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Modern neurosurgeons commonly rely on dural grafts to aid in obtaining watertight closures when the native dura itself cannot be approximated. We present a patient who developed a symptomatic, delayed hypersensitivity reaction to a cellulose-based synthetic dural graft, which resolved after reoperation and removal of the graft. Dural grafts are a safe and common implant utilized in neurosurgery. Nevertheless, as with all implanted material, there is a chance for symptomatic immune reactions to occur. This type of response is exceedingly uncommon, but recognition of this rare presentation may help other providers recognize it in the future. [ABSTRACT FROM AUTHOR]

Introduction: As we emerge from the current pandemic, hospitals, staff, and resources will need to continue to adjust to meet ongoing healthcare demands. Lessons learned during past shortages can be used to optimize peri-procedural protocols to safely improve the utilization of hospital resources. Methods: Retrospective review of patients who underwent elective endovascular intracranial aneurysm treatment was performed. Multivariable logistic regression was used to identify factors associated with patients who were able to be discharged within 24 h of elective procedures. Rates of complications (particularly readmission) were determined. Results: 330 patients underwent elective endovascular aneurysm treatment with 86 (26.1%) discharged within 24 h. Factors associated with earlier discharge included procedure years (2019–2021) and male sex. Patients were more likely to be discharged later (after 24 h) if they underwent stent-coil embolization or flow-diversion. There was no association between discharge timing and likelihood of readmission. Discussion: Our review highlights the safety of earlier discharge and allowed us to prepare a fast-track protocol for same-day discharge in these patients. This protocol will be studied prospectively in the next phase of this study. As we gain more comfort with emerging, minimally invasive endovascular therapies, we hope to safely achieve same-day discharge on a protocolized and routine basis, reducing the demand of elective aneurysm treatments on our healthcare system. Conclusion: We retrospectively demonstrate that early discharge following elective aneurysm treatment is safe in our cohort and provide a fast-track pathway based on these findings for other centers developing similar protocols. [ABSTRACT FROM AUTHOR]

Eagle syndrome (ES) was first described in 1937, to characterize elongation of the styloid process. It is rarely encountered by neurosurgeons but does present the potential for vascular sequelae and neurological complications. We discuss three patients with uncommon presentations of neurovascular compromise with uncommon symptomatology, secondary to ES. Their management ranged from retrospective diagnoses following self-limited events, antiplatelet therapy, and endovascular and surgical interventions. While traumatic fractures, chiropractic manipulation, and history of prior neck surgery have been implicated as the etiologies for ES, congenital cases are common. The styloid process intimately interplays with adjacent neurovascular and nervous structures; its elongation can cause symptoms in 10% of patients. Awareness of this potentially dangerous but rare disease – more commonly seen by our otolaryngology colleagues – may help reduce diagnostic delays when an elongated styloid process is the cause, as surgery may be required. [ABSTRACT FROM AUTHOR]

Background Intracranial stent placement for the treatment of cerebral aneurysms is increasingly utilized in both ruptured and unruptured scenarios. Intravenous (IV) cangrelor is a relatively new antiplatelet agent that was initially approved for coronary interventions. In addition to our institution, five other centers have published their results using IV cangrelor in neurointerventional procedures. This article combines the aneurysm treatment data from all prior studies to provide insight into the safety and efficacy of cangrelor for intracranial aneurysm treatment. Methods A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during aneurysm embolization. 20 additional patients were identified who had not been previously published. In addition, a literature search was performed to identify prior publications regarding cangrelor in neurointervention. The data from these were combined with our institutional results in a pooled-analysis. Results Overall, 85 patients who received IV cangrelor during aneurysm embolization were identified, including 46 ruptured and 39 unruptured cases. The asymptomatic and symptomatic intracranial hemorrhage rates were 4% (2/46) for ruptured cases and 2.6% (1/39) for unruptured cases. The rate of retroperitoneal hematoma and gastrointestinal bleeding was 0%. There were no incidents of intraprocedural thromboembolic complication or intraprocedural in-stent thrombosis in either cohort. One subject suffered an ischemic stroke at 24 hours secondary to in-stent thrombosis in a ruptured case. Conclusions IV cangrelor during aneurysm embolization appears to be safe, with a symptomatic intracranial hemorrhage rate of 4% in ruptured cases and 2.6% in unruptured cases. More research is needed to determine the ideal dosing regimen. [ABSTRACT FROM AUTHOR]

INTRODUCTION: While endovascular coiling has been shown to be a safe treatment option for intracranial aneurysms, there remains concern regarding increased recurrence and retreatment rates. Preliminary studies evaluating hydrogel coated coils have demonstrated decreased recurrence rates compared to bare metal coils. METHODS: A retrospective chart review was done on all patients with anterior communicating artery aneurysms (ACoAAs) treated with endovascular coiling between 2014 and 2018. Treatment groups were divided into hydrogel coated coils or bare metal coils. Patients were categorized into the hydrogel group when = 70% of the coil length was hydrogel coated. RESULTS: Eighty-four ACoAAs were treated with coil embolization between 2014 and 2018. Postoperative imaging was available for 68 patients. Twenty-six patients were categorized into the hydrogel treatment group. Aneurysm recurrence was seen in 7.7% (2/26) of patients treated with hydrogel coated coils compared to 33.3% (14/42) of those treated with bare metal coils (P = 0.03). Subanalysis of patients with ruptured aneurysms revealed decreased recurrence rates in patients treated with hydrogel coated coils at 5.9% (1/17) compared to patients treated with bare metal coils at 39.4% (13/33) (P = 0.01). CONCLUSIONS: Hydrogel-coated coils may reduce recurrence rates in the treatment of both ruptured and unruptured ACoAAs. [ABSTRACT FROM AUTHOR]

Background: Optimal antiplatelet inhibition is vital during cerebrovascular stenting procedures, yet no standardized recommendation exists for antithrombotic therapy in these scenarios. Cangrelor is an intravenous P2Y12 inhibitor with a favorable pharmacokinetic profile for use during neuroendovascular stenting. Methods: A retrospective review of all neuroendovascular patients who underwent stenting between 1 January 2019 and 22 March 2020 and were treated with cangrelor was conducted. Thirty-seven patients met inclusion criteria. Results: All patients were administered a bolus of 5 mcg/kg of cangrelor followed by a maintenance infusion. Antiplatelet effects of cangrelor were monitored using platelet reactivity units (PRU). Based on the initial PRU, seven patients' doses were adjusted with subsequent PRUs in or near the goal range of 50–150. One patient experienced an acute intraprocedural occlusion likely related to a subtherapeutic PRU which subsequently resolved with cangrelor dose adjustment and intra-arterial tirofiban administration, and one patient experienced a post-procedure stent occlusion which required a thrombectomy and intra-arterial tirofiban administration. No hemorrhagic complications occurred. Discussion: Cangrelor utilization during neuroendovascular stenting with maintenance doses of <2 mcg/kg/min with dose adjustments based on platelet function testing has not been previously described. Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability. Conclusion: Cangrelor is a promising alternative to currently available therapies, especially in patients with a high hemorrhagic risk. [ABSTRACT FROM AUTHOR]

The ecotype simulation (ES) and AdaptML algorithms were applied to identify the differences associated with solar exposure and soil texture among the dimensions of ecological divergence for newly divergent Bacillus ecotypes in the Death Valley canyon. The taxa recognized by ES and AdaptML do not seem to encompass the full ecological diversity of the Bacillus subtilis-B. licheniformis clade but several newly discovered clades identified as ecotypes are distinct from any recognized taxon.

Idiopathic intracranial hypertension (IIH) is a common outpatient condition encountered by neurosurgeons and neurologists. Regarding "Safely Traversing Venous Sinus Stenosis: The "Cobra" Technique" 2015/08/08. 5 Schwarz J, Santillan A, Patsalides A. Safely traversing venous sinus stenosis: the "cobra" technique. [Extracted from the article]

The use of flow diversion for the treatment of intracranial aneurysms has gained broad acceptance. Three flow-diverting stents are approved by the Food and Drug Administration for use in the United States. We sought to compare the outcomes and safety profiles between the three devices at our institution.A retrospective review of aneurysms treated with pipeline embolization device (PED), flow re-direction endoluminal device (FRED), and SURPASS was performed for aneurysms treated between 2018 and 2022 at our institution.The study cohort consisted of 142 patients. Precisely, 86 aneurysms were treated with a pipeline, 33 aneurysms were treated with FRED, and 23 aneurysms were treated with SURPASS. The 1-year complete occlusion rates were 59.4%, 60%, and 65%, respectively (0.91). Linear regression models found that only adjunctive coiling predicted aneurysm occlusion at 6 months (p = 0.02), but this effect was lost at 1 year and beyond. There was no significant difference in acute thrombotic or acute hemorrhagic complications between the three cohorts. There was a higher rate of delayed hemorrhagic complications in the SURPASS cohort (10%) compared to the PED (1.3%) and FRED (0%) cohorts (p = 0.04). There was also a higher rate of in-stent stenosis in the SURPASS cohort (20%) compared to the PED (5%) and FRED (3.1%) cohorts (p < 0.01).Treatment with PED, FRED, and SURPASS all resulted in similar complete occlusion rates at 6 months and 1 year. SURPASS was associated with higher in-stent stenosis as well as delayed hemorrhagic complications. Additional future studies evaluating the newest generation of flow-diverting stents with long-term follow-up will be necessary to make any definitive conclusions. [ABSTRACT FROM AUTHOR]

Objective: The Flow-Redirection Endoluminal Device X (FRED X) is a newer generation flow diverter with surface modifications aimed at minimizing thrombogenicity. At present, data on its long-term efficacy are limited. This multicenter study presents the largest series within the United States describing the device's efficacy, safety, and long-term outcomes in treating cerebral aneurysms of varying morphology., Methods: Patients treated with the FRED X for a cerebral aneurysm between February 2022 and February 2024 at 6 high-volume centers across the United States were included. Data were collected regarding demographics, clinical presentation, and procedural efficacy. Angiographic and clinical follow-up outcomes were assessed at 6 and 12 months., Results: A total of 154 patients with 162 aneurysms were treated with 164 FRED X devices over the study period. Overall, 81.8% of the cohort was female with a mean age of 56.8 years. The authors observed satisfactory rates (≥ 99.3%) of device deployment and good wall apposition and neck coverage. One hundred forty-seven (95.5%) patients were functionally independent at discharge (modified Rankin Scale scores 0-2). Rates of adequate occlusion (Raymond-Roy Occlusion Scale score I or II) increased from 84.2% at 6 months to 83.5% at the 12-month follow-up, while rates of in-stent stenosis decreased. All patients (100%) who underwent follow-up were functionally independent at 6 months, and 95.9% were functionally independent at 12 months., Conclusions: This multicenter cohort study demonstrates the ease of FRED X deployment with an adequate safety profile, with low rates of procedural complications and favorable outcomes on follow-up. Rates of aneurysm occlusion increased over time, with a subsequent decrease in stent-associated complications.

Background: The Flow Re-direction Endoluminal Device (FRED) X is a next generation flow-diverting stent for treating intracranial aneurysms. Its surface modification (X technology) aims to minimize device thrombogenicity. Early post-market multicenter data from the US are lacking., Methods: We conducted a retrospective multicenter analysis of consecutive FRED X procedures performed to treat unruptured intracranial aneurysms at four US centers (March 2022 to January 2024). Cases with ruptured aneurysms or extracranial aneurysm location were excluded (n=10). We assessed patient and aneurysm characteristics, antithrombotic management, safety events, and both clinical and angiographic (effectiveness) outcomes., Results: In this cohort, 101 patients underwent FRED X stenting for 117 aneurysms. Most aneurysms were saccular in shape (95.7%) and located at the C6-C7 segments of the internal carotid artery (72.6%). Thromboembolic events occurred in 5.9% of the cases, leading to one instance of permanent procedure related morbidity (1.0%). No procedure related mortality (0%) was observed. Device related issues were recorded in 2.0% of cases. At the 6 month follow-up, complete aneurysm occlusion was achieved in 58% of aneurysms. At the last available follow-up (6-12 months), 74.8% of aneurysms were adequately occluded., Conclusions: FRED X stenting for unruptured intracranial aneurysms demonstrated low rates of neurological morbidity and periprocedural complications. Early aneurysm occlusion rates were appropriate, but further mid-term and long term follow-up is required. These findings support the early safety and effectiveness of the FRED X device for intracranial aneurysm treatment., Competing Interests: Competing interests: SH received salary support from MicroVention via an investigator initiated research grant obtained by the senior author OG. NCF received speaking Honoria from NICO. DA is a consultant for Microvention, Stryker, Q’Apel, Synchron, Penumbra, and Cerenovus, and investor of Von Vascular. ARP is a consultant for Microvention, IRRAS, Penumbra, and NICO. JKB is a consultant for Stryker, Medtronic, Cerenovus, Microvention, Q’Apel Medical, BALT, and Siemens. CMS has research grants from Medtronic, Stryker, Penumbra, Cerenovus, Route 92, MIVI, Balt, Microvention, NICO, and NIH/NINDS, consulting agreements with Medtronic, Stryker, Viz.ai, Balt, Microvention, and Werfen, and ownership of NTI and Reist. OG is a consultant for Microvention, Rapid Medical, and Route 92, and received funding from MicroVention. OG received an investigator initiated study research grant from MicroVention., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Recent literature highlights the adverse effects of recreational marijuana on cerebrovascular pathologies and outcomes. However, its impact on arteriovenous malformation (AVM) outcomes is unknown., Objective: To investigate the differences in AVM outcomes between marijuana users and non-users, focusing primarily on the likelihood of presenting with rupture and secondly, on the effects of other drugs on in-hospital mortality and complications., Methods: Adult patients diagnosed with cerebral AVMs from the National Inpatient Sample were included. Use of recreational drugs, including marijuana, alcohol, opioids, hallucinogens, stimulants, and tobacco, was documented. Univariate and multivariate logistic regression analyses identified associations between drug use and AVM outcomes., Results: A total of 46 480 patients were analyzed, with 11 580 (24.9%) presenting with rupture. Smoking was the most prevalent substance used (18 010, 38.7%), followed by alcohol (3 065, 6.6%), and cannabis (745, 1.6%). Smoking tobacco (OR=0.801; P=0.0002) and cannabis use (OR=0.613; P=0.0523) showed trends towards a protective effect against presentation with AVM rupture. Tobacco use was associated with reduced likelihood of extended length of stay (OR=0.837; P=0.0013), any complications (OR=0.860; P=0.0082), and in-hospital mortality (OR=0.590; P=0.0003). Alcohol use was linked to increased extended length of stay (OR=1.363; P=0.0033) and complications (OR=1.442; P=0.0007)., Conclusions: Stimulant use increases the likelihood of presenting with ruptured AVMs and is associated with higher mortality. Tobacco and cannabis use appear to reduce the possibility of extended hospital stays and complications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Stent development has focused recently on low-profile, self-expandable stents compatible with 0.0165 inch microcatheters. The LVIS EVO is the second-generation version of the Low-Profile Visualized Intraluminal Support (LVIS) with improved visibility and resheathability. The LVIS EVO underwent a limited premarket release (PMR) in December 2023. This study aims to report the early safety and feasibility experience with the LVIS EVO stent for the treatment of intracranial aneurysms in the United States (US)., Methods: This was a multicenter, retrospective, observational study evaluating patients who underwent treatment of an intracranial aneurysm with an LVIS EVO stent after the limited PMR. All physicians who had placed an LVIS EVO stent were asked to input their cases after institutional review board approval was obtained. The data were then sent to a single center for analysis. Any patient aged 18 years or older who underwent treatment of an intracranial aneurysm with a LVIS EVO stent in the US was included from the initial PMR in December 2023 until April 2024. Patient age (or ≤90 years old), sex, preoperative modified Rankin Scale (mRS), aneurysm location, aneurysm measurements, and information about preoperative antiplatelet management were all collected. Data on periprocedural complications, 30-day mortality, discharge mRS, and length of stay were also collected., Results: Some 53 patients with 55 aneurysms underwent treatment with the LVIS EVO stent at 15 institutions. All aneurysms were unruptured. The most common location was the anterior communicating artery (35%) followed by the middle cerebral artery bifurcation (31%). All patients were on dual antiplatelet therapy. The average aneurysm size was 5.2 mm with a neck size of 3.7 mm. The smallest distal parent vessel size was 1.2 mm and 36% of stents were deployed in distal parent vessels <2 mm. All (100%) cases had successful deployment and the stent was repositioned in 10% of cases. A single stent was utilized in 91% of cases. Coils were placed in 48 cases (87.2%) and a microcatheter was jailed in 98% of those cases. Immediate Raymond Roy (RR) Class I occlusion was obtained in 33%, Class II in 22%, Class IIIa in 37%, and Class IIIb in 8% of cases. There were no delayed thromboembolic or hemorrhagic complications., Conclusions: The LVIS EVO is a braided, self-expanding, retrievable stent with enhanced visibility and smaller cell size. The drawn filled tube (DFT) technology results in improved visibility of the stent, allowing for more controlled stent positioning and visualization of vessel wall apposition. All cases in our series had complete neck coverage and good wall apposition. There were no thromboembolic or hemorrhagic complications., Competing Interests: Competing interests: BY is a consultant for Imperative Care and Q’Apel Medical, Inc., and has received speaking honoria from Penumbra. EAS is a consultant for MicroVention, Medtronic, Rapid Medical, iSchemaview, and Cerenovus. AS is a consultant/advisory board member for Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Asahi Intecc Co. Ltd., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., CerebrovaKP, Cerenovus, Contego Medical, Cordis, Corindus, Inc., Endostream Medical, Ltd, Hyperfine Operations, Inc., Imperative Care, InspireMD, Ltd., Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Peijia Medical, Penumbra, Piraeus Medical, Inc., Q’Apel Medical, Inc., Rapid Medical, Serenity Medical, Inc., Shockwave Medical, Inc., Silk Road Medical, StimMed, LLC, Stryker Neurovascular., Synchron Australia Pty Ltd., VasSol, Vesalio, Viz.ai, Inc., WL Gore, and an investor in Adona Medical, Inc., Bend IT Technologies, Ltd., BlinkTBI, Inc., Borvo Medical, Inc., Cerebrotech Medical Systems, Inc., CerebrovaKP, Code Zero Medical, Inc., Cognition Medical, Collavidence, Inc., Contego Medical, CVAID Ltd., E8, Inc., Endostream Medical, Ltd., Galaxy Therapeutics, Inc., Hyperion Surgical, Inc., Imperative Care, Inc., InspireMD, Ltd., Instylla, Inc., Launch NY, Inc., Neurolutions, Inc., NeuroRadial Technologies, Inc. (sold to Medtronic in 2021), Neurovascular Diagnostics, Inc., Peijia Medical, PerFlow Medical, Ltd., Piraeus Medical, Inc., Q’Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp.), Rist Neurovascular, Inc. (purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, Sim & Cure, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, Viseon, Inc., Whisper Medical, Inc., Willow Medtech, Inc. OG is a consultant for MicroVention, Stryker, and Route 92. CM is a consultant and proctor for Cerevasc and Silk Road Medical, and a consultant for MicroVention, Medtronic, Stryker, Navigantis, and Hyerbia. MRG is a consultant for Stryker and Rapid Medical. ARP is a consultant for Microvention, IRRAS, Penumbra, and NICO., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The Enterprise stent (Codman Neuro, Massachusetts, USA) received Food and Drug Administration (FDA) approval in 2007 for stent-assisted coiling (SAC). Since its introduction, newer stents and devices for aneurysm treatment have been developed resulting in a shift in the utilization of this stent from SAC to other off-label indications., Objective: To describe our experience with the Enterprise stent being used for SAC and other off-label indications., Methods: This is a multi-center retrospective review of the use of the Enterprise stent between 2018 and 2023. All patients in which the Enterprise stent was successfully deployed were included in the study., Results: Our study cohort comprised of 194 patients, mostly females (n = 112, 57.7%), with a mean age of 63.2 years ± 14.3. The Enterprise stent was used for SAC in only 24 (12.4%) patients and was used for rescue stenting in stroke in 101 patients (52.1%), treatment of intracranial stenosis in 53 patients (27.3%), treatment of in-stent stenosis in 1 patient (0.5%), and for treatment of dissections in 15 patients (7.7%). From 2018 to 2023, the use of Enterprise stents for SAC significantly decreased ( p  < 0.0001) while the use of Enterprise stents for non-SAC purposes was insignificantly variable ( p  = 0.05)., Conclusion: Our study shows that the Enterprise stent remains a reliable tool in neuroendovascular procedures, even if its original intended use has been supplanted by other devices.