed to require retreatment. There were three procedural-related ischemic strokes and one intracranial hemorrhage from wire perforation of a parent artery not involved by the aneurysm. There were no coil-related adverse events, including no intraoperative aneurysm ruptures and no known aneurysm ruptures after coiling. CONCLUSIONS This assessment of aneurysm occlusion rates and safety profiles in ULTRA Registry study participants demonstrates excellent safety and efficacy profiles for Target Ultra and Nano coils in the treatment of small IAs.

The artery of Davidoff and Schechter (ADS) is the only meningeal branch of the posterior cerebral artery (PCA), supplying the medial tentorial margin and posterior portions of the falx. Given its small size, it is rarely identified on angiographic studies, unless enlarged in pathologies such as dural arteriovenous fistulas (DAVFs) or vascularized masses. This artery was first described by Wollschlaeger and Wollschlaeger in 1965, and to date, only a few reports have described its significance. The objective of this study is to report our experience with the ADS in dural fistulas from 2 tertiary medical centers and to emphasize the importance of recognizing this artery during angiographic examination of vascular tentorial and posterior fossa lesions. To our knowledge, this report demonstrates the largest angiographic case series published to date, recognizing a total of 7 patients with ADS arising secondary to a posterior fossa or tentorial DAVF and one of the largest reported series of DAVFs supplied by the ADS treated by endovascular and surgical techniques. Our cases validate the importance of prompt identification of the ADS for the diagnosis as well as endovascular treatment of vascular malformations in the posterior fossa and tentorial region.

Objective Puig types 2 through 4 venous malformations (VMs) are challenging to treat with sclerotherapy given their robust systemic outflow. Endovenous balloon occlusion offers a means of temporarily occluding systemic venous outflow to allow for more complete sclerotherapy. This study reviews our experience of implementing this technique in patients with Puig advanced (types 2 through 4) VMs. Methods An IRB approved review of treated venous malformations from 2013–2016 revealed 10 patients fitting inclusion criteria. Patient demographics, pre-procedural imaging, intra-procedural technical parameters, and post-procedural follow-up outcomes were recorded. All patients underwent temporary balloon occlusion of a systemic or major draining vein during sclerotherapy. Embolic agents included n-butyl cyanoacrylate glue, sodium tetradecyl sulfate foam, and coils. Standard 5 French angioplasty balloons ranged from 4 to 8 mm diameter and 2 to 8 cm length depending on vessel requiring occlusion. All patients underwent minimum 3-year follow-up questionnaire administration re-assessing resolution of lesion symptomology and post-procedural quality of life (QoL) measures. Results Of the 10 VMs treated, 2 were Type 2, 6 were Type 3, and 2 were Type 4. More than one sclerotherapy session was required in 7/10 patients (mean: 2, range: 1–4). Most common sites of VM systemic drainage included subclavian, popliteal, internal/external jugular, and basilic veins. All patients had no indication for further sclerotherapy following adjunctive balloon occlusion. No non-target embolization or immediate post-procedural complications occurred. Follow-up questionnaires (mean interval: 3 years 6 months, range: 3 years–3 years 11 months) confirmed the persistence of embolization effects, improved QoL, and no additional sclerotherapy sessions for all patients in the cohort. Conclusions Endovenous balloon occlusion as an adjunct to sclerotherapy can be considered when treating patients with types 2–4 venous malformations. This technique lowers the risk of non-target systemic venous embolization, allowing for operator-driven deeper intralesional sclerosant penetration and subsequently maintained treatment efficacy.

Background Subclavian steal phenomenon can cause retrograde flow in the vertebral artery as a result of ipsilateral occlusion of the subclavian artery. This phenomenon has various clinical presentations, such as claudication of the affected extremity or intermittent vertebrobasilar ischemia. Aneurysm formation in the spinal cord circulation is exceptionally rare but may occur secondary to collateral formation in subclavian steal syndrome. Case Description The case presented herein is a 53-year-old male who presented with headache and severe neck pain. Imaging studies revealed that the patient had subarachnoid hemorrhage in the perimedullary and cervicomedullary cisterns and extending to C3-C7 ventrally. Computed tomography angiography reconstruction demonstrated an aneurysmally dilated vessel dorsal to the C6 vertebral body within the spinal canal. Catheter-based angiography of the right subclavian artery demonstrated retrograde flow within the left vertebral artery and confirmed proximal left subclavian artery occlusion, findings diagnostic of subclavian steal. Further, a branch of the right thyrocervical trunk supplied a retrocorporeal artery collateral to the left vertebral artery, which also contributed to the anterior spinal artery. Conclusions After endovascular coiling of the aneurysm, the patient had no neurologic deficits or postoperative complications. Postoperative angiography revealed complete obliteration with no residual aneurysm. Imaging further demonstrated patency of the radiculomedullary (anterior spinal) artery.

INTRODUCTION: Mechanical thrombectomy is revolutionizing treatment of acute stroke due to large vessel occlusion (LVO). Unfortunately, use of the modified Thrombolysis in Cerebral Infarction score (mTICI) to characterize recanalization of the cerebral vasculature does not address microvascular perfusion of the distal parenchyma, nor provide more than a vascular “snapshot”. Thus, little is known about tissue-level hemodynamic consequences of LVO recanalization. Diffuse correlation spectroscopy (DCS) and diffuse optical spectroscopy (DOS) are promising methods for continuous, non-invasive, contrast-free transcranial monitoring of cerebral microvasculature. METHODS: Here we use a combined DCS/DOS system to monitor frontal lobe hemodynamic changes during endovascular treatment of two patients with ischemic stroke due to cervical internal carotid artery (ICA) occlusions. RESULTS AND DISCUSSION: The monitoring instrument identified a recanalization-induced increase in ipsilateral cerebral blood flow (CBF) with little or no concurrent change in contralateral CBF and extracerebral blood flow. The results suggest that diffuse optical monitoring is sensitive to intracerebral hemodynamics in patients with cervical ICA occlusion and can measure microvascular responses to mechanical thrombectomy.

Background Although not standard of care, Cystic Fibrosis patients with recurrent hemoptysis occasionally have coil embolization of bronchial arteries. In the event of recanalization of these arteries in this specific subset of patients, the presence of indwelling coils makes the prospect of conventional particle embolization more difficult, preventing both adequate catheterization of the coiled segment and reflux of the particles. Case presentation In this report, we describe a case of bronchial artery embolization of a complex Cystic Fibrosis patient with massive hemoptysis from recanalized coiled bronchial arteries utilizing a Scepter Balloon Catheter® (Microvention Terumo, USA) in administration of the liquid embolic agent Onyx® (Medtronic, USA). Conclusions The Scepter occlusion balloon catheter allowed for careful placement of the tip within the interstices of the pre-existing coils, allowing for Onyx injection directly into the coil mass without reflux, reconfirming the benefits of Onyx embolization in bronchial artery embolization and providing evidence that the Scepter occlusion balloon catheter should be added to the armamentarium of devices used in complex bronchial artery embolization for Cystic Fibrosis patients with massive hemoptysis.

Cervical carotid artery dissections (CAD) usually produce ischemic symptoms as a result of thromboembolic phenomena, but hemodynamic insufficiency from flow-limiting stenosis can cause symptoms in a few patients [1]. CAD of the distal cervical and petrous ICA can be challenging to treat, particularly in the presence of vessel kinking or marked tortuosity of the distal cervical ICAs. The carotid stent systems used for atherosclerotic disease at the proximal ICA or carotid bulb are typically too stiff and large to safely track into a tortuous distal carotid artery, and the low radial force of the Pipeline flow diverter may occasionally result in inadequate flow restoration and even stent collapse in flow-limiting carotid dissections with large intramural thrombus burden [2,3]. In this paper, via 2 illustrative cases, we detail our experience with the latest iteration of the Neuroform stent system, the Neuroform Atlas (Stryker Neurovascular, Freemont, CA), for treatment of symptomatic flow-limiting distal cervical ICA dissections, with an emphasis on the advantages of the updated stent design.

All phase III trials evaluating medical treatments for traumatic brain injury (TBI), performed to date, have failed. To facilitate future success there is a need for novel outcome metrics that can bridge pre-clinical studies to clinical proof of concept trials. Our objective was to assess diffusion tensor imaging (DTI) and biofluid-based biomarkers as efficacy outcome metrics in a large animal study evaluating the efficacy of cyclosporine in TBI. This work builds on our previously published study that demonstrated a reduced volume of injury by 35% with cyclosporine treatment based on magnetic resonance imaging (MRI) results. A focal contusion injury was induced in piglets using a controlled cortical impact (CCI) device. Cyclosporine in a novel Cremophor/Kolliphor EL-free lipid emulsion, NeuroSTAT, was administered by continuous intravenous infusion for 5 days. The animals underwent DTI on day 5. Glial fibrillary acidic protein (GFAP), as a measure of astroglia injury, and neurofilament light (NF-L), as a measure of axonal injury, were measured in blood on days 1, 2, and 5, and in cerebrospinal fluid (CSF) on day 5 post-injury. Normalized fractional anisotropy (FA) was significantly (

The differential diagnosis for bilateral thalamic edema is extensive and includes vascular, neoplastic, metabolic, and infectious causes. Of the vascular causes of thalamic edema, arterial and venous infarctions are well-documented, but dural arteriovenous fistulas (dAVFs) are a relatively uncommon and widely underrecognized cause of thalamic edema. Dural AVFs are notoriously difficult to diagnose clinically, especially in the absence of hemorrhage, and cross-sectional imaging findings can be subtle. This can result in a delayed diagnosis, and occasionally, an invasive biopsy for further clarification of a purely vascular disease. In this review, we detail our experience with the imaging diagnosis of dAVF as a cause of thalamic edema and present a short differential of other vascular causes.

Supplemental Digital Content is available in the text., 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 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

Aims The purpose of our study was to analyze utilization trends and physician specialty distribution in spinal catheter angiography and magnetic resonance angiography in the Medicare fee-for-service population. Methods Data from the CMS Physician/Supplier Procedure Summary Master Files for 2004 to 2016 were used for this study. The Current Procedural Terminology version 4 codes for spinal magnetic resonance angiography (72159) and spinal catheter angiography (75705) were used to analyze the volumes of these procedures. Using Medicare’s 108 specialty code, we compared procedure volumes among physician specialties. Data analysis was performed using SAS version 9.3 for Windows. Results The volume of spinal catheter angiography performed was 4758 in 2004, peaked at 6869 in 2012, and dropped to 6656 in 2016. Overall, the volume of spinal catheter angiography increased by 40% from 2004 to 2016. Radiologists performed the majority of these procedures (3736 or 56.1%) in 2016, followed by neurosurgeons (2456 or 36.9%), and neurologists (346 or 5.2%). The spinal magnetic resonance angiography volume fluctuated between 0 and 1 from 2004 to 2009, then precipitously increased to 40 in 2010, peaked at 133 in 2011, and declined to 81 in 2016. The volume of spinal magnetic resonance angiography procedures increased by 8000% from 2004 to 2016, with radiologists performing the majority of them. Conclusion Our results show that spinal catheter angiography volumes continue to rise in the Medicare fee-for-service population, and are largely performed by radiologists, neurosurgeons, and neurologists. Although spinal magnetic resonance angiography volumes have started to increase, they comprise only a small fraction of studies performed for vascular evaluation of the spine.

Since the initial reports surfaced of a novel Coronavirus causing illness and loss of life in Wuhan, China, COVID-19 has rapidly spread across the globe infecting millions and leaving hundreds of thousands dead. As hospitals cope with the influx of COVID-19 patients, new challenges have arisen as healthcare systems care for COVID-19 patients while still providing essential emergency care for patients with acute strokes and acute myocardial infarction. Adding to this complex scenario are new reports that COVID-19 patients are at increased risk of thromboembolic complications including strokes. In this paper, we detail our experience caring for acute stroke patients, and provide some insight into neurointerventional workflow modifications that have helped us adapt to the COVID-19 era., Highlights: • COVID-19 continues its relentless march through the United States and the globe, presenting unique challenges for healthcare providers as they treat other emergent conditions while minimizing the risk of COVID-19 exposure and infection. • Acute stroke is especially challenging during the COVID-19 due to time constraints required for effective mechanical thrombectomy to improve neurologic outcomes and survival in patients whose COVID infection status is unknown. • The institutional protocol for mechanical thrombectomy described in this article may help inform models at other centers as they prepare for their respective COVID peaks

Case-control study.The objective of this study was to identify the best laboratory and imaging factors to predict bone biopsy culture positivity in the setting of vertebral discitis/osteomyelitis (VDO).Good predictors of bone biopsy culture positivity in the setting of VDO are unknown.Retrospective review was performed for 46 patients who underwent CT-guided bone biopsy for the evaluation of clinically confirmed VDO. Erythrocyte sedimentation rate, C-reactive protein (CRP), mean CT attenuation of the biopsied bone, and the change in the CT attenuation of the bone compared to unaffected vertebral bone (delta CT attenuation) were measured. Receiver-operator characteristic curve analyses were performed to identify the optimal threshold value for each variable. A multivariable logistic regression model was used to predict the probability of a positive bone culture using delta CT attenuation and CRPx100% fold above normal.For one of the 46 VDO patients, bone cultures were not obtained. Approximately 35.6% (16/45) of bone cultures were positive. The most significant predictors of bone culture positivity were CRP x100% fold above normal (P = 0.011) and delta CT attenuation (P = 0.001). Optimized predictive thresholds were calculated to be CRP 4-fold above normal reference value (90.9% sensitivity, 73.7% specificity), or if the CT attenuation of the affected vertebral body was25.9 HU lower relative to unaffected bone (93.8% sensitivity, 75.0% specificity).Delta CT attenuation, as well as CRP level over four times the upper limits of normal, were the strongest predictors for bone culture positivity in patients with VDO.3.

Acute basilar artery occlusion (BAO) secondary to emergent large vessel occlusion (ELVO) has an extremely poor natural history, with a reported mortality rate up to 95%. Mechanical thrombectomy in the setting of ELVO is generally performed via a transfemoral approach. However, radial access is increasingly being utilized as an alternative. We report our initial multi-institutional experience using primary radial access in the treatment of acute BAO in nine consecutive cases. Technical success defined as a TICI score of 2B or 3 was achieved in 89% of cases. Average puncture to revascularization time was 35.8 minutes. There were no complications related to radial artery catheterization. We contend radial access should potentially be considered as the first-line approach given inherent advantages over femoral access for mechanical thrombectomy for BAO.

Background Fine-needle aspiration (FNA) is utilized in the diagnostic work-up of bone lesions in a number of institutions, either in isolation or in conjunction with core biopsy. We report our experience with FNA of bone-based lesions, including comparison of this approach with concurrent core biopsy specimens. Methods Retrospective review over a 5-year period (2011–2015) revealed 233 cases of bone FNAs. Results The most commonly encountered diagnosis was malignant neoplasm (160 cases, 68.7%); within this group of malignancies, 103 cases (64.4%) represented metastatic carcinoma. Benign lesions were encountered infrequently (9 cases, 3.9%). While 37 cases (15.9%) revealed “no evidence of malignancy,” 12 cases (5.2%) showed atypical findings, 3 cases (1.3%) demonstrated inflammatory conditions, and 12 aspiration biopsies were deemed nondiagnostic (5.2%). In 202 cases, concurrent core biopsies were performed following FNA and rapid on-site evaluation (ROSE). Comparison of the FNA and core biopsy diagnoses among malignant neoplasms revealed 19 diagnostic discrepancies, including 16 cases with a false-negative FNA (7.9% of all FNAs with concurrent core biopsy) and 3 cases with a false-negative core biopsy (1.5% of all cases with corresponding FNA). Conclusion Our findings indicate that FNA of bone lesions is a useful diagnostic technique with high sensitivity, particularly when the cytologic findings are interpreted in conjunction with the core biopsy and pertinent clinical and radiologic findings. In addition, ROSE followed by open, dynamic communication with the performing radiologist leads to an extremely low rate of inadequate core biopsy specimens, resulting in optimal patient diagnosis and management.

Background Collision tumors of the spine are extremely uncommon. Prior reports have detailed intracranial collision tumors comprising meningiomas and astrocytomas, as well as metastases to meningiomas. Spinal collision tumors are even rarer, with only 5 cases in the literature, none involving the osseous spine. In this report, we highlight the salient features of a case of lymphoma metastasis to a preexisting benign osseous hemangioma, resulting in cord compression. Case Description An 81-year-old woman with a known typical T8 vertebral body hemangioma stable for over 6 years was evaluated for increasing back pain, new gait instability, and urinary retention. Magnetic resonance imaging showed a change in the appearance of the T8 hemangioma, with marrow replacement and new associated epidural soft tissue causing cord compression. A biopsy was performed, which showed diffuse large B-cell lymphoma within blood elements, consistent with lymphoma metastasis to a vertebral body hemangioma. The patient was treated with intravenous steroids and radiation therapy. Conclusions Collision tumors of the spine are extremely rare. New or increasingly aggressive appearance of a previously benign spinal osseous lesion should prompt consideration for a collision tumor or malignant transformation of the benign tumor. Biopsy of the lesion should be strongly pursued whenever feasible, as the treatment strategy may vary depending on the histology of the tumor.

Purpose There is now class 1a evidence for the efficacy of mechanical thrombectomy in patients with acute ischemic stroke and a large vessel occlusion (LVO).1 2 Failure to recanalize portends a poor prognosis for the patient with a decreased chance for a good function outcome (modified Rankin Score of 2 or less). The purpose of our study was to evaluate the incidence and causes of persistent occlusion of intracranial large vessel occlusion following mechanical thrombectomy at our high-volume comprehensive stroke center, with the goal of providing some insight into potential ways to increase recanalization rates in future patients. Methods After institutional board approval, a prospectively maintained institutional thrombectomy database for acute ischemic stroke was queried from 2015 to present. Patients with documented large vessel occlusion in the intracranial circulation and failure to recanalize after attempted mechanical thrombectomy were included for analysis. Patient characteristics including age, sex, co-morbidities, baseline NIHSS score, and baseline ASPECTS, were recorded. Rates of symptomatic hemorrhage, final ASPECTS, need for decompressive hemicraniectomy, and outcomes at 90 days (modified Rankin Scale) were also included. The statistical package R was used for analysis. Results 24 out of 368 patients with LVO and acute ischemic stroke had persistent TICI 0 occlusions after attempted mechanical thrombectomy. 15 patients were male. Mean age of patients with persistent TICI 0 was 68.8 years (range 44 to 94 years). A combination of stent-retrievers and direct aspiration (solumbra) was used for mechanical thrombectomy in all cases were the lesion was accessible. The most common reason for persistent TICI 0 was failure to recanalize despite adequate stent apposition and aspiration, which occurred in 18 out of 24 cases, or 75% of cases. Inability to pass a microwire through the site of occlusion was the second most common reason for persistent TICI 0, which occurred in 5 out of 24 of cases (21%). Inability to select the proximal great vessels due to extreme tortuosity only occurred in one case. 11 out of the 24 patients with persistent TICI 0 occlusions died within 90 days of attempted thrombectomy. Conclusions The rate of TICI 0 mechanical thrombectomy was extremely low in our series, accounting for only 7% of thrombectomy cases at our high-volume stroke center. Failure to recanalize the site of large vessel occlusion was the most common reason for persistent TICI 0 after attempted mechanical thrombectomy in our large series, occurring in 75% of persistent TICI 0 cases. In our series, persistent TICI 0 after mechanical thrombectomy had a high mortality rate, nearly 50%. References Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372(1):11–20. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015;372(11):1019–30. Disclosures R. Mattay: None. M. Cox: None. M. McCabe: None. J. Schmitt: None. D. Kung: None. O. Choudhri: None. B. Pukenas: 2; C; Regenxbio, Prevail Therapeutics. R. Hurst: None.

Objective: Faster time to mechanical thrombectomy (MT) is associated with better outcome in acute stroke. In patients transferred from other hospitals where a routine CT has already ruled out hemorrhage, transfer direct to angiography (DTA) suite may reduce door to groin time compared to transfer to CT angiography (CTA) first. However, this may result in unnecessary catheter angiography if many patients would have been excluded based on CTA results. We sought to determine how often CTA and repeat head CT changed the decision to proceed to MT. Methods: An internal transfer database at a comprehensive stroke center (CSC) was used to identify patients transferred from outside facilities for consideration of mechanical thrombectomy from July 2016 to May 2017. Detailed clinical and radiographic data was extracted using a standard case report form. Results: Of 187 patients transferred for MT, 171 underwent CT +/- CTA on arrival, 5 went DTA, and 11 were admitted without imaging or intervention. Among those undergoing CT +/- CTA on arrival, MT was aborted in 110 (64%) patients. Of these, 87 (79%) were aborted directly based on imaging findings, with absence of proximal large vessel occlusion (LVO) amenable to MT being the most common reason (69%), followed by rapid clinical improvement or mild deficit (7%). MT was aborted based on imaging findings in 36% of patients with NIHSS≥10 on arrival at CSC, and in 29% of patients with NIHSS≥15. In patients with outside hospital CTA demonstrating proximal LVO (n=48), MT was aborted in 48% on CSC arrival, mostly based on imaging findings (48%) or dramatic clinical improvement (31%). Use of tPA did not substantively modify any of these findings. CSC arrival to groin puncture tended to be shorter in the patients going DTA compared to CTA (median 39 v 54 min, p=0.06). Conclusions: While transfer DTA may be associated with faster door to groin puncture times, this might result in many patients undergoing unnecessary catheter angiography who would have been excluded based on CT +/- CTA findings. Even in transferred patients with severe stroke deficits on arrival, imaging excludes about 1/3 of patients from MT.

Introduction: Cerebral vasospasm commonly contributes to morbidity in patients who survive aneurysmal subarachnoid hemorrhage. When vasospasm becomes refractory to medical management, endovascular treatment options include intraarterial (IA) vasodilator injections and/or balloon angioplasty. However, IA vasodilators often provide limited angiographic improvements and can cause secondary systemic hypotension. Limitations of balloon angioplasty include restricted use to proximal vessels, risk of rupture with balloon inflation, and temporary vessel occlusion. Methods: We report our initial experience on the use of stent retrievers for five cases of refractory vasospasm. After injecting IA nicardipine and noting minimal angiographic improvement, we deployed the stent retriever for two minutes before the stent was re-sheathed. Results: We show safe and successful angiographic resolution of vasospasm in all cases, with a representative angiography shown in Figure 1. Injection of the left vertebral artery shows vasospasm along the basilar (BA) and posterior cerebral arteries (PCA) (Fig 1A). Narrowing improves significantly after stent deployment in the left PCA and BA (Fig 1B). There were no procedural complications. Conclusion: Stent retrievers have several benefits over balloon angioplasty for treatment of vasospasm. Stent retrievers are non-occlusive, conform easily to the curvature of the vessel, and have a known, safe opening force that prevents vessel rupture. In contrast to balloon angioplasty, stent retrievers have limited surface interface with the lumen, theoretically resulting in less endothelial injury. Lastly, most endovascular surgeons have more technical experience with stent retrievers given its widespread use in mechanical thrombectomy. In summary, stent retrievers can be used as a facile, safe, and effective endovascular treatment and should be considered as one of the emerging therapies for refractory cerebral vasospasm.

The purposes of this study were to document recent trends in stroke intervention at a tertiary-care facility with a comprehensive stroke center and to analyze current procedure volumes and the employment of specialty providers in neurointerventional radiology (NIR).Institutional trends in the volume of mechanical thrombectomy were analyzed on the basis of the number of patients who underwent mechanical thrombectomy from 2013 to 2017. To evaluate the current status of mechanical thrombectomy volumes in the United States, the number of patients in the Medicare fee-for-service database who underwent mechanical thrombectomy in 2016 was assessed. The specialty backgrounds of the various providers who performed mechanical thrombectomy were analyzed. Procedure volumes for intracranial stenting, embolization, and vertebral augmentation procedures were assessed.From 2013 to 2017, the total numbers of mechanical thrombectomy procedures for acute ischemic stroke were 19 in 2013 and 111 in 2017. The total volume of mechanical thrombectomy procedures in the Medicare fee-for-service population in 2016 was 7479. For intracranial endovascular procedures, 20,850 were performed in the U.S. Medicare population in 2015 and 22,511 in 2016. Radiologists performed 45% of procedures in 2016; neurosurgeons, 41%; and neurologists, 11%. When the total numbers of percutaneous brain and spine procedures were combined, radiologists performed 41%; neurosurgeons, 23%; and neurologists, 3%. In 2016, there were a total of 220 active NIR staff at the NIR programs with rotating residents or fellows. In these programs, 49% of staff members were neuroradiologists, 41% were neurosurgeons, and 10% were neurologists. Of the 72 NIR departments with confirmed rotating fellows or residents, 14 had only neuroradiologists on staff, six had only neurosurgeons, and one had only neurologists.Increasing radiology resident interest and participation in NIR should ensure a steady influx of radiologists into the field, continuing the strong tradition of radiology participation, leadership, and innovation in NIR.

Temporomandibular joint (TMJ) arthroscopy is considered a safe, minimally invasive procedure for the treatment of certain TMJ derangements. However, as TMJ arthroscopy is being popularized, more complications are being reported. Though exceedingly rare, arteriovenous fistula (AVF) can occur. We describe a case of superficial temporal artery (STA) fistula formation successfully treated with coil embolization.

Background and purpose Faster time to mechanical thrombectomy (MT) improves outcome in stroke. In patients from other hospitals where a CT has ruled-out hemorrhage, transfer direct-to-angiography (DTA) may reduce door-to-groin time compared to transfer to CT angiography (CTA)+/−repeat CT first. However, this may result in unnecessary catheter angiography. We sought to determine how often CTA+/−CT changed the decision to proceed to MT. Methods Data on patients transferred to our comprehensive stroke center (CSC) from outside facilities for possible MT from 7/2016–5/2017 was extracted from a prospective database and supplemented with chart review. Results Of 170 patients transferred for MT undergoing CT+/−CTA on CSC arrival, MT was aborted in 108 (64%). Of these, 87 (81%) were aborted directly based on imaging findings, with absence of large vessel occlusion or occlusion too distal to be amenable to MT the most common reasons (n = 76), followed by extensive early CT changes (n = 9) and ICH post-tPA (n = 2). Even with NIHSS ≥10 on CSC arrival, MT was aborted based on imaging findings in 35% patients. Time from symptom onset dichotomized as early/late based on median onset-to-CSC arrival (253 min) was an important modifier of proceeding to MT in this group, with 71% of early presenters going to MT compared to 33% of late presenters (p = .003). Conclusions Transfer DTA may result in many patients who would have been excluded based on CT+/−CTA findings undergoing unnecessary catheter angiography. However, a target population for a DTA approach might be identifiable based on severity of deficit and time from onset.

Introduction Duplication of the vertebral artery (VA) is a rare vascular variant, with less than 50 reported cases in the literature. Case series We present four cases of VA duplication and discuss the imaging findings, which highlight the rarely seen VA duplication. Discussion VA duplication is generally considered to be an incidental finding. The VA is formed from the fusion of the longitudinal anastomoses that link the cervical intersegmental arteries, during the 32–40-day stage. The duplication of the VA is a clinically relevant finding for planning of head and neck surgery and neuro-interventional procedures.

Intracranial dural arteriovenous fistulae (DAVF) are rare vascular malformations. They are generally considered to be acquired lesions, often attributed to dural sinus thrombosis and intracranial venous hypertension. The authors encountered a case of DAVF associated with an octreotide-positive vestibular schwannoma. A 46-year-old female had symptoms of right ear congestion accompanied by pulsatile tinnitus and mild hearing loss. Magnetic resonance imaging (MRI) identified a lobulated mass centered at the cerebellopontine angle. Preoperatively, on cerebral angiography, there was an incidental discovery of a DAVF in the right posterior fossa. The decision was made to proceed with resection of the tumor in a staged fashion. Her latest follow-up MRI showed no evidence of recurrent tumor. This is the second reported case of DAVF associated with an intracranial schwannoma. Findings are discussed along with a thorough review of the literature. This case, combined with the data from the literature review, led us to believe that tumor-related angiogenesis might contribute to DAVF formation.

Spontaneous regression of an arteriovenous malformation (AVM) is the phenomenon of partial or complete obliteration of the vascular anomaly without any therapeutic intervention. Complete spontaneous regression is a rare event with limited previously reported cases in the literature. We present a new case of complete spontaneous regression of a right frontal AVM and report findings from the imaging studies. Furthermore, we present the findings of a detailed literature review and discuss hypotheses regarding the pathophysiology of this rare occurrence.

Cerebral microbleeds (CMBs) represent clinically silent haemorrhagic events. Cerebral microbleeds (CMBs) portend negative neurovascular and cognitive outcomes in the general population and are associated with cognitive impairment in persons with haemophilia (PWH). Prevalence, patterns, and risk factors for CMBs in PWH have not been directly compared to persons without coagulopathy.To examine prevalence, patterns, and risk factors for CMBs in PWH vs normal controls.Adults with haemophilia A or B and haemostatically normal controls were recruited. Subjects were excluded if taking an antithrombotic agent other than low-dose aspirin (100 mg). All subjects underwent T2*MRI of the brain; scans were reviewed independently by two neuroradiologists blinded to subject group to determine the presence of CMBs.We recruited 31 PWH and 32 controls. Human immunodeficiency virus (HIV) and history of hepatitis C virus (HCV) infection were more prevalent in PWH; smoking was more common among controls. Cardiovascular (CV) risk factors were similar between groups. Prevalence of CMBs was 35% in PWH and 25% in controls (P = .42). Among PWH, advanced age, history of HCV infection, and CV risk factors were associated with CMBs. Multiple and large (5 mm) CMBs were seen only in PWH.Cerebral microbleeds (CMBs) are common in adults with haemophilia, but not clearly more prevalent than in haemostatically normal controls. In PWH, older age, HCV infection, CV risk factors, and the presence of an inhibitor were associated with CMBs. Large CMBs and multiple CMBs may be more prevalent in PWH than in the general population. The clinical impact of CMBs in PWH requires further study.

Background Intracranial vasculopathy in adult patients with human-acquired immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a rare but increasingly recognized disease entity. Objective We aimed to contribute to and summarize the adult literature describing patients with HIV/AIDS who have intracranial vasculopathy. Methods A retrospective review of adult patients with HIV/AIDS undergoing diagnostic cerebral angiography at our institution from 2007–2013 was performed. A literature review of relevant existing studies was performed. Results Five adult patients with HIV-related aneurysmal and occlusive vasculopathy were diagnosed and/or treated at our institution. A comprehensive review of the literature yielded data from 17 series describing 28 adult patients with HIV/AIDS and intracranial vasculopathy. Our review suggests that low CD4 count, motor weakness, and meningismus may be associated with the sequelae of intracranial vasculopathy/vasculitis in patients with HIV/AIDS. Conclusion Patients with HIV/AIDS who have aneurysmal and stenotic vascular disease may benefit from earlier surveillance with the onset of neurological symptoms. The roles of medical, open surgical, and endovascular therapy in this unique entity will be further defined as the pathological basis of the disease is better understood.

The objective of this article is to report our experience with a technique for CT-guided spine biopsies that we refer to as the "scout no scan" technique.The scout no scan technique can significantly lower radiation exposure while maintaining high diagnostic yields for CT-guided spinal biopsies.

Aim: Super absorbent polyvinyl alcohol-sodium acrylate copolymer microspheres, Quadrasphere microspheres (QSM), are commonly used for drug-eluting bead therapy, however, the literature only reports its use with small molecule chemotherapeutics. This study evaluates the loading and elution characteristics of bevacizumab-loaded QSM. Methods & results: A single vial of QSM was reconstituted with 200 mg of bevacizumab. Drug concentration was determined by ELISA immunoassay. At approximately 90 min, there was maximal loading at 59% of the starting dose. In vitro elution demonstrated 52% of bound bevacizumab was released within the first hour and 68% by 16 h. Conclusion: Bevacizumab can load onto QSM and elute over time. This targeted delivery vehicle may potentially result in more effective treatment and fewer complications related to systemic toxicity.

Although usually asymptomatic, a persistent trigeminal artery (PTA) can rarely be associated with a direct fistula to the cavernous sinus (ie, trigemino-cavernous fistula). We present three patients with trigemino-cavernous fistulas; two were subsequently treated using modern endovascular techniques while the third initially declined therapy. We then review the literature of reported cases of this unusual entity. The aberrant anatomy associated with a PTA presents unique challenges to the management of these lesions, and must be well delineated prior to treatment. Finally, conservative management of trigemino-cavernous fistulas, either de novo or recurrent, may be considered if they demonstrate no evidence of cortical venous reflux and patient symptoms are tolerable.

Adequate dual antiplatelet (AP) therapy is imperative when performing neurovascular stenting procedures. Currently, no consensus for the ideal AP regimen exists. Thus the present study aimed to gain a better understanding of real world practice AP patterns by surveying neurointerventional surgeons.Survey links were emailed to 296 neurointerventional surgeons practicing in the USA, asking 51 questions including demographics, stent specific use, AP pre and post-medication, types of APs, point of care (POC) assessment, complications, and outcomes. Data were collected and analyzed using Research Electronic Data Capture (REDCap).74 participants responded; 56.8% were from academic centers. Participants treated an average of 5.5 aneurysms per month. They placed an average of 1.6 intracranial stents and 1.4 cervical stents per month. Mean number of pipeline embolization devices (PEDs) placed per year was 15.2. Heterogeneity existed regarding AP regimens; the most frequent included acetylsalicylic acid (ASA) 325 mg+Plavix 75 mg daily (for 7 days prior) and ASA 325 mg+Plavix 75 mg daily (for 5 days prior) for routine placement of intracranial and cervical stents, respectively. For emergency placement, ASA 325 mg+Plavix 600 mg (at time of surgery) was the most frequently used. 46.8% routinely used POC testing, most frequently VerifyNow (Accumetrics, San Diego, California, USA); the most common threshold determining a non-responder was30% inhibition. 85.7% used POC for PED placement. Management changes based on POC testing were diverse.The results highlight the heterogeneity of current practices regarding AP medication regimens during neurovascular stenting. Given its importance, evidence based protocols are imperative. Minimal literature exists focusing on neurovasculature, and therefore understanding current practice patterns represents a first step toward generating these protocols.

INTRODUCTION: Mechanical thrombectomy (MT) has dramatically improved the prognosis for acute ischemic stroke (AIS) patients. Despite high recanalization rates, up to half of the patients will not present a good neurological outcome after MT. Therapeutic hypothermia is perhaps the most robust neuroprotectant studied preclinically. MATERIALS AND METHODS: We explored various warming effects that can reduce the effectiveness or potency of selective hypothermia during AIS under conditions similar to actual clinical care. Four different selective hypothermia layouts were chosen. Layouts 1 and 2 used a single catheter without and with an insulated IV bag. Layouts 3 and 4 used two catheters arrange coaxially, without and with an insulated IV bag. Independent variables measured were IV bag exit temperature, catheter inlet temperature, and catheter outlet temperature at four different flow rates ranging from 8 to 25 ml/min over an infusion duration of 20 min. RESULTS: Dominant warming occurs along the catheter pathway compared to warming along the infusion line pathway, ranging from 66% to 72%. Coaxial configurations provided an approximate 4°C cooler temperature benefit on delivered infusate over a single catheter. Brain tissue temperature predictions show that the maximum cooling layout, Layout 4 at maximum flow provides a 1°C within 5 min. CONCLUSION: Significant rewarming effects occur along the infusate flow path from IV bag to site of injury in the brain. Previous selective hypothermia clinical work, using flow rates and equipment at conditions similar to our study, likely produced rapid but not deep tissue cooling in the brain (~ 1°C).